Distressing Discussions in Pediatric Interpreted Medical Encounters: A Qualitative Study of Medical Interpreter Perspectives on Clinician Communication Practices

Abstract

Introduction:

This study explores pediatric medical interpreters’ perspectives on clinician communication practices in medical encounters characterized by distressing content and difficult discussions.

Methods:

In this interpretative phenomenological analysis, thirteen Spanish-English interpreters at a midwestern pediatric hospital were purposively recruited and, in 2021–2022, completed a demographic survey and semi-structured interview on communication in distressing interpreted medical encounters.

Results:

Participants described clinician practices for effective cross-cultural interpreted communication. Identified practices align with standing recommendations on pre-briefing and debriefing, jargon, stakeholder positioning, and teamwork. Novel findings relate to encounters with multiple parties, multilingual pediatric patients with monolingual parents, and coordination among clinicians.

Discussion:

Findings corroborate recommendations for interpreted communication best practices, extend them to distressing pediatric encounters, and offer recommendations for clinicians using interpreting services in distressing encounters. Participants’ insights are distilled into a series of clinician best practices for high-quality interpreted communication during difficult discussions and for strengthening language access services in pediatric medical settings.

Introduction

When communicating with patients and families about distressing or difficult health information, or when delivering bad news, effective communication among clinicians, patients, and families in medical settings is critical (Cypress, 2011; Quinn Rosenzweig et al., 2012; Ranjan et al., 2015). As a matter of patient and family health literacy, stakeholders who cannot communicate using a shared language rely on trained medical interpreters to provide culturally sensitive, accurate, and complete interpretations in interpreted medical encounters (IME) (Lehna, 2005; Schapira et al., 2008). However, some clinicians characterize communicating via interpreters as challenging and disruptive; this impacts trust and rapport with families and jeopardizes health equity in IME (Olen et al., 2022; Williams et al., 2018). Additionally, medical interpreters report feeling emotional distress and, at times, a lack of support from medical colleagues when delivering distressing content in IME (Cline et al., 2021; Lim et al., 2022). To facilitate high-quality, effective communication during difficult IME, clinicians may adopt strategies that facilitate the interpreting process (Hsieh, 2006; Hudelson, 2005; Leanza et al., 2014).

A handful of studies explore clinician, interpreter, and/or family perspectives on effective communication in general IME in adult and pediatric populations. Several studies offer clinician recommendations for improving IME communication with adult populations [Draechslin et al., 2012; International Medical Interpreters Association (IMIA), n.d.; Leanza et al., 2014]. These studies focus on interpreter roles, interpreter best practices, clinician practices, and/or hospital system characteristics that present barriers to effective IME communication. Studies on interpreter perspectives in encounters characterized as “difficult,” such as end-of-life discussions (Norris et al., 2005) or stressful discussions in pediatric settings (Cline et al., 2021; Williams et al., 2018), offer suggestions for improving communication through interpreter-clinician collaboration during the encounter and within the hospital system. Additionally, medical and interpreter association guidelines offer recommendations for clinicians working with interpreters in general medical settings [Association of American Medical Colleges (AAMC), n.d.; IMIA, n.d.]. Despite these resources, the literature on interpreters’ perceptions of clinician practices in difficult or distressing pediatric IME is incomplete, as only a few studies offer any insights on the topic (Cline et al., 2021; Norris et al., 2005; Weaver et al., 2022; Williams et al., 2018). Our study provides an examination of interpreters’ perspectives on distressing communication events in pediatric IME. Interpreter perspectives better inform best practices for effective health communication and foment cross-cultural/cross-linguistic health equity for linguistically minoritized families.

According to interpreters, distressing encounters may involve difficult medical procedures, delivering bad news, discussing complex medical history, end-of-life discussions, and encounters where raw emotions are expressed (Cline et al., 2021; Lim et al., 2022; Norris et al., 2005; Weaver et al., 2022). Interpreters also describe difficult IME as personally distressing due to their own experiences of distress and because they must relay patient and family distress to clinicians (Lim et al., 2022). Interpreters view some units in pediatric hospitals as lending to more distressing discussions [e.g., Prenatal Counseling Clinic, Neonatal Intensive Care Unit (NICU), Pediatric Intensive Care Unit (PICU), Oncology, and Psychology] (Lim et al., 2022). Therefore, in the present study, the authors define distressing IME as encounters that feel difficult because: 1) they contain content that is distressing or disturbing to any or all stakeholders; 2) they cause observable patient and/or family distress; and/or 3) the health situations involved are generally viewed as inciting difficult or distressing emotions (Lim et al., 2022). This study highlights effective clinician communication practices during distressing pediatric IME based on interpreter perspectives and experiences.

