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New Zealand (NZ) has an increasingly diverse population, and health services now deal with significant numbers of Limited English Proficiency (LEP) patients. The international literature shows that identifiable misunderstandings occur far more frequently in consultations with LEP patients1, and that failure to use a professional interpreter leads to increased risk of adverse outcome.2,3Language barriers have been found to increase risks to patient safety4,5 and affect clinicians ability to understand symptoms and treat disease.6 Despite these risks, interpreters are often not used for complex reasons that go beyond time constraints and lack of interpreter availability, with doctors often preferring to get by without an interpreter even when interpreters are readily available.7 In many cases, family members are relied upon for interpreting.7-13The small amount of NZ research in this field has shown that bilingual medical students are on occasion asked to interpret for patients in hospitals, sometimes resulting in unsafe practice,14 and that there are difficulties in communication with LEP patients for general practitioners in Auckland.10,15,16There is no evidence available on how frequently communication is a problem for LEP patients in NZ hospitals.District Health Boards (DHBs) in areas with large immigrant populations now have policies that interpreters be used for LEP patients17-19. For example, Capital & Coast DHBs policy states that an interpreter is required when chealth professionals assess that an interpreter is necessary to ensure safe and adequate assessment, planning, and intervention of care and treatment, e.g. to obtain informed consentd, outlines the risks of using untrained interpreters, gives guidance on how to assess the need for an interpreter and how to use one, and states who should bear the cost.Interpreting services are still not fully developed in NZ, and there is no NZ accreditation system for interpreters. Telephone interpreters are now readily available, since the establishment in 2003 of cLanguage Lined which provides affordable, accessible telephone interpreting services.In most circumstances they are able to provide an interpreter at the time of the request in many languages, often utilising interpreters in Australia. However, uptake is only slowly increasing, and the service is only available from 9am to 6pm Monday to Friday and 9am to 2pm on Saturdays.While the literature on use of interpreters in medical care has frequently explored patient and/or clinician satisfaction, effects on quality of care, and patterns of use, we have found none that specifically explores clinicians perceptions of the increased clinical risk when interpreters are not used. The aim of this study is to explore clinicians perceptions of the communication difficulties experienced with LEP patients and the clinical risks these difficulties pose in hospitals in the Wellington area. It also explores patterns of interpreter use among these clinicians.Methods The study was conducted in two phases, the first a survey of senior health professionals in the two District Health Boards in the Wellington Area, and the second a questionnaire targeted to a small number of clinicians as they actually encountered LEP patients. Approval to conduct this study was granted by the Central Regional Ethics Committee. Phase 1In Phase 1 of the study, an e-mail asking respondents to complete a survey online was sent to all clinicians who consulted independently in Wellington, Kenepuru and Hutt Hospitalsthis included senior doctors, registrars, dentists, physiotherapists, occupational therapists, social workers and nurses in Capital & Coast District Health Board (CCDHB) and Hutt Valley District Health Board (HVDHB). We excluded house surgeons and ward nurses but included district nurses and specialist nurses (diabetes, respiratory etc). In addition, paper copies of the survey were also distributed in the Emergency Department of Wellington Hospital, and the survey link may have been forwarded by some respondents to colleagues. In total the survey was distributed to around 900 health professionals. A list of survey questions is provided in Appendix 1. In addition to demographic questions, the survey asked clinicians questions about: What languages they speak, How often they see LEP patients, How often they use interpreters (professional or otherwise) with LEP patients, Their awareness of DHB policy on interpreters and knowledge of how to access them, and Whether they felt that communication difficulties significantly affected their care of LEP patients. Within the survey, an LEP patient was defined as ca person for whom English is not their first language AND whose level of English limits the extent of communication in the consultation. This group includes 1) Speakers with very little English, such that consultation is not possible without an interpreter OR 2) Speakers with some English but insufficient English to conduct a comprehensive consultation.d Data were exported from the online survey to Microsoft Excel/Access software for data cleaning (e.g. removing duplicate responses) and further organisation (e.g. calculating number of languages spoken by each respondent.) Descriptive statistics were calculated using Microsoft Excel software; 95% confidence intervals and formal statistical tests were calculated using R (R 2.9.1, R Foundation, Austria). Phase 2Phase 2 of the study investigated the actual communication between a small number of LEP patients and clinicians in patient consultations, and an equal number of English proficient patient consultations. This phase was conducted predominantly in the Emergency Department (ED) of Wellington Hospital where there was clinician support for the research. Some interviews were also conducted at the ED Short Stay Unit, a medical ward where patients were transferred from ED, the Medical Assessment and Prioritisation Unit, the Outpatient Department, the Pacific Congestive Heart Failure Unit, and the Neonatal Unit. When a patient presented who was registered as born outside NZ, a research nurse spoke with the clinician to determine if there had been any language difficulty. When language difficulty was identified, the nurse interviewed the clinician at a convenient time and noted their answers to a questionnaire (see Appendix 2). To provide a comparison group, the clinician was interviewed regarding consultation with the next English proficient patient after this LEP patient. Questions covered whether this was a first consultation with the patient, the complexity of the consultation, any communication difficulties, whether there was extra clinical risk as a result of these, as well as the clinicians assessment of the patients English-speaking ability and details of any interpreter usage. The research nurse also noted any additional comments that the clinician made about communication with LEP patients in general. The same list of questions was used for the LEP patients and the comparison group patients. Data analysisDescriptive statistics were mostly used to summarise clinicians responses. For categorical data regarding knowledge and use of interpreters, 95% confidence intervals are reported in the text. Ordinal data on frequency of interpreter use and frequency of communication problems were analysed using non-parametric tests, as noted in the results section - non-parametric equivalents of the t-test/ANOVA for comparing answers between groups (Wilcoxon Signed Ranks Test, Mann-Whitney test, Kruskal-Wallis test), and non-parametric versions of correlations (Spearmans rank correlation coefficient) when asking whether scores on one ordinal variable were associated with higher scores on another ordinal variable. McNemars Chi-squared statistic was used to ask whether knowledge of DHB policy was independent of practical knowledge on how to access interpreters. Results Phase 1 A total of 141 responses were received, which was a 15.6% return rate. Not all survey responses contained answers to all questions. Demographic characteristicsMost of the respondents (85%) were of European (64% NZ European) ethnicity (calculated using prioritised ethnicity20), with the remainder split between Asian (5.7%), M\u0101ori (3.5%), Pacific (2.8%) and Other (2.1%). They were predominantly female (64%). In terms of positions held, the largest group of respondents were Senior Medical Officers (38%), with significant numbers of registrars (24%) and nurses (21%). Senior House Officers made up 5% and Others (12%) included 6 occupational therapists, 5 social workers, 4 senior dentists, a hand therapist and a midwife. The level of experience of the respondents ranged from 1 year to 42 years, with a median of 15.5 years. Language background of respondentsMost respondents (72%) were monolingual English speakers, but more than a quarter (28%) were bi- or multilingual. NZ Europeans had a lower level of bi- or multi-linguality compared to other ethnicities, as shown in Table 1. Table 1. Number of languages spoken by respondents, by ethnicity (Phase 1) Prioritised ethnicity Number of languages spoken Percentage who speak more than 1 language 1 2 or more NZ European European M\u0101ori Pacific Asian Other 79 16 3 2 2 0 10 16 2 2 6 3 11.2% 50.0% 40.0% 50.0% 75.0% 100.0% Total 102 39 27.7% The most commonly spoken additional languages were European languages, as shown in Table 2. Table 2. Languages spoken by respondents (Phase 1) Languages spoken in addition to English Number of respondents % of total respondents European languages Eastern Asia languages African languages Central Asian languages Pacific languages (including M\u0101ori) Middle Eastern languages NZ Sign Language 34 9 7 4 4 2 1 23.9% 6.3% 4.9% 2.8% 2.8% 1.4% 0.7% Respondents interaction with LEP patients and interpretersAbout a third of respondents (32.17%) reported seeing no LEP patients on a regular basis, and almost another third saw one to two patients per week, as shown in Figure 1. About 35% saw three to seven LEP patients per week. The survey asked two questions about interpreter use: cWhen you see a patient with Limited English Proficiency (LEP) do you use an interpreter?d and cDo you use a professional interpreter (paid by the DHB)?d, with responses on a five point scale ranging from never to always. Results are shown in Table 3 (note that the column headings reflect the fact that only 3 of the 5 points on the scale were labelled in the questionnaire). Figure 1. Number of Limited English Proficiency (LEP) patients seen per week Table 3. Frequency of interpreter use (Phase 1) Variables Never About half Always No response Interpreter use 7 (5%) 29 (21%) 40 (29%) 41 (30%) 19 (14%) 7 Professional Interpreter use 17 (13%) 37 (27%) 34 (25%) 27 (20%) 20 (15%) 8 Although few respondents reported never using any form of interpreter, there is wide variation in the frequency of interpreter use among those who do. A slightly higher proportion reported never usingprofessional interpreters with again a wide variation of frequency of use. More respondents reported knowing how to access an interpreter if they needed one (84%; CI=77-89%) than reported awareness of their DHBs policy on interpreters (65%; CI=56-72%). Twenty-five percent lacked awareness of both the policy and of how to access professional interpreters (CI=18-33%), while 60% knew both the policy and how to access professional interpreters (CI=50-67%). Answers to these two questions appeared to group together (85% of all respondents answered yes to both or no to both) and there was no tendency for respondents to either know the DHB policy but not how to access interpreters, or vice versa (McNemar Chi-squared=0.273, p=0.602). Most respondents felt that communication difficulties with LEP patients have a significant effect on care at least some of the time, with 49% feeling that difficulties occurred more than half the time (see Table 4). Table 4: Perceived frequency of significant effect of communication difficulties on care of LEP patients (Phase 1) Never About half Always No response Frequency (percentage) 4 (3%) 37 (27%) 28 (21%)

