Communication challenges between nurses and migrant paediatric patients

Abstract

Background

Many people receiving medical treatment in Switzerland speak none of the country’s four languages or English, which is a major communicative barrier for health staff. Appropriate treatment in hospitals depends on the successful communication between hospital staff and patients. Consequently, migrant patients can be particularly challenging for hospital staff.

Aims

The aim of this project was to examine the following topics: (a) which communicative challenges hospital nurses are confronted with in the care of migrant paediatric patients and how they cope with them, and (b) what requirements nurses (and other stakeholders) have regarding a digital communication aid to improve the care of migrant paediatric patients in the hospital setting.

Methods

This study used a qualitative approach. The following steps of data collection were undertaken: (a) two literature searches corresponding to the research questions, (b) a focus group interview with paediatric hospital nurses, (c) observation of communication between paediatric nurses/healthcare professionals and children/parents through shadowing, (d) short interviews with paediatric nurses who were being shadowed, and (e) a focus group interview with experts. Data analysis was based on thematic analysis and was supported by MAXQDA software.

Results

Evaluation of the data showed there are multiple communicative challenges that emerge in the care of migrant paediatric patients. These challenges influence each other and appear at different moments in the hospital stay. Additionally, the results revealed that digital communication aids must be user friendly and easily accessible.

Conclusions

This study highlights the areas of hospital care in which a digital communication aid could be feasible. However, many of the described communication challenges stem from issues that cannot be solved solely with a digital communication aid. Instead, strategies to tackle these issues must be embedded in the training of nursing staff, in the hospital management strategy and at the political level.

Introduction

Due to political and demographic developments, many countries are facing challenges related to migration. Switzerland is no exception and in 2017 the proportion of foreign people in the general population reached over 37% (BFS, 2017). The main language spoken of approximately 700,000 people (around 9% of the total population) living in Switzerland is not one of the four national Swiss languages. Additionally, approximately 200,000 of these people neither understand a national language nor English (Swiss Hospitals for Equity, 2016). Studies have shown the health status of members of the migrant population is worse in many ways than that of the general Swiss population. Due to language barriers, the treatment and care they receive is often not equivalent to that of the non-migrant population (Langer and Wirth, 2014). As a result, the Federal Office of Public Health has launched programmes to promote the health of the migrant population in Switzerland and thus contribute to equal health opportunities (Bundesamt für Gesundheit, 2013).

To provide high-quality care and treatment and ensure the wellbeing of patients, clear and comprehensible communication between health personnel and patients is essential (Tang and Newcomb, 1998). Language barriers have a significant negative influence on the quality of treatment. They impede medical care, make therapeutic success more difficult, impair treatment quality and adherence to therapy and thus endanger patient safety (Goenka, 2016). They can cause overuse, underuse or even misuse of services and lead to unnecessary cost expenditures (Swiss Hospitals for Equity, 2016; Bischoff and Steinauer, 2007). Adequate and cost-effective treatment in hospitals requires successful communication between medical staff and their patients. Therefore, migrant patients are a particular challenge, especially for nurses (Metz, 2010). Previous studies have shown the use of professional interpreters is the most effective method for overcoming these language barriers (Lion et al., 2015; Flores et al., 2012). However, such interpreters are not always available, either due to lack of time or due to their cost (Langer et al., 2013). Consequently, relatives or multilingual hospital staff are often utilised for translation services, although this is known to be associated with many problems (Flores et al., 2012). To overcome such communication barriers, nurses often improvise using ad hoc aids (Kaufmann et al., 2018). This can lead to unsatisfactory situations, both for the patients and nurses. However, there are often situations in which patients and nurses do not require an interpreter but do need more than gestures or ad hoc aids. To assist in such situations, a digital communication device tailored to the needs of patients could provide such support (e.g. in daily communication, at night or in unplanned encounters) (Day and Song, 2017; Crowley et al., 2017).

