Advanced Practice Nursing and Communication: Impact of a Cultural Specific Trained Interpreter

Abstract 

Communication in health care involves the ability to effectively gather information from patients, make and communicate diagnoses, and inform patients of associated treatments and other medical care. Barriers, nonetheless, are often encountered in this process especially when dealing with patients from diverse backgrounds whose main language of communication is not English. In such cases, communication breakdown is likely to occur, prompting the intervention of a mediator. The mediator could either be a professionally trained interpreter or an interpreter with no training. This paper seeks to make a comparison between a cultural specific trained interpreter and a phone translator with no specialized training. Ten research articles were collected and reviewed from the Cochrane Library, along with PsycINFO, CINAHL, EBSCO, and PubMed. Further research for articles was also conducted on the World Wide Web, using keywords like Limited English Proficiency, health disparities, language barriers, physician-patient communication, and quality care. Appraisal of the research was done using the Cochrane Collaboration and fundamentals of evidence-based healthcare concepts and Melnyk and Fineout-Overholt rating of evidence. Results showed that language barriers largely affect Limited English Proficiency patients in seeking medical attention and that using professional interpreters is in most cases related to improved clinical care for patients with limited proficiency in English. In addition, further research needs to be done on healthcare encounters involving mediation by an interpreter and providers should be aware of the vast roles and perceptions of interpreters, determining the best means to work with them for the most preferable outcomes. 

Advanced Practice Nursing and Communication: Impact of a Cultural Specific Trained Interpreter versus a Phone Translator with No Specialized Training on Care 

A Systematic Review 

Introduction 

Effective communication entails the ability to pass across information accurately. In medical care, effective communication is especially important for the medical care provider in dealing with patients. Nonetheless, barriers are often encountered especially when dealing with patients from diverse backgrounds whose main language of communication is not English. In such cases, communication breakdown is likely to occur, prompting the intervention of a mediator. The mediator could either be a professionally trained interpreter or an interpreter with no training. This paper seeks to make a comparison between a cultural specific trained interpreter and a phone translator with no specialized training. 

A number of factors affect effective communication with patients. Factors that influence how providers interact with patients include face-saving, time, non-verbal communication, whether the communication is face to face or technology-mediated, and how it employs the aid of an interpreter. A huge percentage of communication occurs non-verbally, influenced by factors such as the tone of voice that an individual uses or body language (Capell, 2007, pg. 187). On the other hand, time requirement is a barrier to interpreter use, and clinicians occasionally feel it uses up time for other patients (Seers et al., 2013, pg.134). Individuals might also to want to be liked, avoid conflict, or minimize embarrassment in communication (Capell, 2007, pg. 189). Most importantly, nonetheless, the use of an interpreter in communication is meant to aid in addressing the cultural and linguistic barriers faced. 

Background 

Description of the Condition 

Effective communication entails the ability to pass across information accurately. In medical care, effective communication is especially important for the medical care provider in dealing with patients. Effective communication will enable the provider to get accurate data from the patient for effective diagnoses. For instance, the more comfortable the patient is in conversing, the more likely they will disclose all details pertaining to their individual conditions. On the other hand, the provider who is attentive to details will most likely pick up these among other non-verbal cues. Further effective communication in care will enable accuracy in treatments and results (Karliner et al., 2007, pg.727). The patient is able to get and adhere to prescriptions accurately. For the advanced practice nurse, this condition is especially important. Advanced practice nursing specialty roles include the provision of care through diagnosis and treatment. Thus, the APN and other providers need to be well conversant with effective communication procedures. Nonetheless, barriers are often encountered especially when dealing with patients from diverse backgrounds whose main language of communication is not English. In such cases, communication breakdown is likely to occur, prompting the intervention of a mediator. 

Description of the Intervention 

Intervention, in this case, involves using a mediator, who plays the role of interpreter to enable communication between the care provider and the patient. In most cases, a translator is necessary for this role, often picked from among immediate friends, family members, or even culturally diverse staff members. It has, however, been indicated that barriers may occur in such cases especially due to the lack of training. Translators, in this case, may be incapable of communicating health terminology as expected by the care provider, for instance. Moreover, certain cultural affiliations may hinder the translator from translating certain words. The patient, additionally, may not be comfortable enough to share certain private information, especially when the translator is a family member (Bauer & Alegría, 2010, pg.770). A trained interpreter, thus, plays a significant role in this case. 