Methods

This interpretative phenomenological study was designed to explore the lived experiences of Spanish-English medical interpreters who were asked to reflect on and openly discuss communication in distressing pediatric IME. The study was informed by a relativist ontology, asserting that reality is subjective and varies individually (Parahoo, 2014), and a subjectivist epistemology, positing that reality is dependent on individuals’ subjective knowledge of it (Grix, 2019). Rooted in an interpretivist paradigm, an interpretive phenomenological approach (IPA) was used throughout the research process to explore participants’ lived experience and perceptions on the study topics (Creswell et al, 2018; van Manen, 2016). IPA was deemed an effective approach for these reasons, and because it recognizes researcher and participant subjectivity and interpretation in the co-creation of meaning (Oerther, 2020). The research team is interdisciplinary, drawing from interpreting studies, medicine, and psychology. IPA was effective for engaging the various subjectivities and positionalities of the team, alongside those of research participants (see “Positionality” and “Data Analysis” below). Semi-structured, individual, face-to-face interviews were determined a suitable approach for assessing participant lived experience, and the virtual setting from researcher and participant homes was sufficiently private and safe for discussing distress communication. Data was analyzed in multiple rounds with an IPA approach, described in detail below. The consolidated criteria for reporting qualitative research (COREQ) was used during the design of this study (Tong et al., 2007).

Positionality Statement

Positionality refers to the “stance or positioning of the researcher in relation to the social and political context of the study—community” and influences the research design and analysis (Coghlan & Brydon-Miller, 2014; Creswell, 2014). Author positionality is as follows: AO is a White, American, multilingual woman, professor of Translation & Interpreting Studies, and Spanish-English translator and interpreter. PSL is a multilingual Asian-American woman, a 1.5 generation immigrant, and a pediatric psychologist. SE is an educational psychology graduate student and first-generation, multilingual immigrant woman of Hispanic (Colombian-Cuban) background. MCS is a White, American man and physician practicing pediatric Critical Care Medicine. CBR identifies as a White, American man and Critical Care pediatric physician. KAB is a White, American, cisgender woman and clinical psychology graduate intern. JBT is a White, American, cisgender woman and clinical psychology graduate student. WHD is a White, American man and pediatric psychologist.

Procedure

The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013) to safeguard participant protections and minimize risk of distress. Because participants were asked to discuss their lived experience interpreting in distressing medical encounters, the research team provided mental health resources and an on-call psychologist to support their emotional wellbeing. The study was approved by the institutional review board of the University of Wisconsin-Milwaukee (IRB # 20.124) and informed consent was provided by all participants.

Materials

All participants completed a standard demographics survey and a qualitative interview. The interview guide, developed by the authors of this study, asked participants about four main concepts: perspectives on communication facilitation; identification and communication of patient and family distress; perceptions of clinician practices during distressing encounters; and resources for medical interpreter emotional wellbeing (see Table 1. Interview Guide). The section related to clinician practices in distressing encounters is the focus of this paper. Participants were given the prompts: “We’re going to ask you about things that make interpreting for distressed families easier or more difficult: a) Is there anything that makes it easier or harder to interpret family distress to a provider? b) Are there specific things that clinicians do or expect that make it easier or harder to communicate?”

Table 1.

Interview Guide

Introduction: For the purpose of this interview, please think about families you’ve worked with in pediatric hospitals. The family could include the patient’s legal guardians, or someone important in the patient’s life that cares for them, and siblings, rather than solely the patient’s biological parents. Please also think about a variety of medical providers that you’ve worked with, including nurses, physicians, and trainees. In order to protect your confidentiality and that of families and medical providers, please avoid the use of protected health information, including patient, family, or provider names.

Section 1: Background and Motivation

1. Why did you become a medical interpreter?

a. Follow up (if participant did not answer question): What in your life inspired you to do this work?

2. What training did you get to become an interpreter?

3. What do you think is most important in your work as an interpreter? Why?

Section 2: Interpreting Practice and Communication Style

Say, “please remember to think about pediatric medical encounters while answering the following questions.”

4. Interpreters help people who do not speak the same language understand what is being said from one person to another. When you are interpreting, what are some things you do to help people understand each other? Why?

a. What are things you wouldn’t do to help people understand each other? Why?

5. Are there other ways of interpreting during medical encounters?

a. Which of these ways of interpreting do you prefer to use? Why?

b. Which of these ways of interpreting do patients prefer interpreters to use? Why?

c. Which of these ways of interpreting do providers prefer interpreters to use? Why?

6. What are things medical providers do that help you do your job more effectively?

a. What are things medical providers do that make your job more difficult?

7. Now, thinking about patient nonverbal communication: Whose role is it to communicate the patient’s nonverbal behaviors in medical encounters? Why?

a. (if they say “interpreter”): How do you communicate patient nonverbal behaviors to the provider?

8. How comfortable are you communicating providers’ verbal and/or nonverbal emotion to patients? Why?

Very uncomfortable Somewhat uncomfortable Neutral Somewhat comfortable Very comfortable

9. How about conveying patients’ verbal and/or nonverbal emotions to providers? Why?

Very uncomfortable Somewhat uncomfortable Neutral Somewhat comfortable Very comfortable

10. We would like you to think of times when you felt more aligned with either a patient or a provider.

Note: If participant asks what is meant by aligned, say, “we’re keeping the definition of ‘alignment’ open, so what does aligned mean to you?” Aligned can be whatever the subject interprets it to be.

a. In what situations would you feel more aligned with the patients?

b. In what situations would you feel more aligned with providers?

Section 3: Identifying Distress and Disclosure of Family Distress to the Provider

Say, “please remember to think about pediatric medical encounters while answering the following questions.”

