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The purpose of this qualitative study was to gain understanding about the experience of pediatric nurses caring for limited English proficient (LEP) patients and families in the in-patient setting and how nurses navigate the communication gap.
A decade ago the Office of Minority Health (OMH, 2001) set 14 National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care. OMH encouraged the healthcare community to evaluate and incorporate the standards in an effort to eliminate disparities and improve the health of all people. In addition, the Institute of Medicine (2009) and The Joint Commission (2010) recognized the important role care providers play in the achievement of health through cultural competence, communication, and patient and family centered care. Nurses play a key role in meeting the individual’s communication needs (Patak et al., 2009). Through assessment of the patient’s oral and written communication needs and preferred language; the nurse contributes to the responsibility of effectively communicating when providing care, treatment, and services. Patient-centered communication improves safety and quality of care (The Joint Commission, 2010).
Nurses have a professional obligation to advocate for the needs of patients, regardless of the setting or the system’s shortfalls (American Nurses Association, 2001). As part of the health care community, nurses are expected to meet national standards and be vital partners in ensuring patients reach optimal levels of health. They are frequently the gate-keeper of information, collaborating with physicians and coordinating multi-disciplinary care. A nurse’s ability to perform in the expected role is challenged when a communication barrier exists. This barrier doubles for nurses caring for in-patient pediatric patients, a specialty in which the nurse has a responsibility to both the child and family. Literature providing guidance for nurses navigating the language gap in the inpatient pediatric setting is non-existent. Research exploring how nurses bridge the language barrier and identification of best practices and outcomes would benefit patients, families, and nurses.
Methods:
An exploratory qualitative design using phenomenology was used to describe the experiences of nurses caring for patients and families with LEP. Using purposive sampling in a 400+ bed tertiary care children’s medical center in the Southwestern United States, 15 direct care Registered Nurses from medical-surgical in-patient units, with at least one year of experience in caring for patients and families with LEP, were recruited. Private audio-taped interviews, lasting approximately 60 minutes, were conducted in the medical center. All interviews were transcribed verbatim and verified for accuracy by the principal investigator. An investigator designed demographic survey was administered to nurse participants at the end of the interview. The researcher instructed participants to describe his/her experience in providing care for patients and families who speak little to no English. Probing, open ended questions were used to explore the nurse’s decision-making process, communication methods and resources, and feelings associated with caring for patients and families with LEP. At the end of the interview, the researcher summarized and verified the main points with the participant. Using phenomenology (van Manen, 1984), the transcripts were analyzed for and categorized into thematic groupings which described nurses’ thoughts, feelings, examples, behaviors, emotions, and statements that reflected their lived experiences in caring for patients and families with LEP.
Results:
Of the 15 pediatric nurse participants, 13 were female, 70% between 20 to 39 years old, 53% with less than 5 years nursing experience, and 53% with a bachelor’s degree in nursing or higher. Of about 12,400 discharges in 2013, 8% of the households reported speaking Spanish and almost 1% reported speaking a language other than Spanish or English. Nurses stated caring for at least one, and frequently more than one, family with LEP per shift. Two nurses reported proficiency in speaking, reading and understanding Spanish. Each nurse described their feelings of dissatisfaction, frustration, sadness, and defeat when caring for patients and families with LEP. Nurses expressed differences in their definitions of care related to English vs non-English speaking families and patients. When nurses were assigned non- English speaking families and patients and reflected on their shift experiences, they stated they provided the same physical care, nursing tasks, and assessments as for English speaking families and patients. Task-oriented care did not satisfy their vision of ideal, holistic nursing care such as engagement, communication, emotional support, room presence, counsel, and comfort. As described by one nurse, “…not that I’m not giving good nursing care in and of itself, but it makes me feel that I’m not caring for them as I would like to care for them”. Rather than relying upon communication, nurses explained numerous nonverbal (“Because you know your face speaks a thousand words.”), environmental (“I’ll be extra aware to look at the trash bag for diapers..”), and behavioral (“I try to watch them, if they point to something…”) cues used to gather information from their patients and families.
Conclusion:
In order to “decenter” and move to “unknowing” for data interpretation, the researchers had to abandon previous assumptions that pediatric nurses would recount their daily experiences in a structured, step-by-step process. Instead the nurses described a compromised personal paradigm of care accompanied by emotional distress when taking care of patients and families with LEP. The findings could be used to guide nursing leadership in making patient assignments and assessing their nurses for potential signs of burnout and emotional distress related to the communication challenges. Suggestions for future research include: (1) replication of this study in international settings where English is not the primary language and (2) exploratory qualitative study describing the patients and families’ experiences and perceptions when receiving care from a healthcare provider who does not speak their language.