How the Intervention Might Work 

The trained interpreter is capable of handling culturally and linguistically diverse circumstances due to the level of preparation. The intervention, thus, works, by addressing limitations faced with the lack of an interpreter. Such include the inability of the provider to accurately communicate health terminology to the patient or of the patient to communicate important details related to their specific condition. The trained interpreter is keen on non-verbal and verbal communication, especially as related to culture-specific situations. For instance, the trained interpreter may note the importance of time management based on the initial accuracy of the information provided by the patient. Notably, patients who value personal time are more likely to be more straight-forward in highlighting characteristics essential to their diagnosis than those who do not. (Capell, 2007, pg. 188). The trained interpreter, thus, is more accurate than using an untrained family member. 

Why Is It Important To Do This Review? 

A comparison of the effectiveness of a trained interpreter compared to a non-trained phone translator is important for a variety of reasons. First, in this case, a phone translator refers to a telephone mediated option for translation that is either computer-aided or enables one to be connected to a human translator. Thus, the translation, in this case, is offered from the context of the lack of training in the ability to deal with the specific culture and health factors associated with medical care cases. A comparison is thus important in order to establish which would be a more appropriate option in particular circumstances for Limited English Proficiency or culturally limited patients. Further use includes the ability to minimize negative results in health outcomes often associated with the ineffectiveness in communication. 

Objectives 

To determine the most effective communication option between trained interpreters and non-trained translators for medical care providers and Limited English Proficiency or culturally limited patients. 

To minimize negative health outcomes associated with ineffective communication between patients and care providers. 

To improve the quality of care for patients with Limited English Proficiency or other communicative cultural barriers. 

PICOT Question 

Does the Advanced Practice Nurse or medical provider seeking effective communication with patients have a better chance at improved communication and care when the nurse or medical provider is assisted by a cultural specific trained interpreter versus a phone translator with no specialized training? 

Population - Advanced Practice Nurses/Medical care providers caring for patients with Limited English Proficiency (LEP) or cultural limitations. 

Intervention - The cultural specific trained interpreter’s role in establishing effective communication between patients and care providers. 

Comparison - The phone translator with no specialized training whose only role is to re-word concepts to English. 

Outcome - When the cultural specific trained interpreter is involved in establishing effective communication between the patients and the care providers, effective communication and better health-care results are realized. 

Time -Pre and post-care including up-to six months full patient recovery period. 

Methods 

Data Collection 

Data Sources. For the data sources, the researcher performed a systematic search in English for publications not older than the year 2000. Searches were conducted in the Cochrane Library, along with PsycINFO, CINAHL, EBSCO, and PubMed. Particularly, in conducting searches on the Cochrane Library, the researcher focused on evidence-based healthcare concepts, especially as provided by the Cochrane Collaboration Fundamentals of Care. The approach enabled a focus on reviews of published literature that use a Meta-Narrative method and concentrate on the basis upon which nursing care is delivered. Further research for articles was also conducted on the World Wide Web, using keywords like Limited English Proficiency, health disparities, language barriers, physician-patient communication, and quality care. The searches produced over 900 results. 

Inclusion/Exclusion. Of the over 900 results, the researcher included all peer-reviewed articles published in the English language, as well as those containing relevant data on effective communication practices between care providers and patients in culturally-diverse circumstances. Articles that made comparisons between interpreters and translators were also included focusing on satisfaction levels among patients, clinical results, success in communication, and use of clinical care approaches. Nonetheless, certain articles were excluded, especially those whose abstracts showed less focus on communication between patients and providers affected by cultural barriers and/or use of interpreters and translators in such cases. Additionally, articles that solely focused on special cases such as sign language were excluded, along with those that did not refer to primary data. The final selection of articles was based on the types of studies, participants, interventions, and outcomes. A mixture of experimental/non-experimental reports, qualitative/quantitative studies, and systematic reviews were included. 