11. What indicates to you that a family is distressed?

Note: If participants ask what we mean by distress, say “what does distress mean for you? What did distress look like to you when you interpreted for families?”

a. Great, we are interested in the full spectrum of distressed families. Families may present distress in many ways, including the ways you’ve mentioned, withdrawing, being difficult, or being tearful.

b. Do you notice cultural differences when families express distress? If so, what have you noticed?

12. If a patient is distressed, should it be brought up in the interpreted medical encounter?

a. If not, why?

b. If yes, who should bring it up in the encounter? What makes you choose that person?

c. If they say interpreter, ask:

i. What do you consider when deciding whether to bring up that a patient is feeling distressed?

ii. Describe how you would communicate that a patient is distressed to the provider?

Note: Ensure that interpreters talk about nonverbal and verbal communication.

iii. When is the appropriate time to communicate that to the provider?

13. How would you handle an encounter in which the patient expressed distressed, and the provider doesn’t notice?

a. What if the provider doesn’t address the patient’s distress?

14. How would you handle an encounter in which you believe the patient is distressed and the provider doesn’t notice?

a. What if the provider doesn’t address the patient’s distress?

15. We’re going to ask you about things that make interpreting for distressed families easier or more difficult: Note: Ensure that interpreters talk about easier and harder characteristics.

a. Is there anything that makes it easier or harder to interpret family distress to a provider?

b. Are there specific things that providers do or expect that make it easier or harder to communicate?

Say, “We understand that it is normal for interpreters to manage communication between patients and providers and in different situations, that can mean different things.”

16. In what situations would you feel the need to edit or leave out what the patient/family said? Why?

a. In what situations would you feel the need draw attention to what the patient/family said? Why?

17. In what situations would you feel the need to edit or leave out what a provider said? Why?

a. In what situations would you feel the need draw attention to what a provider said? Why?

18. Have you talked to a provider about a family’s distress after an encounter or stopped interpreting during an encounter to talk to a provider about a family’s distress?

a. If so, can you talk about that and why you discussed the family’s distress?

b. If not, have you ever felt like you wanted to talk to a provider about a family’s distress? What stopped you?

Section 4a: Impact of Disclosing Intense/traumatic Information to Families and/or Providers.

19. Can you tell us about the kinds of interpreting encounters in which you feel personally distressed because of the information being discussed?

a. What about the information being discussed is personally distressing?

b. Outside of interpreting difficult content, are there other things at home, work, or elsewhere that make you feel more distressed when interpreting?

20. Have you ever left an interpreting encounter because it was too stressful or distressing?

1. If the interpreter answers no: Have you ever wanted to leave an interpreting encounter because it was too stressful or distressing?

2. What about the assignment was challenging or distressing?

Section 4b: Resources and Supports for Interpreters

21. What resources do you know of that you can use to minimize feeling distressed after interpreting for families?

a. Which of those do you use?

b. What are the barriers to accessing those resources?

22. What coping strategies do you use when actively interpreting for a distressing family encounter at work? What about when recovering from a distressing family encounter at work or at home?

23. When you are dealing with traumatic information, have you ever disclosed these situations to a colleague because you felt distressed?

a. What happened after disclosing to a colleague?

24. What resources and supports for interpreters do you think should be made available in the hospital to decrease feeling distressed in this line of work?

Final Thoughts

25. Is there anything else on these topics I haven’t asked you about that you think would be helpful for us to know?

To assess the functionality of the interview guide and to gauge the feasibility and acceptability of the project, three medical interpreters were asked to participate in a pilot study and complete a cognitive interview (Beatty & Willis, 2007). The interview guide was edited based on the pilot and cognitive interviews. Medical interpreters who participated in the pilot study rated the interview questions as somewhat easy to listen to and understand. They shared that they felt comfortable answering the questions and that the interview was “non-threatening.” They also suggested that defining “distress” might be helpful for answering questions. Since the research team considered it important to receive broad perceptions relating to concepts of distress, the research team refrained from defining this term and instead provided the interview prompt: “If participants ask what is meant by distress, say: ‘What does distress mean for you? What did distress look like to you when you’ve interpreted for families?”’

Recruitment

A professional relationship between the authors and hospital interpreting services was established prior to study commencement to obtain permissions and input for conducting the study. Purposive sampling was used. Spoken language, in-person interpreters who worked at a large, free-standing pediatric hospital in the Midwestern United States were recruited via a monthly newsletter and a recorded video that summarized the aims of the project. Interpreters were eligible to participate if they were at least 18 years old, were employees or contract interpreters, had worked in at least one pediatric care setting, and had access to a device that could connect to the internet. Interpreters for all language pairs working regularly in the hospital were recruited; only Spanish-English interpreters participated.

Participants

Thirteen spoken language interpreters participated in the study. All participants interpreted Spanish-English as their language pair. Most participants identified as female (84.6%) and as Hispanic, Latino/Latina/Latinx (76.9%). Participants were employees of the children’s hospital (6, 46%) or in-house contractors from an external language services provider (7, 54%). Interpreting experience ranged from 2 to 20 years, with 2 to 13 years of experience in pediatrics. All interpreters had experience in high intensity or acuity clinics (e.g., Pediatric Intensive Care Unit). Participants are referred to as “participants” and/or by a unique participant number (e.g., Participant 1) throughout the study. When participants broadly refer to “interpreters,” the term “interpreters” is used.