Summary

Abstract

Aim

To explore clinicians perceptions of the communication difficulties experienced with Limited English Proficiency (LEP) patients and the clinical risks these difficulties pose in hospitals, as well as patterns of interpreter use among these clinicians.

Method

Senior health professionals in the two District Health Boards (DHBs) in the Wellington Area (about 900) of New Zealand were sent an electronic survey. Twenty clinicians were interviewed about their experience in 22 consultations with LEP patients, and an equal number with English proficient patients. Descriptive statistics were calculated, and 95% confidence intervals and formal statistical tests.

Results

141 responses were received to the survey. There was a high level of awareness of how to access interpreters (84%) and lesser awareness of DHB interpreter policy (65%). Most respondents felt that communication difficulties with LEP patients have a significant effect on care at least sometimes, but there is a wide variation in reported actual use of interpreters, with only 14% always using an interpreter. In the actual consultations studied, no professional interpreters were used despite clinician acknowledgement of increased clinical risk.

Conclusion

Even when clinicians are aware of policy, of how to obtain interpreters, and of the increased clinical risk in the situation, this does not necessarily lead to high levels of interpreter use with LEP patients.

Author Information

Ben Gray, Senior Lecturer, Department of Primary Health Care and General Practice, Otago University Wellington School of Medicine and Health Sciences, Wellington; James Stanley, Research Fellow (Biostatistician), Deans Department, Otago University Wellington School of Medicine and Health Sciences, Wellington; Maria Stubbe, Senior Lecturer/Senior Research Fellow, Department of Primary Health Care and General Practice, Otago University Wellington School of Medicine and Health Sciences, Wellington; Jo Hilder, Research Fellow, Department of Primary Health Care and General Practice, Otago University Wellington School of Medicine and Health Sciences, Wellington

Acknowledgements

The authors wish to thank Nita Hill for conducting the interviews in Phase 2, and the clinicians who participated in this research.