Data Extraction 

The researcher proceeded by assigning non-random samples into groups for review. At this stage, the researcher sought to exclude thesis papers and dissertations from the samples, along with any other articles that did not meet the exclusion criteria yet were previously overlooked. Articles were also further narrowed down based on publication dates, and more recent articles were preferred. The articles were abstracted with a focus on primary and secondary data, number and types of participants, geographical settings, study settings, types of interpreters used in the studies and descriptions of their training, study designs, included languages, comparison groups, main findings, and statistical analyses. The abstraction and consequent tallying would allow for the eventual determination of the qualities of each of the studies used. For purposes of the research, moreover, the term translator was broadly used to refer to any party present to facilitate oral language communication between the patient and the medical care provider. On the other hand, interpreter or trained interpreter was used to refer to one who had been paid and professionally trained to facilitate communication between the two parties. To minimize bias, selected studies were further critically evaluated by the researcher with the help of a mentor. Discrepancies in methods used and samples selected were discussed before selected articles could be included. References were, at this stage, carefully scrutinized for relevance, and those with references considered ineligible were excluded. Finally, the outcomes of the studies were analyzed for bias, and articles with evidence of exaggeration were excluded. Selected articles had large samples, defined the groups being studied by their language/cultural proficiency and the need for interpreters, and employed a systematic approach to the identification of issues. 

Data Management 

As required, ten reports were collected in total. The articles were reviewed and analyzed for important information. A review of level of evidence was further summarized in a table. 

Results 

Description of Studies 

Of the ten selected studies, only one directly compared professionally trained interpreters to non-trained interpreters. 9 explored factors that determine need for and use of interpreters. 

Results of the Search 

Key-words (2000-2018	Cochrane Library	PsycINFO	CINAHL	EBSCO	PubMed
Limited English Proficiency	34	118	200	2000	400
Health disparities	12	110	110	900	400
Language barriers	10	90	104	400	220
Physician-patient communication	14	100	156	400	340
Quality care	50	120	430	22000	1000

The interventions applied in the selected studies were appraised for evidence through the application of Melnyk and Fineout-Overholt rating of evidence along with the Cochrane Collaboration fundamentals of evidence-based healthcare concepts. 

Included Studies (Attached) 

Grading of Evidence 

Level of Evidence	Number of Articles/ Results
1- Systematic review & meta-analysis of randomized controlled trials	0
2-RCT	1
3-Controlled Trial	1
4-Cohort Study	5
5- Systematic review of descriptive & qualitative studies	2
6- Single descriptive or qualitative study	0
7- Expert opinion	1

Discussion 

Effective communication with patients is essential for the improvement of care. However, studies pooled in this research reveal challenges especially in regards to culture-specific and minority language communication. Additionally, the review process shows methods for improving communication. Below are the categories of main results, including recommendations for improving effectiveness in communication between the patient and the medical care provider. 

Summary of Main Results 

Non-Verbal Communication . Research from various sources indicated that a number of factors affect effective communication with patients. Jen Capell (2007), particularly, explored some these factors. For instance, she highlights non-verbal communication and the differences in interpretation across cultures as a factor that may affect interaction with patients. Patients, in this case, tend to be freer in disclosing information about their health when non-verbal cues associated with good communication are used compared to the contrary. Notably, a huge percentage of communication occurs non-verbally, influenced by factors such as the tone of voice that an individual uses or body language (Capell, 2007, pg. 187). Still, the cultural background associated with an individual affects how these cues are used and interpreted (Rosenberg et al., 2007, pg.287). A high-context culture individual, for instance, tends to read more into nonverbal cues. Thus, if an advanced practice nurse from a low-context culture uses cues suggesting disinterest, a patient from a high-context culture will respond accordingly, often withholding relevant information and treatment, or expressing general dissatisfaction with the mode of care advanced to them. In one particular research, nurses expressed concern with this form of disengagement, noting that when interpreters appear unconcerned, it rubs off on the patients and their families (Nailon, 2006, pg. 125). Thus, non-verbal communication becomes a crucial factor for interpreters to be more conversant in. 