Data Collection

Data collection was conducted with the finalized interview guide. Interviews were conducted virtually and in private from participant and researcher homes in 2021–2022. AO, PSL, KAB, and JBT (i.e., interviewers), all of whom received training in theory and application of qualitative methodology, conducted the interviews. Participants were assigned code numbers to anonymize recordings and subsequent transcripts. To center participant’ lived experience, questions were open-ended. Prompts were included to allow researchers to engage in dialogue and ask about topics arising in participant responses (Smith et al., 2009). Researchers also took notes during interviews to organize their thoughts and follow-up questions (Creswell, 2014). Interviewers completed field notes detailing the main concepts discussed. Interviews were approximately 45 minutes in duration. All participants had the option to interview in English or Spanish. All opted to conduct their interviews in English. Interviews were audio-recorded, and audio recordings were de-identified prior to verbatim transcription. Researcher notes, audio recordings, and transcripts were stored in a protected location. Recruitment stopped once data saturation was achieved (Hennink & Kaiser, 2022).

Data Analysis

Interview recordings were transcribed verbatim, and transcriptions were reviewed by the coding team (AO and PSL). Following protocols outlined in Smith et al. (2009), Saldaña (2016), and Larkin & Thompson (2012), the Co-PIs (AO and PSL) analyzed data in rounds to organize interpreter experiences and create a narrative synthesis of data based on themes. Co-PIs independently read transcripts and wrote initial notes on perceived patterns of meaning. Next, Co-PIs met to discuss initial perceptions and bracket potential biases in data analysis. Afterward, Co-PIs independently reviewed batches of three transcripts to identify emergent patterns of words and phrases representing participant “objects of concern,” (meaningful events, actions, etc.) and participants’ understanding of them (Larkin & Thompson, 2012). Co-PIs convened after independently analyzing batches of transcripts to establish provisional codes and operational definitions; discuss coder positionality and biases influencing data interpretation; record emergent codes; and reach coding consensus through discussions. A provisional code book and operational definitions were written after this round of coding. AO and PSL then revisited the transcripts to finalize codes, update the codebook, and address any remaining coding discrepancies. QSR NVivo Software was used to code all data with finalized codes. Once all data was coded, Co-PIs reviewed data for overarching themes. Subsequently, AO and PSL reviewed codes and themes with additional research team members (SE, WHD, CBR, and MCS), and later presented results to the entire team for debriefing and discussion. For the section of data analyzed in this study, finalized themes are: 1) clinician communication practices prior to IME, 2) clinician communication practices during IME, and 3) systems-level factors impacting IME communication.

Trustworthiness and Credibility

Six participants volunteered to participate in a subsequent member checking exercise with AO and PSL. Member checks were conducted individually and virtually and consisted of an open discussion of overarching themes emerging from the data. Member checking validated results for accuracy and credibility. Peer debriefing was utilized after coding and thematic synthesis prior to finalizing results. Documentation of team meetings and theme consensus were used to ensure qualitative credibility, dependability, and confirmability, which parallel quantitative validity and reliability (Nowell et al., 2017).

Results

When asked about specific clinician behaviors or expectations that make it easier or harder to communicate when families are distressed, interpreters discussed three overarching themes: clinician communication practices prior to IME, clinician communication practices during IME, and systems-level factors impacting communication. Results and recommendations per theme are summarized in Table 2.

Table 2.

Factors Impacting Communication in Interpreted Medical Encounters: Recommendations Based on Study Themes