Correspondence

Dr Ben Gray FRNZCGP, Senior Lecturer, Department of Primary Health Care and General Practice, Otago University Wellington School of Medicine and Health Sciences, PO Box 7343, Wellington South, New Zealand. Fax: +64 (0)4 3855539

Correspondence Email

ben.gray@otago.ac.nz

Competing Interests

None.

Roberts C, Moss B, Wass V, et al. Misunderstandings: a qualitative study of primary care consultations in multilingual settings, and educational implications.[see comment]. Medical Education. 2005;39(5):465-75.Flores G. The impact of medical interpreter services on the quality of health care: a systematic review. Med Care Res Rev. 2005;62(3):255-99.Karliner LS, Jacobs EA, Chen AH, Mutha S. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res. 2007;42(2):727-54.Divi C, Koss R, Schmaltz S, Loeb J. Language proficiency and adverse events in US hospitals: a pilot study. International Journal for Quality in Health Care. 2007.Cohen AL, Rivara F, Marcuse EK, et al. Are language barriers associated with serious medical events in hospitalized pediatric patients? Pediatrics. 2005;116(3):575-9.Karliner LS, Perez-Stable EJ, Gildengorin G. The language divide: The importance of training in the use of interpreters for outpatient practice. J Gen Intern Med. 2004;19(2):175-83.Diamond LC, Schenker Y, Curry L, Bradley EH, Fernandez A. Getting by: underuse of interpreters by resident physicians. J Gen Intern Med. 2009;24(2):256-62.Atkin N. Getting the message across-professional interpreters in general practice. Aust Fam Physician. 2008;37(3):174-6.Auckland Area Health Board. Report of the Working Party on Interpreting Services, Cartwright Implementation Taskforce, Editor. Auckland Area Health Board: Auckland; 1990.Chan I, Lloyd T, Tong K. The use of interpreters by South Auckland GPs. New Zeal Fam Physician. 1999;26(4).Garrett PW, Forero R, Dickson HG, et al. How are language barriers bridged in acute hospital care? The tale of two methods of data collection. Aust Health Rev. 2008;32(4):755-64.Gerrish K. The nature and effect of communication difficulties arising from interactions between district nurses and South Asian patients and their carers. J Adv Nurs. 2001;33(5):566-574.Kuo DZ, O'Connor KG, Flores G, Minkovitz CS. Pediatricians' use of language services for families with limited English proficiency. Pediatrics. 2007;119(4):e920-7.Yang C-F, Gray B. Bilingual medical students as interpreters--what are the benefits and risks? NZ Med J. 2008;121(1282):15-28.Wearn A, Goodyear-Smith F, Everts H et al. Frequency and effects of non-English consultations in New Zealand general practice. NZ Med J. 2007;120(1264):U2771.Gray B. English language difficulties at general practices in Auckland, New Zealand: a major limitation to good practice. NZ Med J. 2007;120(1264).Auckland District Health Board. The Interpreter Service. www.adhb.govt.nz/downloads/services/interpreter-manual.pdfCapital & Coast District Health Board. Use of interpreter services (Version No. 3): Wellington, New Zealand; 2010.Camplin-Welch V. Cross-Cultural Resource for Health Practitioners working with Culturally and Linguistically Diverse (CALD) Clients. Waitemata District Health Board and Refugees as Survivors NZ Trust: Auckland, New Zealand; 2007.Ministry of Health. Ethnicity Data Protocols for the Health and Disability Sector.http://www.moh.govt.nz/moh.nsf/indexmh/ethnicity-data-protocols-feb1994Gray B, Hilder J, Donaldson H. Why do we not use trained interpreters for all patients with limited English proficiency? Is there a place for using family members? Australian Journal of Primary Health. 2011;17 (3): 240-249.Statistics New Zealand. Quick Stats about Culture and Identity (2006 Census Data).http://stats.co.nz/Census/2006CensusHomePage/QuickStats/quickstats-about-a-subject/culture-and-identity/languages-spoken.aspxStandiford CJ, Nolan E, Harris M et al. Improving the provision of language services at an academic medical center: ensuring high-quality health communication for limited-English-proficient patients. Academic Medicine. 2009;84(12):1693-7.