Time. Other than the above, research showed that time and the differences across cultures affect communication with patients. People from individualistic backgrounds, for instance, highly value scheduling and private time, approaching the concept of time from an ownership perspective. As a result, they often appreciate it when schedules are honoured, and they are not kept waiting for long before being attended to (Capell, 2007, pg. 188). Thus, they are quicker at giving details of their visit, disclosing important information to the care provider about their condition. To the contrary, patients from a collectivist background view time differently, often with the perspective that time should be shared, and that establishing proper rapport is essential before the main issue can be discussed. Such patients may often take longer before revealing all the important details of their condition, and care-providers need to be more patient with them. Three studies revealed that time has a significant influence on interpreter utilization in medical set-ups. Additional time requirement is a barrier to interpreter use, and clinicians occasionally felt it used up time for other patients (Seers et al., 2013, pg.134). 

Face-Saving. Face-saving is also another important barrier in communication across cultures identified from the various articles explored. The concept refers to the tendency of individuals to want to be liked, avoid conflict, or minimize embarrassment (Capell, 2007, pg. 189). In this case, a patient or care-provider form a collectivist background will be more careful about hurting others, often avoiding making comments that will embarrass the other. In a situation where only one party, thus, values face-saving, conflict is likely to occur, negatively impacting care given to patients. Inflation of adherence to an exercise program, for example, may be a response to ‘save face’ for fear of offending a nurse. Unfortunately, such situations further affect the use of interpreters in medical setups. Seers et al. (2013) note that certain participants in the research would feel their patients would get offended if the services of an interpreter were sought. 

Face-to-Face Communication. Face to face communication is affected by cultural and personal communication styles discussed above. Some articles showed that care providers need to determine when communication is necessary and the best ways to approach this in spite of the dissimilarities that may exist in personal and cultural approaches to communication between the care provider and the patient. 

Mediated Communication. Mediated communication refers to that which occurs other than face to face, often with the help of assistive technologies. Such communication is limited in communication across cultures considering the main language in which they are written that are unfavourable to non-English speaking communities (Capell, 2007, pg. 190). The articles revealed that while certain print media like pamphlets are becoming increasingly common, most are directly translated from English, paying less attention to culture-specific needs. Other than this, it is widely assumed that with the advent in technological advancement, most patients can be accessed through the internet. This, however, is not always the case, especially for minority groups. 

Interpreters or Translators. Results showed that limited English proficiency significantly contributes to poor health results. Particularly, language barriers largely affect LEP patients in seeking medical attention. The patients have less access to care and limited visits by physicians. Moreover, higher cases of poor adherence to treatment are reported among LEP patients, along with “follow-up for chronic illnesses, decreased comprehension of their diagnoses and treatment after emergency department (ED) visits, decreased satisfaction with care, and increased medication complications (Karliner et al., 2007, pg.728).” Further, reviews indicated differences between interpreters and translators, with the latter involving mere substitution and the former entailing rewording of concepts to a different language. Moreover, the articles showed that in many cases, family members are used as interpreters, however with limitations including lack of training and inappropriateness of certain topics (Bauer & Alegría, 2010, pg.770). One article highlighted that the Ministry of Health highly advises against using children as interpreters for this reason (Capell, 2007, pg. 190). Qualitative studies further showed that in certain cases, interpreters modified information transmitted in an attempt to make it culturally-appropriate, which may, in fact, be detrimental to health provision (Capell, 2007, pg. 190). 

Overall Completeness and Applicability of Evidence 

Overall, the selected articles are all complete and effective in their applicability of evidence. Each of the articles entails varied qualitative and quantitative approaches in the collection of data. In some of the studies, interviews were used to collect qualitative data while others involved a more systematic review of relevant literature and others used questionnaires. For instance, Roberts et al. (2007) use questionnaires among a sample of 3358 professionals to establish the nature and extent of language awareness among culturally diverse populations. Karliner et al. (2007) on the other hand, review articles to determine the impact of trained interpreters on treating patients with limited proficiency in English. Others entailed the collection of statistics/data from selected samples. Eventually, each of these is accurately applied to the conclusions made. Karliner et al. (2007), for instance, concludes that professional interpretation is associated with improved clinical care. 