Theme 1: Communication Practices Prior to IME	Theme 2: Communication Practices During IME	Theme 3: Systems-level Factors Impacting Communication in IME
Support Interpreters’ Preparedness: • Request interpreters in advance when possible and share information about the encounter as soon as able. • Consider that interpreters might have rushed from another encounter. Allow space and time to ensure that interpreters are mentally, emotionally, and physically ready to interpret. Ensure Interpreters’ Briefing: • Meet with interpreters privately before an encounter to brief them on the medical context and aims of the encounter. • Highlight areas where providers anticipate nuanced, complex, or emotional conversations, so that interpreters can prepare vocabulary and clarify meaning with providers in advance. Coordinate Message with Other Parties: • Discuss with other parties (e.g., other subspecialists, nursing staff, other members of team) to ensure consistent messaging for interpreters and families. • If the interpreter has worked with the family before, ask them what information they have interpreted. Interpreters may know what families have already heard. • Consider asking the patient’s nurse for additional context or updates, and do so, ideally, with the interpreter present.	Optimizing Setting for IME: • Providers should position themselves to have eye-contact with patient/family. • Ensure interpreter is in position to see and hear all parties’ communications (verbal and nonverbal). • The encounter is tetradic or tetradic+: do all parties need to be present? Designate a clinician to manage communication so that one person speaks at a time. Make room in the conversation for interpreter to render information without side conversations occurring in the space. • Allow extra time for IME. Speaking/Linguistic Considerations: • Speak directly to patient/family in first person. • Speak in short, clear phrases or sentences. • While pausing is helpful, pauses should be between thoughts rather than in the middle of thoughts/phrases/ideas. • Consistent with joint-commission guidance, communication should be at or below 5th grade reading level. • Speak clearly and avoid medical jargon. • Avoid slang, idioms, puns, jokes, adages, and other utterances that may be regional or require cultural knowledge. • Allow the interpreter time to interpret completely what has been said and avoid interrupting. Provider Disposition/Attitude: • Use empathic communication to show concern for patients and families. Kindness towards patients/families resonates with interpreters and facilitates effective communication. • Leave external stresses and attitudes outside of encounters as much as possible since negative attitudes can further encumber IME. • Be mindful of your body language and what it conveys to families.	Background Knowledge: • Remember that interpreters are trained professionals and adhere to codes of ethics and standards of practice. • Know relevant guidance, rules, and resources governing interpreters at your institution. • Understand that interpretations will not match what you say in the number of words or length of the interpretation due to structural and conceptual differences in languages. • Remember that interpreters play multiple roles. Work with them as they move among message conveyer, message and cultural clarifier, and advocate roles. Learning and Development: • Understand that IME present unique opportunities to collaborate with bilingual cultural experts and to learn about and better understand your patients/families. • Seek out opportunities to learn about working with interpreters more effectively. If no opportunities exist, develop them with your interpreter colleagues. • Debrief with interpreters after encounters to get their perspectives on what to improve and what went well in the IME, and to discuss any doubts you have about patient/family understanding. • Know that interpreters are communication experts and may observe elements of miscommunication. Be receptive to their feedback and utilize their skills to optimize communication. Relational: • Interpreters are busy professionals. Be patient and express gratitude where appropriate. • Get to know the interpreters! Exchanging pleasantries before or after encounters can go a long way. • Treat interpreters as colleagues and specialized members of the treating team. • If you work with trainees, teach/role-model good practices for working with interpreters, so they too can develop IME best practices. Troubleshooting: • If there are concerns about the fidelity of messages being interpreted, rather than questioning the interpreter, consider using a “read back” directed at the patient/family (e.g. “That was a lot. Can you tell me what you understood from what I said to be sure that I am communicating well?”). • If you have concerns about the accuracy of interpretation, pause and discuss your concerns with the interpreter outside the patient/family room.

Clinician communication practices prior to IME

Participants reported that when clinicians brief them prior to interpreting, communication in distressing IME is improved. Participant 1 said that “going into what will be emotional situations prepared makes a huge difference.” Participant 2 said that knowing “what’s happening: are we making major decisions in this appointment? Are we discussing end of life?” facilitates distress communication in IME. Some participants reported that before going into IME, “we are never warned what we are going to be talking about” (Participant 3), and “if I get called last minute and I am available and I go, then I’m walking into the unknown” (Participant 4). Participants also noted that it is helpful when clinicians allow time for interpreters to conduct a pre-session at the beginning of IME with families and clinicians. In pre-sessions, interpreters inform all parties of interpreter roles and practices, suggest communication practices for stakeholders in IME, and gauge participant language varieties.

Clinician communication practices during IME

During distressing IME, participants cited that clinician attitudes toward patients and families may negatively influence communication (e.g., “they [clinicians] don’t seem as patient;” Participant 4). Alternatively, “clinicians who have good demeanor with their patients, who are kind, and who seem like they actually care regardless of where the patient is from and regardless of what language they speak” (Participant 5) positively impacts communication in distressing pediatric IME. Participants also noted that the terms or expressions clinicians use play a role in difficult discussions. Lay terms, as opposed to medical jargon, is more effective when speaking with distressed families [e.g., “when the clinician just speaks to the family like they’re speaking to a family member, they’re just trying to explain something in layman—just easy terms—like, I think that’s great;” (Participant 4)]. Participants also expressed that culture-specific items, such as sayings and expressions, can be difficult to interpret. For example, Participant 5 explained, “a lot of those sayings may not be easy to interpret because there’s no real—an equivalent in the other language or in the other culture for the saying.”

In addition to what clinicians say, how they say it also impacts communication in distressing IME. Clinicians who convey partial ideas or thoughts make communication more difficult, as a participant explained: “Some of them [clinicians] will say a couple of words and then they expect you to interpret but I’m like, ‘say a whole sentence or a whole thought,’ and that helps me a lot and that helps the family understand too” (Participant 2). Other participants highlighted clinician register and pausing as important. When clinicians “lower the register or they pause during the time that they’re talking, [it] makes it easier for us to communicate” (Participant 6). Participants reported that when clinicians enunciate clearly and use short phrases to convey meaning, communication is higher quality in distressing IME.

Additionally, Participant 1 and Participant 5 identified clinician positioning as important in distressing IME (e.g., where clinicians position themselves vis-à-vis the interpreter and the patient/family). Finally, Participant 5 and Participant 7 found it helpful when clinicians look at and speak directly to families instead of speaking to interpreters during distressing encounters.