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New Zealand (NZ) has an increasingly diverse population, and health services now deal with significant numbers of Limited English Proficiency (LEP) patients. The international literature shows that identifiable misunderstandings occur far more frequently in consultations with LEP patients1, and that failure to use a professional interpreter leads to increased risk of adverse outcome.2,3Language barriers have been found to increase risks to patient safety4,5 and affect clinicians ability to understand symptoms and treat disease.6 Despite these risks, interpreters are often not used for complex reasons that go beyond time constraints and lack of interpreter availability, with doctors often preferring to get by without an interpreter even when interpreters are readily available.7 In many cases, family members are relied upon for interpreting.7-13The small amount of NZ research in this field has shown that bilingual medical students are on occasion asked to interpret for patients in hospitals, sometimes resulting in unsafe practice,14 and that there are difficulties in communication with LEP patients for general practitioners in Auckland.10,15,16There is no evidence available on how frequently communication is a problem for LEP patients in NZ hospitals.District Health Boards (DHBs) in areas with large immigrant populations now have policies that interpreters be used for LEP patients17-19. For example, Capital & Coast DHBs policy states that an interpreter is required when chealth professionals assess that an interpreter is necessary to ensure safe and adequate assessment, planning, and intervention of care and treatment, e.g. to obtain informed consentd, outlines the risks of using untrained interpreters, gives guidance on how to assess the need for an interpreter and how to use one, and states who should bear the cost.Interpreting services are still not fully developed in NZ, and there is no NZ accreditation system for interpreters. Telephone interpreters are now readily available, since the establishment in 2003 of cLanguage Lined which provides affordable, accessible telephone interpreting services.In most circumstances they are able to provide an interpreter at the time of the request in many languages, often utilising interpreters in Australia. However, uptake is only slowly increasing, and the service is only available from 9am to 6pm Monday to Friday and 9am to 2pm on Saturdays.While the literature on use of interpreters in medical care has frequently explored patient and/or clinician satisfaction, effects on quality of care, and patterns of use, we have found none that specifically explores clinicians perceptions of the increased clinical risk when interpreters are not used. The aim of this study is to explore clinicians perceptions of the communication difficulties experienced with LEP patients and the clinical risks these difficulties pose in hospitals in the Wellington area. It also explores patterns of interpreter use among these clinicians.Methods The study was conducted in two phases, the first a survey of senior health professionals in the two District Health Boards in the Wellington Area, and the second a questionnaire targeted to a small number of clinicians as they actually encountered LEP patients. Approval to conduct this study was granted by the Central Regional Ethics Committee. Phase 1In Phase 1 of the study, an e-mail asking respondents to complete a survey online was sent to all clinicians who consulted independently in Wellington, Kenepuru and Hutt Hospitalsthis included senior doctors, registrars, dentists, physiotherapists, occupational therapists, social workers and nurses in Capital & Coast District Health Board (CCDHB) and Hutt Valley District Health Board (HVDHB). We excluded house surgeons and ward nurses but included district nurses and specialist nurses (diabetes, respiratory etc). In addition, paper copies of the survey were also distributed in the Emergency Department of Wellington Hospital, and the survey link may have been forwarded by some respondents to colleagues. In total the survey was distributed to around 900 health professionals. A list of survey questions is provided in Appendix 1. In addition to demographic questions, the survey asked clinicians questions about: What languages they speak, How often they see LEP patients, How often they use interpreters (professional or otherwise) with LEP patients, Their awareness of DHB policy on interpreters and knowledge of how to access them, and Whether they felt that communication difficulties significantly affected their care of LEP patients. Within the survey, an LEP patient was defined as ca person for whom English is not their first language AND whose level of English limits the extent of communication in the consultation. This group includes 1) Speakers with very little English, such that consultation is not possible without an interpreter OR 2) Speakers with some English but insufficient English to conduct a comprehensive consultation.d Data were exported from the online survey to Microsoft Excel/Access software for data cleaning (e.g. removing duplicate responses) and further organisation (e.g. calculating number of languages spoken by each respondent.) Descriptive statistics were calculated using Microsoft Excel software; 95% confidence intervals and formal statistical tests were calculated using R (R 2.9.1, R Foundation, Austria). Phase 2Phase 2 of the study investigated the actual communication between a small number of LEP patients and clinicians in patient consultations, and an equal number of English proficient patient consultations. This phase was conducted predominantly in the Emergency Department (ED) of Wellington Hospital where there was clinician support for the research. Some interviews were also conducted at the ED Short Stay Unit, a medical ward where patients were transferred from ED, the Medical Assessment and Prioritisation Unit, the Outpatient Department, the Pacific Congestive Heart Failure Unit, and the Neonatal Unit. When a patient presented who was registered as born outside NZ, a research nurse spoke with the clinician to determine if there had been any language difficulty. When language difficulty was identified, the nurse interviewed the clinician at a convenient time and noted their answers to a questionnaire (see Appendix 2). To provide a comparison group, the clinician was interviewed regarding consultation with the next English proficient patient after this LEP patient. Questions covered whether this was a first consultation with the patient, the complexity of the consultation, any communication difficulties, whether there was extra clinical risk as a result of these, as well as the clinicians assessment of the patients English-speaking ability and details of any interpreter usage. The research nurse also noted any additional comments that the clinician made about communication with LEP patients in general. The same list of questions was used for the LEP patients and the comparison group patients. Data analysisDescriptive statistics were mostly used to summarise clinicians responses. For categorical data regarding knowledge and use of interpreters, 95% confidence intervals are reported in the text. Ordinal data on frequency of interpreter use and frequency of communication problems were analysed using non-parametric tests, as noted in the results section - non-parametric equivalents of the t-test/ANOVA for comparing answers between groups (Wilcoxon Signed Ranks Test, Mann-Whitney test, Kruskal-Wallis test), and non-parametric versions of correlations (Spearmans rank correlation coefficient) when asking whether scores on one ordinal variable were associated with higher scores on another ordinal variable. McNemars Chi-squared statistic was used to ask whether knowledge of DHB policy was independent of practical knowledge on how to access interpreters. Results Phase 1 A total of 141 responses were received, which was a 15.6% return rate. Not all survey responses contained answers to all questions. Demographic characteristicsMost of the respondents (85%) were of European (64% NZ European) ethnicity (calculated using prioritised ethnicity20), with the remainder split between Asian (5.7%), M\u0101ori (3.5%), Pacific (2.8%) and Other (2.1%). They were predominantly female (64%). In terms of positions held, the largest group of respondents were Senior Medical Officers (38%), with significant numbers of registrars (24%) and nurses (21%). Senior House Officers made up 5% and Others (12%) included 6 occupational therapists, 5 social workers, 4 senior dentists, a hand therapist and a midwife. The level of experience of the respondents ranged from 1 year to 42 years, with a median of 15.5 years. Language background of respondentsMost respondents (72%) were monolingual English speakers, but more than a quarter (28%) were bi- or multilingual. NZ Europeans had a lower level of bi- or multi-linguality compared to other ethnicities, as shown in Table 1. Table 1. Number of languages spoken by respondents, by ethnicity (Phase 1) Prioritised ethnicity Number of languages spoken Percentage who speak more than 1 language 1 2 or more NZ European European M\u0101ori Pacific Asian Other 79 16 3 2 2 0 10 16 2 2 6 3 11.2% 50.0% 40.0% 50.0% 75.0% 100.0% Total 102 39 27.7% The most commonly spoken additional languages were European languages, as shown in Table 2. Table 2. Languages spoken by respondents (Phase 1) Languages spoken in addition to English Number of respondents % of total respondents European languages Eastern Asia languages African languages Central Asian languages Pacific languages (including M\u0101ori) Middle Eastern languages NZ Sign Language 34 9 7 4 4 2 1 23.9% 6.3% 4.9% 2.8% 2.8% 1.4% 0.7% Respondents interaction with LEP patients and interpretersAbout a third of respondents (32.17%) reported seeing no LEP patients on a regular basis, and almost another third saw one to two patients per week, as shown in Figure 1. About 35% saw three to seven LEP patients per week. The survey asked two questions about interpreter use: cWhen you see a patient with Limited English Proficiency (LEP) do you use an interpreter?d and cDo you use a professional interpreter (paid by the DHB)?d, with responses on a five point scale ranging from never to always. Results are shown in Table 3 (note that the column headings reflect the fact that only 3 of the 5 points on the scale were labelled in the questionnaire). Figure 1. Number of Limited English Proficiency (LEP) patients seen per week Table 3. Frequency of interpreter use (Phase 1) Variables Never About half Always No response Interpreter use 7 (5%) 29 (21%) 40 (29%) 41 (30%) 19 (14%) 7 Professional Interpreter use 17 (13%) 37 (27%) 34 (25%) 27 (20%) 20 (15%) 8 Although few respondents reported never using any form of interpreter, there is wide variation in the frequency of interpreter use among those who do. A slightly higher proportion reported never usingprofessional interpreters with again a wide variation of frequency of use. More respondents reported knowing how to access an interpreter if they needed one (84%; CI=77-89%) than reported awareness of their DHBs policy on interpreters (65%; CI=56-72%). Twenty-five percent lacked awareness of both the policy and of how to access professional interpreters (CI=18-33%), while 60% knew both the policy and how to access professional interpreters (CI=50-67%). Answers to these two questions appeared to group together (85% of all respondents answered yes to both or no to both) and there was no tendency for respondents to either know the DHB policy but not how to access interpreters, or vice versa (McNemar Chi-squared=0.273, p=0.602). Most respondents felt that communication difficulties with LEP patients have a significant effect on care at least some of the time, with 49% feeling that difficulties occurred more than half the time (see Table 4). Table 4: Perceived frequency of significant effect of communication difficulties on care of LEP patients (Phase 1) Never About half Always No response Frequency (percentage) 4 (3%) 37 (27%) 28 (21%)