Quality of the Evidence 

From the above, it was noted that selected articles had large samples, defined the groups being studied by their language/cultural proficiency and the need for interpreters, and employed a systematic approach to identification of issues. Thus, the used evidence was determined to be of high quality further considering the extraction and inclusion methods employed in their selection. 

Potential Biases in the Review Process 

Potential biases in the review process include the limitation of research to an English cultural-strong sample. Notably, challenges experienced in communication in a hospital with English as the main language of communication may not be the same experienced in an environment that is local-language oriented. Other biases may include the small sample of articles selected from the vast variety available that may not be effectively representative of the sample. Experience of researchers may also lead to additional biases not directly noticed. 

Strengths and Weaknesses 

Time constraints could not have allowed a wider variety of articles to be considered. Moreover, there was limited research specifically focused on advanced practice nurses and communication thus the general focus on medical care providers. Also, limited research made this comparison to phone translators, to which non-trained interpreters, in general, did however apply. Still, articles were of high quality. Particularly, qualitative studies adhered to internal validity, objectivity, external validity, and reliability as advanced by Lincoln and Guba’s Framework of Quality Criteria. 

Lessons Learned 

A number of factors affect effective communication with patients. Non-verbal communication and the differences in interpretation across cultures affects interaction in that patients tend to be freer in disclosing information about their health when non-verbal cues associated with good communication are used among other cases. Time requirement is a barrier to interpreter use and face-saving affects the use of interpreters in that participants in the research would feel their patients would get offended if the services of an interpreter were sought. Face to face communication is affected by cultural and personal communication styles and technologically-mediated communication can be biased towards English-speaking communities. Language barriers largely affect LEP patients in seeking medical attention as they have less access to care and limited visits by physicians along with poor adherence to treatment. Family members are sometimes used as interpreters with limitations including lack of training and inappropriateness of certain topics. In certain cases, interpreters modified information transmitted in an attempt to make it culturally-appropriate, which may be detrimental to health provision 

Next Steps/ Recommendations 

Most of the results showed the benefit of using interpreters other than relying on gestures or family members. Further, some articles suggested the benefits of employing the use of trained interpreters. Notably, trained interpreters are taught medical terminology, memory, and concentration, and tend to generally edit messages more appropriately, eliminating some challenges previously highlighted (Capell, 2007, pg. 190). One particular study sought to determine whether professional medical interpreters positively impact clinical care for patients with limited English proficiency using a peer-review approach. The study revealed that using professional interpreters is in most cases related to improved clinical care for patients with limited proficiency in English (Karliner et al., 2007, pg.727). Another article suggested language awareness training, a crucial element for trained interpreters (Roberts et al., 2007, pg.1177). One specific research further particularly indicated that ‘The use of hospital-trained interpreters has been associated with higher patient satisfaction when compared with the use of ad hoc or telephone interpretation (Nailon, 2006, pg.120).” Trained interpreters, thus, may be the solution to vast challenges faced in communication between patients and advanced practice nurses. One significant challenge of this, however, highlighted in up to 4 of the articles, is the high cost of trained professionals. 

Estrada and Meissas (2017) suggest the need for further extensive research on healthcare encounters involving mediation by an interpreter. Particularly, they propose that focus be placed on health literacy and particular language mechanisms and how these affect disparities in health outcomes. Moreover, they emphasize on the need for practitioners to be well prepared to handle patients with limited proficiency in English (Estrada & Messias, 2017, pg.504). Similarly, Hsieh et al. (2013) propose that providers be aware of the vast roles and perceptions of interpreters, determining the best means to work with them for the most preferable outcomes. Overall, thus, this research recognizes the essential role of a trained translator compared to a phone translator with no specialized training. Further, it seeks to not only encourage the application of trained interpreters in practice (particularly for the advanced practice nurse/care provider) but also provide for an understanding of the many factors that influence/hamper the interpreter’s role and strategies to deal with them (including a recommendation for further studies). 