Systems-level factors

Clinician communication practices due to systems-level challenges were found to diminish health communication in distressing IME. For example, participants said time constraints or clinicians who feel rushed impact communication with distressed families and with other clinicians. Participants also reported that breakdowns in clinician team and clinician-interpreter discussions compromised the quality of distress communications. For example, Participant 8 noted:

It’s harder when the clinician enters, or they might be a specialist and they don’t know exactly what’s going on…and so they kind of ask the patient the same questions. They say, ‘Oh what did the specialist say,’ instead of like looking up in the chart and then seeing what that specialist said…Which probably doesn’t help when the patient is already feeling distressed.

Additionally, participants identified clinician education or knowledge of best practices for working with interpreters as important factors. Participant 2 explained that sometimes interpreters must educate clinicians on how to work with interpreters before or during IME. Participant 2 said that “our most seasoned clinicians, they pick up on all this stuff. They’re so good. But…we get a lot of new residents and fellows…so that’s usually when I bring it up,” referring to best practices for working with interpreters.

Participants also described communication difficulties in distressing IME when many people are involved in the encounter. For context, IME in adult settings typically involves communication among a triad (clinician-interpreter-patient). In pediatric settings, communication is triadic when pediatric patients are not involved in the conversation (clinician-interpreter-parents/families). When pediatric patients are involved in the conversation, the encounter may be tetradic+ (IME involving more four or more parties; e.g., clinicians-interpreter-parents-child). See Figure 1 for a description of basic triadic and tetradic+ IME. In tetradic+ encounters, bilingual pediatric patients may communicate directly with clinicians in English. Consequently, parents may not understand conversations between clinicians and bilingual pediatric patients. In such cases, interpreters may simultaneously interpret patient-clinician conversations to parents. During simultaneous interpreting, interpreters listen to messages in language A and immediately interpret them into language B as the messages are spoken. In this interpreting mode, two people in the encounter are speaking different languages at the same time. Participants reported that in tetradic+ encounters like these, it can be more challenging to convey all aspects of patient-clinician discussions to parents or family members. For example, Participant 7 reported: “at some point the conversation gets lost or words get lost because you’re trying to make sure that mom is understanding but also trying to keep up with what the kid and the doctors are saying at the same time.” Another participant identified the need to switch between consecutive (turn taking) and simultaneous interpreting modes. Along these lines, Participant 1 said it is important “in the pediatric realm… when the teenager speaks English and the mom speaks Spanish, making sure that you jump into simultaneous instead of consecutive interpreting so that you’re not omitting things.”

Figure 1.

Basic Forms of Triadic, Tetradic, and Tetradic+ IME

Similarly, participants said that interpreting in distressing IME is more challenging when multiple clinicians (e.g., during rounds) or family members talk over one another or at the same time. Participant 1 discussed this phenomenon: “Everybody is talking at the same time. You cannot be interpreting for everybody at the same time. Remember, you have one mouth, two ears. You can hear 10 people at the same time, but you cannot talk 10 times at the same time.” Participant 5 connected tetradic+ IME to the importance of conducting a pre-session with families and patients prior to interpreting:

A lot of times if you’re in that type of situation where the parent doesn’t speak English, the child, who’s the patient, speaks both English and Spanish, the doctor may be asking questions of the child, the child knows exactly what the doctor said. So I have to make sure that before the encounter, when I do my pre-session, I kind of try and get a feel for where the patient’s or the child’s language skills are. And through that, if I realize that the child does know the language and is completely capable of answering the question that the doctor just asked in English, I have to make sure that the child understands that they need to wait till I interpret what the doctor said before they provide an answer. So that’s part of what I need to kind of figure out before the encounter begins.

Finally, participants explained that IME communication is improved when clinicians are receptive to interpreters, when clinicians and interpreters have established working relationships, and when there is a sense of teamwork between clinicians and interpreters. Participant 5 reported: “When you work with your doctors, you kind of know your doctors. You know their cues sometimes. They give you the look, and it’s like, ‘Hey, this is your time to come in.’ Sometimes you create that bond with your doctors, that you know when to come in and you know their style and how they work.”

Discussion

This study explored pediatric medical interpreters’ perceptions of clinician communication practices that facilitate or hinder communication in pediatric IME with distressing content. Participants reported that medical clinicians play an important communicative role in distressing IME. Participants stated that clinician communication practices directly impact interpreters’ ability to facilitate cross-language, cross-cultural communication, and ultimately influence the quality and effectiveness of communication. Results from this study substantiate existing guidelines for quality IME communication and extend these guidelines to novel recommendations for clinician communication in distressing IME.

Results from this study align with existing recommendations for facilitating effective communication during IME from professional associations and studies conducted in adult and pediatric hospitals (see Table 3 for existing and novel recommendations in triadic and tetradic+ IME). Some of these recommendations include:

Table 3.

Clinician Best Communication Practices in Triadic and Tetradic+ IME.

Triadic IME

Meet with interpreters prior to IME to indicate context and communication goals (pre-brief).

When the IME begins, allow for a pre-session (interpreters introduce themselves, explain the interpreting process, and check patient/caregiver language variety).

IME may take extra time. Allow sufficient time for the encounter.

Approach patients/families with a positive attitude.

Position yourself and other participants so all parties can see each other whenever appropriate.