Summary

Abstract

Aim

To explore clinicians perceptions of the communication difficulties experienced with Limited English Proficiency (LEP) patients and the clinical risks these difficulties pose in hospitals, as well as patterns of interpreter use among these clinicians.

Method

Senior health professionals in the two District Health Boards (DHBs) in the Wellington Area (about 900) of New Zealand were sent an electronic survey. Twenty clinicians were interviewed about their experience in 22 consultations with LEP patients, and an equal number with English proficient patients. Descriptive statistics were calculated, and 95% confidence intervals and formal statistical tests.

Results

141 responses were received to the survey. There was a high level of awareness of how to access interpreters (84%) and lesser awareness of DHB interpreter policy (65%). Most respondents felt that communication difficulties with LEP patients have a significant effect on care at least sometimes, but there is a wide variation in reported actual use of interpreters, with only 14% always using an interpreter. In the actual consultations studied, no professional interpreters were used despite clinician acknowledgement of increased clinical risk.

Conclusion

Even when clinicians are aware of policy, of how to obtain interpreters, and of the increased clinical risk in the situation, this does not necessarily lead to high levels of interpreter use with LEP patients.

Author Information

Ben Gray, Senior Lecturer, Department of Primary Health Care and General Practice, Otago University Wellington School of Medicine and Health Sciences, Wellington; James Stanley, Research Fellow (Biostatistician), Deans Department, Otago University Wellington School of Medicine and Health Sciences, Wellington; Maria Stubbe, Senior Lecturer/Senior Research Fellow, Department of Primary Health Care and General Practice, Otago University Wellington School of Medicine and Health Sciences, Wellington; Jo Hilder, Research Fellow, Department of Primary Health Care and General Practice, Otago University Wellington School of Medicine and Health Sciences, Wellington

Acknowledgements

The authors wish to thank Nita Hill for conducting the interviews in Phase 2, and the clinicians who participated in this research.

Correspondence

Dr Ben Gray FRNZCGP, Senior Lecturer, Department of Primary Health Care and General Practice, Otago University Wellington School of Medicine and Health Sciences, PO Box 7343, Wellington South, New Zealand. Fax: +64 (0)4 3855539

Correspondence Email

ben.gray@otago.ac.nz

Competing Interests

None.