Conclusion 

Effective communication entails the ability to pass across information accurately. Factors that influence how providers interact with patients include face-saving, time, non-verbal communication, whether the communication is face to face or technology-mediated, and how it employs the aid of an interpreter. Limited English proficiency significantly contributes to poor health results. Language barriers largely affect Limited English Proficiency patients in seeking medical attention. Using professional interpreters is in most cases related to improved clinical care for patients with limited proficiency in English. There is a need for further extensive research on healthcare encounters involving mediation by an interpreter. Providers should be aware of the vast roles and perceptions of interpreters, determining the best means to work with them for the most preferable outcomes. For practice, this research has vast implications. For the advanced practice nurse, for instance, it is established that using a trained interpreter is more effective than the researched alternative. Consequently, training for interpreters is encouraged as well as the need for providers to understand their vast roles. For research, implications entail the need to further analyze these roles and consequent results, particularly in the context of vast other culturally diverse groups apart from English-speaking communities. 

References 

Bauer, A. M., & Alegría, M. (2010). Impact of patient language proficiency and interpreter 

service use on the quality of psychiatric care: a systematic review.  Psychiatric Services ,  61 (8), 765-773. 

Capell, J. (2007). Communicating with Your Clients: Are You as “Culturally Sensitive” as You 

Think?.  Physiotherapy Canada ,  59 (3), 184-193. 

Estrada, R. D., & Messias, D. K. H. (2017). Language Co-Construction and Collaboration in 

Interpreter-Mediated Primary Care Encounters With Hispanic Adults.  Journal of Transcultural Nursing , 1043659617747523. 

Hsieh, E., Pitaloka, D., & Johnson, A. J. (2013). Bilingual health communication: distinctive 

needs of providers from five specialties.  Health communication ,  28 (6), 557-567. 

Karliner, L. S., Jacobs, E. A., Chen, A. H., & Mutha, S. (2007). Do professional interpreters 

improve clinical care for patients with limited English proficiency? A systematic review of the literature.  Health services research ,  42 (2), 727-754. 

Luan Erfe, B. M., Siddiqui, K. A., Schwamm, L. H., Kirwan, C., Nunes, A., & Mejia, N. I. 

(2017). Professional medical interpreters influence the quality of acute ischemic stroke care for patients who speak languages other than English.  Journal of the American Heart Association ,  6 (9), e006175. 

Nailon, R. E. (2006). Nurses’ concerns and practices with using interpreters in the care of Latino 

patients in the emergency department.  Journal of transcultural nursing ,  17 (2), 119-128. 

Roberts, G. W., Irvine, F. E., Jones, P. R., Spencer, L. H., Baker, C. R., & Williams, C. (2007). 

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Rosenberg, E., Leanza, Y., & Seller, R. (2007). Doctor–patient communication in primary care 

with an interpreter: physician perceptions of professional and family interpreters.  Patient Education and Counseling ,  67 (3), 286-292. 

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Tables and Figures 

Title	Method	Outcomes
Impact of patient language proficiency and interpreter  service use on the quality of psychiatric care: a systematic review.	Systematic review	“ Evaluation in a patient's non-primary language can lead to incomplete or distorted mental status assessment (Bauer Alegría, 2010).”
Communicating with Your Clients: Are You as “Culturally Sensitive” as You  Think?	Expert opinion	Various factors affect cultural interaction and intercultural communication
Language Co-Construction and Collaboration in  Interpreter-Mediated Primary Care Encounters With Hispanic Adults.	Situational Analysis	Interpreter mediated communication is situation within various systems
Bilingual health communication: distinctive  needs of providers from five specialties.	Interviews	Providers differ in expectations on interpreters’ abilities
Do professional interpreters  improve clinical care for patients with limited English proficiency? A systematic review of the literature.	Systematic review of literature	Use of professional interpreters is associated with improved clinical care
Nurses’ concerns and practices with using interpreters in the care of Latino  patients in the emergency department.	Interviews	Care providers have minimal lingual ability in local area language
Language awareness in the bilingual healthcare setting: a national survey.	Questionnaires	Positive relation between providers’ use of language in practice and language proficiency
Is it time to talk? Interpreter  services use in general practice within Canterbury.	Mixed methods study	Barriers to interpreter service include expectations