What is needed in culturally competent healthcare systems? A qualitative exploration of culturally diverse patients and professional interpreters in an Australian healthcare setting
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Culturally competent health care service delivery can improve health outcomes, increasing the efficiency of clinical staff, and greater patient satisfaction. We aimed to explore the experience of patients with limited English proficiency and professional interpreters in an acute hospital setting.
In-depth interviews explored the experiences of four culturally and linguistically diverse communities with regards to their recent hospitalisation and access to interpreters. We also conducted focus group with professional interpreters working. Data were analysed using an inductive thematic approach with constant comparison.
Individual interviews were conducted with 12 patients from Greek, Chinese, Dari and Vietnamese backgrounds. Focus groups were conducted with 11 professional interpreters. Key themes emerged highlighting challenges to the delivery of health care due distress and lack of advocacy in patients. Interpreters struggled due to a reliance on family to act as interpreters and hospital staff proficiency in working with them.
In an era of growing ethnic diversity this study confirms the complexity of providing a therapeutic relationships in contemporary health practice. This can be enhanced by training towards the effective use of professional interpreters in a hospital setting. Such efforts should be multidisciplinary and collective in order to ensure patients don’t fall through the gaps with regards to the provision of culturally competent care.
KeywordsAccess to care Culture competence Inpatient medicine Interpreters Qualitative
Low English proficiency
Monash Medical Centre
Australia has diverse and growing migrant populations with 190 different countries and 300 different ancestries represented . Results from the most recent Australian Census showed that that up to 28.5% of the Australian population where born overseas 2016 . It has been well established that patients from culturally and linguistically diverse backgrounds (CALD) experience poorer healthcare access and health care outcomes. These disparities have been shown to exist even when CALD population have similar medical conditions to English speaking patients [3, 4]. Such disparities are in part due to language barriers which make communication with the health system difficult . How to provide accessible and quality health care is a serious challenge for the Australian health system.
Patterns of health care access among CALD patients with low English proficiency (LEP) highlight the experience of compromised care, longer hospital stays, higher rates of medical errors, and poorer patient satisfaction [6, 7, 8, 9]. Existing health services need to adapt in order to promote the health and wellbeing of CALD populations. The provision of a culturally competent health care service has been posited as a key factor towards improving health outcomes, increasing the efficiency of clinical staff, and improving patient satisfaction. Growing work highlights key organisational components that have been shown to promote cultural competency including: the provision of health professional training and creating policies that streamline care and facilitate communication . However barriers towards the provisions of culturally competent care include a lack of value in and resources towards staff training and education as well as the provision of culturally appropriate health education materials and other support to help patients navigate the health system .
Effective communication coupled with identification of and respect for cultural differences is essential to the delivery of culturally competent care. To achieve this health services need to facilitate clinician understanding of how patients from CALD populations understand disease and illness, view the causation and prognosis of their illness, describe their symptoms, understand treatment processes and how they perceive their role . For example, some CALD patients do not consider it acceptable behaviour to ask questions within the health care context. As a results they are greater risk of not understanding their condition, being able to follow their treatment plan nor understand their health care rights [13, 14].
In an Australian context, interpreters are frequently provided as a means to overcome language barriers and help CALD populations to interact with and navigate the healthcare system. Despite evidence showing the association between interpreter access and better health care experiences and outcomes for patients with LEP [15, 16, 17, 18], there remains an under-use of interpreters. Reasons for not using interpreters stems from the perceived lack of interpreter availability and increased workload when using interpreters [15, 19, 20]. Instead health services frequently use family members or untrained staff, such as bilingual or non-medical staff, to act as interpreters . Use of non-accredited interpreters has been shown to compromise the quality of care as they lack vocabulary to interpret complex medical terminology, leading to misunderstanding and errors in translation toward key care components such as symptom identification and participation in medical decision making [21, 22]. It is important for us to understand the impact of not providing professional interpreter services on patient health care journeys. Findings can identify gaps in service provision that are not consistent with culturally competent health care and inform practice improvement.