Roberts C, Moss B, Wass V, et al. Misunderstandings: a qualitative study of primary care consultations in multilingual settings, and educational implications.[see comment]. Medical Education. 2005;39(5):465-75.Flores G. The impact of medical interpreter services on the quality of health care: a systematic review. Med Care Res Rev. 2005;62(3):255-99.Karliner LS, Jacobs EA, Chen AH, Mutha S. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res. 2007;42(2):727-54.Divi C, Koss R, Schmaltz S, Loeb J. Language proficiency and adverse events in US hospitals: a pilot study. International Journal for Quality in Health Care. 2007.Cohen AL, Rivara F, Marcuse EK, et al. Are language barriers associated with serious medical events in hospitalized pediatric patients? Pediatrics. 2005;116(3):575-9.Karliner LS, Perez-Stable EJ, Gildengorin G. The language divide: The importance of training in the use of interpreters for outpatient practice. J Gen Intern Med. 2004;19(2):175-83.Diamond LC, Schenker Y, Curry L, Bradley EH, Fernandez A. Getting by: underuse of interpreters by resident physicians. J Gen Intern Med. 2009;24(2):256-62.Atkin N. Getting the message across-professional interpreters in general practice. Aust Fam Physician. 2008;37(3):174-6.Auckland Area Health Board. Report of the Working Party on Interpreting Services, Cartwright Implementation Taskforce, Editor. Auckland Area Health Board: Auckland; 1990.Chan I, Lloyd T, Tong K. The use of interpreters by South Auckland GPs. New Zeal Fam Physician. 1999;26(4).Garrett PW, Forero R, Dickson HG, et al. How are language barriers bridged in acute hospital care? The tale of two methods of data collection. Aust Health Rev. 2008;32(4):755-64.Gerrish K. The nature and effect of communication difficulties arising from interactions between district nurses and South Asian patients and their carers. J Adv Nurs. 2001;33(5):566-574.Kuo DZ, O'Connor KG, Flores G, Minkovitz CS. Pediatricians' use of language services for families with limited English proficiency. Pediatrics. 2007;119(4):e920-7.Yang C-F, Gray B. Bilingual medical students as interpreters--what are the benefits and risks? NZ Med J. 2008;121(1282):15-28.Wearn A, Goodyear-Smith F, Everts H et al. Frequency and effects of non-English consultations in New Zealand general practice. NZ Med J. 2007;120(1264):U2771.Gray B. English language difficulties at general practices in Auckland, New Zealand: a major limitation to good practice. NZ Med J. 2007;120(1264).Auckland District Health Board. The Interpreter Service. www.adhb.govt.nz/downloads/services/interpreter-manual.pdfCapital & Coast District Health Board. Use of interpreter services (Version No. 3): Wellington, New Zealand; 2010.Camplin-Welch V. Cross-Cultural Resource for Health Practitioners working with Culturally and Linguistically Diverse (CALD) Clients. Waitemata District Health Board and Refugees as Survivors NZ Trust: Auckland, New Zealand; 2007.Ministry of Health. Ethnicity Data Protocols for the Health and Disability Sector.http://www.moh.govt.nz/moh.nsf/indexmh/ethnicity-data-protocols-feb1994Gray B, Hilder J, Donaldson H. Why do we not use trained interpreters for all patients with limited English proficiency? Is there a place for using family members? Australian Journal of Primary Health. 2011;17 (3): 240-249.Statistics New Zealand. Quick Stats about Culture and Identity (2006 Census Data).http://stats.co.nz/Census/2006CensusHomePage/QuickStats/quickstats-about-a-subject/culture-and-identity/languages-spoken.aspxStandiford CJ, Nolan E, Harris M et al. Improving the provision of language services at an academic medical center: ensuring high-quality health communication for limited-English-proficient patients. Academic Medicine. 2009;84(12):1693-7.

