Pharmacists, nurses, and physicians’ perspectives and use of formal and informal interpreters during medication management in the inpatient setting

https://doi.org/10.1016/j.pec.2022.107607Get rights and content

Highlights

  • Individuals with LEP may experience communication barriers with healthcare professionals which can result in adverse outcomes.

  • This study examined inpatient clinicians’ perspectives and use of interpreters during medication management in the hospital.

  • Interviews with clinicians found suboptimal comunication with patients and families, including use of informal interpreters and lack of translated materials.

Abstract

Objective

Language barriers during inpatient medication management can occur during medication reconciliation on admission and discharge, and during the hospitalization. Understanding inpatient clinicians’ experiences with language barriers and use of interpreters can help inform interventions aimed at improving medication management with Limited English Proficient (LEP) patients. Our objective was to examine clinicians’ experiences with language barriers around inpatient medication management.

Methods

We used semi-structured interviews with pharmacist technicians, pharmacists, nurses, and physicians working in a tertiary care hospital. We used the constant comparison method to guide data collection and analysis.

Results

We interviewed 14 providers. Nurses and physicians perceived lack of time to use formal interpreters, particularly during busy or night shifts. Clinicians strongly preferred virtual and in-person interpreter services over telephonic services, and highlighted communication challenges with patients with low health literacy, concerns about the quality of interpretation, and inconsistencies in the use of translated materials.

Conclusions

Ensuring access to formal interpreters during all shifts, translation of materials into the patient/caregiver’s language, and access to in-person/virtual services would improve quality of care for LEP patients.

Practice implications:

Current laws require use of interpreters, but do not provide for their reimbursement, resulting in suboptimal use. Reimbursement for interpreter services may increase their availability.

Introduction

Approximately 8.6% of the population in the U.S., or 25 million people, have Limited English Proficiency (LEP), defined as speaking English less than “very well” [1]. Individuals with LEP are more likely to lack health insurance, live below the poverty line, have lower health literacy, and have less than a high school education compared to those with English proficiency [2]. Individuals with LEP may experience significant communication barriers with healthcare professionals which can result in adverse outcomes [3], [4]. Communication errors can occur when healthcare providers use informal interpreters such as family members or non-qualified staff [5]. Use of trained, formal interpreters is associated with improved quality of care and patient satisfaction [6]. Yet due to a variety of barriers, including lack of perceived need, time, and availability, medical professionals may not always use formal interpreters [7], [8]. A 2019 study found that fewer than 60% of patients with LEP reported that their medical provider always explained things in a way they could understand [9]. As a result, patients with LEP are more likely to have serious adverse events during hospitalization, have a longer length of stay in the hospital, and have a higher risk of 30-day hospital readmissions compared to non-LEP patients [10], [11], [12], [13].

Language barriers in medication management can occur during medication reconciliation on admission or discharge and during inpatient medication administration, leading to serious safety and quality concerns [5], [14], [15], [16], [17]. One study in a Dutch hospital found that nurses sometimes skipped safety protocols regarding double-checking names and birth dates prior to administering medications in patients with language barriers [15]. Nurses also had a difficult time measuring pain levels in patients with language barriers, opting for visual inspections or skipping pain assessments. These practices could lead to a systematic undertreatment of pain among patients with language barriers [18]. Moreover, medications often change significantly during and after hospitalization, requiring important communication exchanges with patients and caregivers [14], [16]. This important information exchange can be significantly hampered in the presence of language barriers. In a study of 308 Spanish-, Chinese- and English-speaking patients across two hospitals, researchers found that LEP patients were less likely to understand discharge instructions, including the category or purpose of discharge medications [14].

While some studies have examined perceptions and experiences with language barriers in the inpatient setting, few have examined clinicians’ experiences with language barriers specifically around medication management in the hospital. Moreover, few studies have examined inpatient pharmacists’ experiences with language barriers. This study is part of a larger study examining intrahospital medication management and post-discharge patient counseling [19]. The objective of this specific study was to describe clinicians’ perspectives about linguistic and cultural barriers to providing medication management, education, and counseling to LEP patient and caregivers.

Section snippets

Setting

The study was conducted among pharmacist technicians, pharmacists, nurses, and physicians working in a tertiary care hospital in Southern California. California has one of the highest proportions of LEP residents in the U.S. Nearly 24% of Californians – 1 in 4 – are LEP [20], and 44.6% of California residents report speaking a language other than English at home. In Los Angeles County, where this study took place, the proportion of residents who are LEP in some communities is higher than 50%

Results

We interviewed 14 providers, including 1 pharmacy technician, 6 pharmacists, 3 nurses, and 4 physicians as part of this study. Data on the interviewees is included in Table 1. Our interviewees were 64% female and had a median of 9.5 years of work experience after clinical training (range: 6–21). Interviews lasted 60–90 min. We identified six major themes across our qualitative data.

  • 1.

    Perceptions of lack of time and urgent issues led to the use of informal interpreters by physicians and nurses,

Discussion

In this qualitative descriptive study of clinicians working in a tertiary care hospital in Southern California, we found that nurses and physicians used informal interpreters when perceiving lack of time and high workloads. We also found issues of trust from patients around both formal interpreters and healthcare professionals, as older patients in particular preferred family members to interpret. Finally, we found strong preferences for virtual and in-person interpreter services over

Funding

This work was supported by the National Institutes of Aging, grant numbers 3R01AG058911–03S1, R01AG058911, and K01AG076865.

Credit author statement

MSK conceived of the study idea, conceptualized the study design, conducted the interviews, analysed the data, and wrote and edited the manuscript. JCB conduced the literature review, co-conducted the interviews and co-analysed the data.

Declaration of Competing Interest

The authors have no interest to disclose.

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