As part of a larger study exploring hospital related outcomes of patients from culturally and linguistically diverse backgrounds , we aimed to explore the experience of patients with limited English proficiency and professional interpreters in an acute hospital setting.
This qualitative study explored the delivery of culturally competent health care in an Australian acute hospital setting. A data source triangulation approach was used to increase study validity and data richness by capturing different perspectives of the same phenomenon . First, we undertook semi-structured interview across four culturally and linguistically diverse communities with regards to their recent hospitalisation and access to interpreters. We also conducted focus groups (FGs) with professional interpreters working at Monash Health. Recruitment occurred between May and June 2017. This project received approval from the Monash Health Human Research Ethics Committee (project number 14293Q).
Potential participants were recruited as part of a larger study (methods reported elsewhere ). In brief, patients admitted to the General Medicine program at Monash Medical Centre (MMC) or Dandenong Hospital (DH) during the 2015–16 financial year, who were identified as having LEP and whose preferred language was either Greek, Chinese, Dari or Vietnamese. These languages were chosen as they were the most prevalent participant groups meeting the following criteria: admitted and received services from a trained interpreter on at least one occasion during an admission in the 2015–16 financial year with an additional admission in the same year without access to a trained interpreter were prioritised. Patients meeting inclusion criteria were mailed a letter of invite to the study, including study information, in their preferred language. After 2 weeks the researchers, using relevant interpreters, phoned each patient to answer questions and make an interview time at a convenient time and location, typically the patients home. Written consent was obtained prior to the interview commencing.
Focus groups were conducted at MMC (n = 6) and DH (n = 5). Recruitment was open to all professional interpreters, however to maximise participation the FGs were arranged by the Interpreter Service site manager at each site. Thus FGs formed a convenience sample. Detailed information was given about the study, time and location of each focus group and all participants provided written informed consent.
In-depth interviews (n = 12) were conducted by two researchers (JW and TP) with the assistance of interpreters using an interview schedule . Interviews began by asking participants to share their ‘story’ of hospital admission and subsequent questions explored their experience of access to an interpreter or not. The semi-structured nature permitted flexibility for participants to elaborate upon or cover important topics that would not have otherwise surfaced, for example the experience of feeling confusion during ward rounds . Emergent themes informed continuing data collection and sampling continued until thematic saturation (two co-coders agreeing that no new themes were emerging) was achieved.
Focus group methodology has been described elsewhere . Questions specific to this study’s research aim explored the experience of interpreting for patients from culturally and linguistically diverse backgrounds in a busy, acute hospital setting. Thematic saturation was achieved.
Qualitative data analysis has been described in an earlier publication of clinician experience of language discordance . Briefly, interview and FGs were recorded with participant consent and transcribed verbatim, with identifying data removed. Data analysis was guided by an inductive thematic approach  whereby the first step involved sustained engagement with the data through an initial reading and re-reading of transcripts to identify units of meaning and initial codes. Following team discussion initial codes were used to identify key categories and the primary author merged codes. In the final step, emerging categories were refined and grouped together into a theme. Rigour was upheld through immersion in data, reflexive analysis, peer debriefing and consensus coding between team members and discussion with a broader team . Coders also captured exemplar quotes supporting each theme.
“I don’t want to complain…” – Limitations towards advocacy.
“I feel over overwhelmed. I felt not able to communicate [in my own language] - this was very torture-some.” (Mandarin, Participant (P)1)
“Because we are unfamiliar with the hospital protocol and procedure….so, we will just follow what the doctors’ instructions are.” (Mandarin, P2)
“If you can’t communicate effectively I would feel a bit in a disadvantage position, but on the other hand I do understand a bit of it. There are other patients who don’t, and for them it’s even worse.” (Greek, P5).