For the PDF of this article,
contact nzmj@nzma.org.nz

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New Zealand (NZ) has an increasingly diverse population, and health services now deal with significant numbers of Limited English Proficiency (LEP) patients. The international literature shows that identifiable misunderstandings occur far more frequently in consultations with LEP patients1, and that failure to use a professional interpreter leads to increased risk of adverse outcome.2,3Language barriers have been found to increase risks to patient safety4,5 and affect clinicians ability to understand symptoms and treat disease.6 Despite these risks, interpreters are often not used for complex reasons that go beyond time constraints and lack of interpreter availability, with doctors often preferring to get by without an interpreter even when interpreters are readily available.7 In many cases, family members are relied upon for interpreting.7-13The small amount of NZ research in this field has shown that bilingual medical students are on occasion asked to interpret for patients in hospitals, sometimes resulting in unsafe practice,14 and that there are difficulties in communication with LEP patients for general practitioners in Auckland.10,15,16There is no evidence available on how frequently communication is a problem for LEP patients in NZ hospitals.District Health Boards (DHBs) in areas with large immigrant populations now have policies that interpreters be used for LEP patients17-19. For example, Capital & Coast DHBs policy states that an interpreter is required when chealth professionals assess that an interpreter is necessary to ensure safe and adequate assessment, planning, and intervention of care and treatment, e.g. to obtain informed consentd, outlines the risks of using untrained interpreters, gives guidance on how to assess the need for an interpreter and how to use one, and states who should bear the cost.Interpreting services are still not fully developed in NZ, and there is no NZ accreditation system for interpreters. Telephone interpreters are now readily available, since the establishment in 2003 of cLanguage Lined which provides affordable, accessible telephone interpreting services.In most circumstances they are able to provide an interpreter at the time of the request in many languages, often utilising interpreters in Australia. However, uptake is only slowly increasing, and the service is only available from 9am to 6pm Monday to Friday and 9am to 2pm on Saturdays.While the literature on use of interpreters in medical care has frequently explored patient and/or clinician satisfaction, effects on quality of care, and patterns of use, we have found none that specifically explores clinicians perceptions of the increased clinical risk when interpreters are not used. The aim of this study is to explore clinicians perceptions of the communication difficulties experienced with LEP patients and the clinical risks these difficulties pose in hospitals in the Wellington area. It also explores patterns of interpreter use among these clinicians.Methods The study was conducted in two phases, the first a survey of senior health professionals in the two District Health Boards in the Wellington Area, and the second a questionnaire targeted to a small number of clinicians as they actually encountered LEP patients. Approval to conduct this study was granted by the Central Regional Ethics Committee. Phase 1In Phase 1 of the study, an e-mail asking respondents to complete a survey online was sent to all clinicians who consulted independently in Wellington, Kenepuru and Hutt Hospitalsthis included senior doctors, registrars, dentists, physiotherapists, occupational therapists, social workers and nurses in Capital & Coast District Health Board (CCDHB) and Hutt Valley District Health Board (HVDHB). We excluded house surgeons and ward nurses but included district nurses and specialist nurses (diabetes, respiratory etc). In addition, paper copies of the survey were also distributed in the Emergency Department of Wellington Hospital, and the survey link may have been forwarded by some respondents to colleagues. In total the survey was distributed to around 900 health professionals. A list of survey questions is provided in Appendix 1. In addition to demographic questions, the survey asked clinicians questions about: What languages they speak, How often they see LEP patients, How often they use interpreters (professional or otherwise) with LEP patients, Their awareness of DHB policy on interpreters and knowledge of how to access them, and Whether they felt that communication difficulties significantly affected their care of LEP patients. Within the survey, an LEP patient was defined as ca person for whom English is not their first language AND whose level of English limits the extent of communication in the consultation. This group includes 1) Speakers with very little English, such that consultation is not possible without an interpreter OR 2) Speakers with some English but insufficient English to conduct a comprehensive consultation.d Data were exported from the online survey to Microsoft Excel/Access software for data cleaning (e.g. removing duplicate responses) and further organisation (e.g. calculating number of languages spoken by each respondent.) Descriptive statistics were calculated using Microsoft Excel software; 95% confidence intervals and formal statistical tests were calculated using R (R 2.9.1, R Foundation, Austria). Phase 2Phase 2 of the study investigated the actual communication between a small number of LEP patients and clinicians in patient consultations, and an equal number of English proficient patient consultations. This phase was conducted predominantly in the Emergency Department (ED) of Wellington Hospital where there was clinician support for the research. Some interviews were also conducted at the ED Short Stay Unit, a medical ward where patients were transferred from ED, the Medical Assessment and Prioritisation Unit, the Outpatient Department, the Pacific Congestive Heart Failure Unit, and the Neonatal Unit. When a patient presented who was registered as born outside NZ, a research nurse spoke with the clinician to determine if there had been any language difficulty. When language difficulty was identified, the nurse interviewed the clinician at a convenient time and noted their answers to a questionnaire (see Appendix 2). To provide a comparison group, the clinician was interviewed regarding consultation with the next English proficient patient after this LEP patient. Questions covered whether this was a first consultation with the patient, the complexity of the consultation, any communication difficulties, whether there was extra clinical risk as a result of these, as well as the clinicians assessment of the patients English-speaking ability and details of any interpreter usage. The research nurse also noted any additional comments that the clinician made about communication with LEP patients in general. The same list of questions was used for the LEP patients and the comparison group patients. Data analysisDescriptive statistics were mostly used to summarise clinicians responses. For categorical data regarding knowledge and use of interpreters, 95% confidence intervals are reported in the text. Ordinal data on frequency of interpreter use and frequency of communication problems were analysed using non-parametric tests, as noted in the results section - non-parametric equivalents of the t-test/ANOVA for comparing answers between groups (Wilcoxon Signed Ranks Test, Mann-Whitney test, Kruskal-Wallis test), and non-parametric versions of correlations (Spearmans rank correlation coefficient) when asking whether scores on one ordinal variable were associated with higher scores on another ordinal variable. McNemars Chi-squared statistic was used to ask whether knowledge of DHB policy was independent of practical knowledge on how to access interpreters. Results Phase 1 A total of 141 responses were received, which was a 15.6% return rate. Not all survey responses contained answers to all questions. Demographic characteristicsMost of the respondents (85%) were of European (64% NZ European) ethnicity (calculated using prioritised ethnicity20), with the remainder split between Asian (5.7%), M\u0101ori (3.5%), Pacific (2.8%) and Other (2.1%). They were predominantly female (64%). In terms of positions held, the largest group of respondents were Senior Medical Officers (38%), with significant numbers of registrars (24%) and nurses (21%). Senior House Officers made up 5% and Others (12%) included 6 occupational therapists, 5 social workers, 4 senior dentists, a hand therapist and a midwife. The level of experience of the respondents ranged from 1 year to 42 years, with a median of 15.5 years. Language background of respondentsMost respondents (72%) were monolingual English speakers, but more than a quarter (28%) were bi- or multilingual. NZ Europeans had a lower level of bi- or multi-linguality compared to other ethnicities, as shown in Table 1. Table 1. Number of languages spoken by respondents, by ethnicity (Phase 1) Prioritised ethnicity Number of languages spoken Percentage who speak more than 1 language 1 2 or more NZ European European M\u0101ori Pacific Asian Other 79 16 3 2 2 0 10 16 2 2 6 3 11.2% 50.0% 40.0% 50.0% 75.0% 100.0% Total 102 39 27.7% The most commonly spoken additional languages were European languages, as shown in Table 2. Table 2. Languages spoken by respondents (Phase 1) Languages spoken in addition to English Number of respondents % of total respondents European languages Eastern Asia languages African languages Central Asian languages Pacific languages (including M\u0101ori) Middle Eastern languages NZ Sign Language 34 9 7 4 4 2 1 23.9% 6.3% 4.9% 2.8% 2.8% 1.4% 0.7% Respondents interaction with LEP patients and interpretersAbout a third of respondents (32.17%) reported seeing no LEP patients on a regular basis, and almost another third saw one to two patients per week, as shown in Figure 1. About 35% saw three to seven LEP patients per week. The survey asked two questions about interpreter use: cWhen you see a patient with Limited English Proficiency (LEP) do you use an interpreter?d and cDo you use a professional interpreter (paid by the DHB)?d, with responses on a five point scale ranging from never to always. Results are shown in Table 3 (note that the column headings reflect the fact that only 3 of the 5 points on the scale were labelled in the questionnaire). Figure 1. Number of Limited English Proficiency (LEP) patients seen per week Table 3. Frequency of interpreter use (Phase 1) Variables Never About half Always No response Interpreter use 7 (5%) 29 (21%) 40 (29%) 41 (30%) 19 (14%) 7 Professional Interpreter use 17 (13%) 37 (27%) 34 (25%) 27 (20%) 20 (15%) 8 Although few respondents reported never using any form of interpreter, there is wide variation in the frequency of interpreter use among those who do. A slightly higher proportion reported never usingprofessional interpreters with again a wide variation of frequency of use. More respondents reported knowing how to access an interpreter if they needed one (84%; CI=77-89%) than reported awareness of their DHBs policy on interpreters (65%; CI=56-72%). Twenty-five percent lacked awareness of both the policy and of how to access professional interpreters (CI=18-33%), while 60% knew both the policy and how to access professional interpreters (CI=50-67%). Answers to these two questions appeared to group together (85% of all respondents answered yes to both or no to both) and there was no tendency for respondents to either know the DHB policy but not how to access interpreters, or vice versa (McNemar Chi-squared=0.273, p=0.602). Most respondents felt that communication difficulties with LEP patients have a significant effect on care at least some of the time, with 49% feeling that difficulties occurred more than half the time (see Table 4). Table 4: Perceived frequency of significant effect of communication difficulties on care of LEP patients (Phase 1) Never About half Always No response Frequency (percentage) 4 (3%) 37 (27%) 28 (21%)

Summary

Abstract

Aim

To explore clinicians perceptions of the communication difficulties experienced with Limited English Proficiency (LEP) patients and the clinical risks these difficulties pose in hospitals, as well as patterns of interpreter use among these clinicians.