Use lay language and avoid sayings and jokes.

Use an appropriate/consultative register with patients and caregivers.

Speak in short, straightforward phrases and complete thoughts.

When culturally appropriate, look at patients and caregivers when speaking.

Allow for interpreter clarifications.

Debrief with interpreters after encounters to hear their perspectives or concerns.

Treat interpreters as teammates and colleagues.

Seek training and teach medical trainees IME best practices.

Tetradic+ IME

All best practices for triadic IME apply to tetradic+ IME. Special considerations for tetradic+ encounters include:

Become familiar with the different modes of interpreting used in tetradic IME.

During pre-brief, express your preferences regarding interpreting modes.

Identify essential IME participants and ask others to step out.

Designate a clinician to manage speaker turn taking and/or create a plan for managing communication flow with the interpreter.

Coordinate more frequent pauses for interpretation.

Check in with parents frequently when speaking to patients in a shared language.

Watch for interpreter signals for when to pause or resume conversations with patients.

Ask parties involved to refrain from conversing when interpreters are interpreting.

If tetradic+ communication becomes unwieldy, pause the IME and consult with the interpreter outside the room.

Adjust communication expectations and goals during encounters if needed.

1. Prior to IME, conducting pre-briefs and informing interpreters of encounter communication goals (AAMC, n.d.; Cline et al., 2021; Hudelson et al., 2005; Leanza et al., 2014; Norris et al., 2005; Rhodes et al., 2021; Silva et al., 2022b; Weaver et al., 2022; Williams et al., 2018).

2. Clinicians and healthcare organizations allowing interpreters time to conduct pre-sessions with clinicians and families on best practices for working with interpreters (IMIA, n.d.; Tribe & Thompson, 2017; Wiener & Rivera, 2004).

3. Using lay language and avoiding expressions with no clear equivalent in the target language (IMIA, n.d.; Hudelson et al., 2005; Norris et al., 2005; Silva et al., 2022b; Weaver et al., 2022).

4. Using an appropriate/consultative register with patients (Hadziabdic et al., 2013; Silva et al., 2022b).

5. Speaking in short, straightforward phrases (IMIA, n.d.; Hadziabdic et al., 2013; Juckett et al., 2014; Leanza et al., 2014; Silva et al., 2022b; Wiener & Rivera, 2004).

6. Considering clinician time constraints and allotting sufficient time for the encounter (IMIA, n.d.; Norris et al., 2005; Tam et al., 2020; Williams et al, 2018).

7. Using correct positioning so parties can see each other (AAMC, n.d.; Leanza et al., 2014)

8. Clinicians looking directly at patients/families (AAMC, n.d.; IMIA, n.d.; Hadziabdic et al., 2013; Juckett et al., 2014; Leanza et al., 2014; Rhodes et al., 2021; Silva et al., 2022b; Weaver et al., 2022).

9. Approaching patients requiring interpreting services with a positive attitude (Hadziabdic et al., 2013).

10. Debriefing with interpreters after encounters (IMIA, n.d.; Leanza et al., 2014; Lim et al., 2022; Norris et al., 2005; Silva et al., 2022b; Weaver et al., 2022; Wiener & Rivera, 2004).

11. Establishing a sense of teamwork and collegiality with interpreters (Hadziabdic et al., 2013; IMIA, n.d.; Rhodes et al., 2021; Williams et al., 2018).

The discussion of these practices by this cohort of pediatric medical interpreters further validates the above as best practices in high-acuity, pediatric medical encounters. Additionally, participants in this study advocated for clinician training, especially for residents and fellows, to improve their adherence to the aforementioned practices. These recommendations have also been reported elsewhere (Silva et al., 2022a).

Novel findings in this study relate to multilingual health communication in tetradic+ IME. Participants noted that pediatric encounters are more challenging to facilitate when bilingual patients speak directly with English-speaking clinicians while their family members who require interpreting services are present. Literature on clinician communication in language-concordant pediatric encounters highlights the increased degree of communication difficulty in triadic encounters (clinician-parent-child) compared with dyadic encounters (patient-clinician). This is due to the quantity and quality of health information being relayed; the need for clinician sensitivity to both the patient and parents’ feelings; the importance of building trust with parents and pediatric patients; and the need to create an environment in which all parties can express concerns, perspectives, and suggestions (Damm et al., 2015; Mărginean et al., 2017). These challenges apply to pediatric IME and may be exacerbated by the cultural and linguistic variance among clinicians, parents, and children.

In tetradic+ IME, participants reported having to manage the flow of communication and mode switching (consecutive and simultaneous) while interpreting. This includes having to interrupt monolingual clinician-patient conversations to allow for parent interjections, clarifications, and corrections. Interpreters in tetradic+ encounters may also need to signal to patients and clinicians to pause their conversation so that interpreters can relay statements to parents and wait for a response. They reported that sense and meaning may be lost more easily when interpreters try to capture and convey information while also managing the communication flow. Participants in this study said tetradic+ IME encounters are challenging for these reasons.