“Yeah, there were times that the doctors were coming and saying the stuff and there was no interpreter and then I wouldn’t understand what they said.” (Dari P1)
“Whatever they offer I accept. I have no knowledge in the health area so I thank to the doctor and the nurse helping me.” (Vietnamese, P1)
“If there can be interpreters present - that will be the best thing” - Experiences of access to and use of interpreters.
“I don’t want to create trouble with the hospital and also I have to face my language difficulty - if there can be interpreters present that will be the best thing.” (Mandarin, P3)
“They would call an interpreter, not all the times, not from the beginning, but I did have an interpreter whenever I had to do scans.” (Dari, P1)
Participants who had had previous admissions to hospital often noted that their need for an interpreter has already been established and an interpreter was automatically booked. Alternatively other participants who had had multiple admissions and wanted to ensure access to an interpreter said their children would phone ahead to, “Arrange with the hospital for an interpreter.” (Greek, P3)
“It depends when we had the admission, whether it was during the day or during the night, if it is at night we didn’t have an interpreter….. So, I would take one of our children along with us.” (Greek P1)
“I feel very bad due to the fact that I have been in Australia for 60 years and I can’t speak English and answer a question put to me in the English language.” (Greek P2)
“I feel overwhelmed…” – Limited communication causes frustration and isolation.
“I knew when they would come around because they would give me medication, and if I was in pain I will endure it until they arrive.” (Greek, P2)
“Nurses would go more often to the patients who spoke English” (Greek P4).
“Later on there were nurses, either they can speak in Mandarin or in Cantonese who are on duty, but then when none of them are on duty, we are stuck, but we have to cope with it… you have to cope with it.” (Mandarin P3).
“They don’t pay enough attention. They assume that I am an idiot - not worth it.” (Greek, P3)
“If I don’t understand, I ask to stop as my daughter is coming” – The role of family members.
“If I don’t understand, I say no stop, my daughter coming”. (Greek P1)
“My children speak fluent English, but they don’t speak fluent Greek, especially when it comes to medical terminology and they can’t explain properly….. So…even if they can understand anything, they can’t express everything you know the way an interpreter would”. (Greek P3)
Constraints to accurate interpreting: “We are here to facilitate communication”
“If staff think the daughter is here, the cleaner is here, that will be quicker, easier” (DH, FG)
“Staff have booked an interpreter – but when the daughter comes in before me then they [staff] would prefer to use the daughter rather than wait for me the interpreter.” (MMC, FG)
“They [staff) ask for me to stay back so I can tell the patients or can ask the patients a few questions about caring for them. I try to. ”(MMC, FG)
Family as interpreters
“When clinicians are communicating with patients up in the ward, there is an assessment made about the patient’s English language proficiency ….and it is not necessarily the patient who is making that assessment. Often they [clinicians] incorrectly assume that the patient has a greater level of language proficiency. Even patients tend to overestimate their ability to communicate in English because they can go and pay for a newspaper.”(DH, FG)
“[Patients] children often do not have sufficient language skills on the one hand and also, in other cases, interpret half the truth.” (MMC, FG)
“We need the cooperation from the professional to help to work with us. If the professional keeps going with the family members, which is easy…every conversation we are left out.”(MMC, FG)
“And when you have a family member they don’t tell it exact, it is hard. But if I am there and they don’t speak properly then I can jump in and said ‘No it is not.’ There are two things not telling the truth or misinterpreting information.” (DH, FG)
“And then you start from scratch and then you feel like oh my God! And the patient is already frustrated, not understanding what is happening. They want go home soon. and if they do go home…they will be back into hospital again because the picture of their health is wrong from the beginning.” (MMC, FG)
Working with clinicians
Staff familiarity and confidence
“[They don’t tell them] because they don’t want their loved one to know what’s exactly going on -it is a cultural thing.” (DH, FG)
“The thing is you can’t assume that they [patient] know the connection between going home, taking medication and staying here are the same thing. But, you know, if you get the background you explain a little bit more as an interpreter ….that helps…”(DH, FG)
“They [staff] are not allowing the opportunity to ask questions or to understand what is going on.” (MMC, FG)
Concern for accurate information exchange
“Lack of awareness of the service. I think sometimes as well is that given the high turnover of staff, not everyone is then familiar with how to access to service.” (MMC, FG)