Method

Senior health professionals in the two District Health Boards (DHBs) in the Wellington Area (about 900) of New Zealand were sent an electronic survey. Twenty clinicians were interviewed about their experience in 22 consultations with LEP patients, and an equal number with English proficient patients. Descriptive statistics were calculated, and 95% confidence intervals and formal statistical tests.

Results

141 responses were received to the survey. There was a high level of awareness of how to access interpreters (84%) and lesser awareness of DHB interpreter policy (65%). Most respondents felt that communication difficulties with LEP patients have a significant effect on care at least sometimes, but there is a wide variation in reported actual use of interpreters, with only 14% always using an interpreter. In the actual consultations studied, no professional interpreters were used despite clinician acknowledgement of increased clinical risk.

Conclusion

Even when clinicians are aware of policy, of how to obtain interpreters, and of the increased clinical risk in the situation, this does not necessarily lead to high levels of interpreter use with LEP patients.

Author Information

Ben Gray, Senior Lecturer, Department of Primary Health Care and General Practice, Otago University Wellington School of Medicine and Health Sciences, Wellington; James Stanley, Research Fellow (Biostatistician), Deans Department, Otago University Wellington School of Medicine and Health Sciences, Wellington; Maria Stubbe, Senior Lecturer/Senior Research Fellow, Department of Primary Health Care and General Practice, Otago University Wellington School of Medicine and Health Sciences, Wellington; Jo Hilder, Research Fellow, Department of Primary Health Care and General Practice, Otago University Wellington School of Medicine and Health Sciences, Wellington

Acknowledgements

The authors wish to thank Nita Hill for conducting the interviews in Phase 2, and the clinicians who participated in this research.

Correspondence

Dr Ben Gray FRNZCGP, Senior Lecturer, Department of Primary Health Care and General Practice, Otago University Wellington School of Medicine and Health Sciences, PO Box 7343, Wellington South, New Zealand. Fax: +64 (0)4 3855539

Correspondence Email

ben.gray@otago.ac.nz

Competing Interests

None.

Roberts C, Moss B, Wass V, et al. Misunderstandings: a qualitative study of primary care consultations in multilingual settings, and educational implications.[see comment]. Medical Education. 2005;39(5):465-75.Flores G. The impact of medical interpreter services on the quality of health care: a systematic review. Med Care Res Rev. 2005;62(3):255-99.Karliner LS, Jacobs EA, Chen AH, Mutha S. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res. 2007;42(2):727-54.Divi C, Koss R, Schmaltz S, Loeb J. Language proficiency and adverse events in US hospitals: a pilot study. International Journal for Quality in Health Care. 2007.Cohen AL, Rivara F, Marcuse EK, et al. Are language barriers associated with serious medical events in hospitalized pediatric patients? Pediatrics. 2005;116(3):575-9.Karliner LS, Perez-Stable EJ, Gildengorin G. The language divide: The importance of training in the use of interpreters for outpatient practice. J Gen Intern Med. 2004;19(2):175-83.Diamond LC, Schenker Y, Curry L, Bradley EH, Fernandez A. Getting by: underuse of interpreters by resident physicians. J Gen Intern Med. 2009;24(2):256-62.Atkin N. Getting the message across-professional interpreters in general practice. Aust Fam Physician. 2008;37(3):174-6.Auckland Area Health Board. Report of the Working Party on Interpreting Services, Cartwright Implementation Taskforce, Editor. Auckland Area Health Board: Auckland; 1990.Chan I, Lloyd T, Tong K. The use of interpreters by South Auckland GPs. New Zeal Fam Physician. 1999;26(4).Garrett PW, Forero R, Dickson HG, et al. How are language barriers bridged in acute hospital care? The tale of two methods of data collection. Aust Health Rev. 2008;32(4):755-64.Gerrish K. The nature and effect of communication difficulties arising from interactions between district nurses and South Asian patients and their carers. J Adv Nurs. 2001;33(5):566-574.Kuo DZ, O'Connor KG, Flores G, Minkovitz CS. Pediatricians' use of language services for families with limited English proficiency. Pediatrics. 2007;119(4):e920-7.Yang C-F, Gray B. Bilingual medical students as interpreters--what are the benefits and risks? NZ Med J. 2008;121(1282):15-28.Wearn A, Goodyear-Smith F, Everts H et al. Frequency and effects of non-English consultations in New Zealand general practice. NZ Med J. 2007;120(1264):U2771.Gray B. English language difficulties at general practices in Auckland, New Zealand: a major limitation to good practice. NZ Med J. 2007;120(1264).Auckland District Health Board. The Interpreter Service. www.adhb.govt.nz/downloads/services/interpreter-manual.pdfCapital & Coast District Health Board. Use of interpreter services (Version No. 3): Wellington, New Zealand; 2010.Camplin-Welch V. Cross-Cultural Resource for Health Practitioners working with Culturally and Linguistically Diverse (CALD) Clients. Waitemata District Health Board and Refugees as Survivors NZ Trust: Auckland, New Zealand; 2007.Ministry of Health. Ethnicity Data Protocols for the Health and Disability Sector.http://www.moh.govt.nz/moh.nsf/indexmh/ethnicity-data-protocols-feb1994Gray B, Hilder J, Donaldson H. Why do we not use trained interpreters for all patients with limited English proficiency? Is there a place for using family members? Australian Journal of Primary Health. 2011;17 (3): 240-249.Statistics New Zealand. Quick Stats about Culture and Identity (2006 Census Data).http://stats.co.nz/Census/2006CensusHomePage/QuickStats/quickstats-about-a-subject/culture-and-identity/languages-spoken.aspxStandiford CJ, Nolan E, Harris M et al. Improving the provision of language services at an academic medical center: ensuring high-quality health communication for limited-English-proficient patients. Academic Medicine. 2009;84(12):1693-7.

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