Similarly, participants in this study identified challenges in distressing IME when many people are involved in the encounter. Having several parties in the room may lead to multiple conversations or statements occurring simultaneously. This impacts interpreters’ abilities to hear what is said, accurately relay meaning, and convey patient or parent concerns back to clinicians. When interpreters invest cognitive resources into these activities, fewer resources are available for accuracy and completeness in rendering content. Interpreting is a highly demanding cognitive practice and resources can become depleted quicky in complex encounters with multiple parties (García et al., 2020).

Finally, a new finding in this study is that clinicians who are not communicating with one another can present challenges for IME stakeholders. Participants noted that clinicians may speak with families without knowing what other clinicians on the care team have previously told patients and families. Participants said that this may cause further distress for families, may be uncomfortable for interpreters, and could suggest care team disorganization. All of this, in turn, could impact family-clinician trust. In some hospital settings, the breakdown in clinical team communication is a risk of the clinical training environment. Since multiple levels of trainees (fellows, residents, and medical students) are expected to interact with families, there is the potential for miscommunication of information over multiple encounters. Strong communication among diverse members of treating and teaching teams is crucial for ensuring the health literacy of language-diverse families in IME.

Clinical implications

Clinicians in tetradic+ IME should focus on collaborating with interpreters for optimal multicultural and multilingual health communication, especially in encounters with distressing content. While clinician awareness of interpreter practices is the first step in making tetradic+ encounters more productive, clinicians can also adopt specific behaviors and practices in these settings (see Table 3). These include:

1. Coordinate more frequent or appropriate pausing for interpretation.

2. Check in with parents/family members frequently and watch interpreter signals for when to pause or resume conversations with patients, especially when both clinician and patient speak the same language.

3. Understand that interpreters might interrupt or switch modes of interpreting depending on the kind of communication in the encounter. Although simultaneous mode can be distracting to clinicians and it may feel that interpreters are speaking over them, it is used so that family members can receive an immediate interpretation of conversations in case they need to correct or add information.

4. Be open to interpreter management of communication flow in complex communicative settings. Interpreters may raise their hands or signal in other ways that one speaker must pause. They do this not to be rude, but so they can accurately convey what has been said before content becomes buried under increasing amounts of information.

5. Play an active role in managing speaker turn taking and pausing along with the interpreter, so that interpreters can focus their cognitive resources on conveying accurate and complete messages.

6. Conduct a brief meeting with interpreters before the encounter to determine how to manage language flow when parents and patients have different language practices and abilities. This is especially important when discussions will be difficult or distressing.

7. Clinicians who are experienced in successfully working with interpreters should brief other participating clinicians who have not learned IME communication best practices prior to the IME.

These recommendations suggest that clinician-interpreter teamwork is imperative because it may: 1) prevent sense and meaning loss among IME stakeholders; 2) increase diagnostic accuracy; 3) ensure parties involved have space to communicate concerns or ask questions, and 4) support interdisciplinary team members in their respective practices.

Participants’ reflections on inconsistent messaging from different specialties is a reminder that not all barriers are specific to IME. Multiple prior studies have found that parents are frequently frustrated by inconsistent and incomplete information (Debelić et al., 2022; Meert et al., 2008; Rennick et al., 2019). Results from this study indicate that this is also a problem in IME, which may be exacerbated by linguistic and cultural differences between clinicians and families. To remedy this, clinicians and trainees should be meticulous in reviewing primary data and convening with consulting, collaborating, and teaching clinicians to ensure consistent messaging prior to meeting with families in IME.

Limitations

Although all language pairs were recruited to participate in this study, only Spanish-English interpreters participated. External agency interpreters and video-remote or telephonic interpreters were not included in the participant pool. These factors may limit the degree to which this study’s findings generalize to non-Spanish-English interpreters, or to interpreters working remotely and who come from external agencies. Additionally, only qualitative measures were used in this study regarding the primary topic. While this was purposeful in this exploratory study, a follow-up quantitative survey would enhance understanding of the phenomena participants discussed in this study.

Conclusion

These findings validate clinician “best practices” specifically in pediatric, high-distress settings and expand on recommendations for communication in distressing pediatric encounters, in particular with regard to tetradic+ IME. This study also points to the importance of baseline good communication. Attention to communication practices is perhaps even more consequential in IME than in language-concordant encounters due to the need for an interpreter and the language transfer process. Additionally, this study reinforces the important role clinicians play in managing the flow of distressing IME and communicating amongst themselves to prevent family mistrust of care teams, including interpreters. Clinicians can help create an environment of belonging and mutual respect for their interpreter colleagues and for families that use interpreting services by educating themselves on best practices for communicating in IME (Lor et al., 2019). Clinicians can also request education on working with interpreters, and advocate for interpreters and interpreting services as an integral component of linguistically and culturally effective care. All parties in IME can take part in improving health equity for language-diverse families by cultivating quality language access services.

Future studies may consider the feasibility, acceptability, and efficacy of IME communication practices from clinician, family, and interpreter perspectives, and their impacts on patient health outcomes and trust among IME stakeholders. Further research into tetradic+ pediatric IME with bilingual patients and monolingual family members is warranted. Finally, comparative studies on guidelines for working with interpreters in medical health settings, and in psychological and mental health settings, may identify gaps in medical guidelines for working with interpreters in distressing IME.