“If the clinician calls me afterwards say what you think about you know, I said this this this that, you know what I mean. In the session I cannot say, ‘excuse me you [patient] are not telling the truth’… it is not our role.”(MMC, FG)
“It is very difficult and often after the consultation I am busy, I am going somewhere else when I am stopped by the professional to say: ‘Can you say anything you know about the meeting and so forth’” (DH, FG)
This qualitative study involving interviews with patients with LEP and professional interpreters highlighted barriers to the delivery of a high quality, culturally competent health service. A central finding of this study was that patients with LEP felt overwhelmed and frustrated when unable to advocate for themselves and were not involved in decision about their own care. However patients felt guilty when they didn’t speak English which subsequently lead to them being passive in encounters with health professionals. Professional interpreters felt their services were not given priority and that family members were used to interpret in the first instance, despite the potential for inaccurate information exchange. Similarly professional interpreters observed the reliance on bilingual staff as a convenient alternative communication strategy.
All participants reported the reliance on family members and untrained staff, who were not skilled in interpreting medical terminology, was a barrier to accessing professional interpreters. This is consistent with previous research demonstrating that untrained staff do not have the skills in accurately translate medical terminology . Further unskilled interpreters may not perceive cultural norms such as when CALD patients are perceived as being shy or show agreement with clinicians, even though they don’t actually understand what is being said .
This study also highlighted the experience of distress in patients when they perceived they were being overlooked by clinicians. Evidence highlights that dealing with emotions is complex and this is further compounded in CALD patients when language barriers exist and when clinicians do not respond empathically [31, 32]. We posit that the provision of culturally competent care requires educating clinicians to better detect the presence of psychological disturbance.
The delivery of culturally competent care is a challenge to many countries experiencing increasing numbers of migration and our findings echo this challenge, despite legislation to facilitate the availability of professional interpreters . We identify key training components for clinicians working with CALD patient such as: developing cultural awareness, involving patients in communication and information sharing, and how to effective work alongside professional interpreters. Further, we suggest that training towards providing culturally competent care also should be provided on an ongoing basis in order to sustain benefits to patients  and reinforce clinician behaviour . However given barriers to the use of professional interpreters ongoing efforts need to made by clinicians and administrative to address barriers to access and meet legislative requirements [35, 36].
Strengths and limitations
We have previously reported on the outcomes of the clinician experience of language discordance . This study generates important in-depth insight into the patient journey from a patient and interpreter perspective. Findings consistently highlight the need for greater access to and use of professional interpreters in order to provide the opportunity for communication, reassurance and earlier evaluation and treatment where necessary.
As many countries experience growing cultural diversity there is need for the provision of enhanced care to patients from CALD background and access to interpreters. This can be promoted by training towards the effective use of professional interpreters in a hospital setting. Such efforts should be multidisciplinary and collective in order to ensure patients don’t fall through the gaps with regards to the provision of culturally competent care.
The authors thank the all participants.
JW completed data analysis with support from TP. JW drafted the manuscript for publication and TH, TP contributed to the content and revision of the manuscript. LT, EM, TP contributed to working group meetings and revisions. JW managed revisions, literature and checking of the manuscript. All authors read and approved the final version.
This project was supported by Partnerships & Service Design, Monash Health who contributed to the study design, data collection, and analysis and reporting.
Ethics approval and consent to participate
This project received approval from Monash Health Human Research Ethics Committee (Monash Health Ref: RES-17-0000104 L). All participants in the qualitative phase of this study provided written informed consent.
Consent for publication
The authors declare that they have no competing interests.
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