Research questions and aims

This study examines the communicative challenges that nurses working in hospitals face when caring for migrant paediatric patients (MPPs) and their parents. It also explores the strategies that nurses use to overcome such communication barriers. The aim of this study was to define adequate criteria for the future development of digital communication aids in the care of MPPs, including the aspects of both content and functionality. Therefore, this study focused on the following research questions:

1. Which communicative challenges do nurses face with MPPs and their parents and how do they deal with them?

2. What requirements do nurses (and other stakeholders) have for a digital communication aid?

Methodology

Design

To examine the perspectives of nurses working with MPPs and their parents, a qualitative design was chosen. Qualitative research methodology is very suitable for exploring people's perspectives and experiences (Mayan, 2009). This study consisted of individual interviews, focus group interviews and shadowing at a paediatric unit in a Swiss university hospital.

Study site and participants

This study was conducted at an inpatient paediatric unit of a university polyclinic in the German-speaking region of Switzerland, treating patients 2 to 16 years of age. This inpatient unit focuses care on cardiology, neurology, nephrology, diabetes, metabolic diseases and psychosomatic diseases. The patient spectrum of the unit is heterogeneous in regard to nationalities and typically 20% of the children treated annually are non-Swiss. In 2017, 35 different nationalities of patients were treated. A large proportion of foreign-language speaking patients was important for this study. Also important for this study was that patients should not have been hospitalised for too long to ensure there was enough diversity in the observations (average length of stay at the unit was 6.63 days). Also, when possible, patients needed to be old enough to speak well independently and to not be seriously ill. The participating paediatric nurses (PNs) all worked in the above-mentioned unit. They were all females aged 20 to 53 years, with work experience ranging from very little to a lot (up to 30 years). Some PNs were Swiss, whereas others had a migration background.

The primary stakeholders (PNs, MPPs and their parents; note that ‘parents’ refers to biological parents and legal guardians) in the paediatric setting were defined by the research team. As parents are essential participants in communication (Jaeger et al., 2013) (see Figure 1) the focus of this study was on PNs and their communication with MPPs, as well as with their parents. The secondary and peripheral stakeholders were identified based on literature search one and through shadowing in the field. They were also affected by communication problems; however, they were not the focus of this study.

Figure 1.

Stakeholder overview.

Data collection

Numerous steps in data collection were undertaken from February to October 2018, including two separate systematic literature searches (as there were two research questions).

Systematic literature search one

A systematic search in the literature for the last 10 years was undertaken in the following databanks: Pubmed, Web of Science and CINAHL. Inclusion criteria consisted of scientific articles, expert opinions, grey literature (government and World Health Organization documents, migration services documents), English abstracts with full-text articles, along with German full-text articles with English abstracts. Articles originating from Switzerland, Europe and from the international level, were included. The focus was on communicative challenges nurses experienced in the hospital setting with children with a migration background (linguistic/cultural background), from the perspective of the stakeholders (‘care staff’, ‘children’, ‘parents’ and ‘translators’ (interpreters)).

One person (author five) carried out the systematic literature search (see Prisma, Figure 2), including a search for grey literature in Google. Two authors (authors two and five) separately read the abstracts and then together either included or excluded them (n = 23 excluded). Thereafter, the potentially included articles were examined separately by two authors (two and five) and were either included or excluded (n = 19 excluded), with the reasons for exclusion being given. The included studies (n = 15) were then read by two authors (authors one and two), and their connection to the research question was highlighted. Key topics were identified through this process.

Figure 2.

Prisma literature search one.

Systematic literature search two

A second literature search was conducted to discover what scientific articles existed regarding digital aids in the hospital setting. Due to time and financial constraints in the project, only one database was searched (Pubmed) and included snowballing, along with a search in the grey literature. Inclusion criteria were the same as with the first search; however, it was instead based on the last 5 years. The articles needed to demonstrate a focus on a combination of the following terms: computers, handheld computers, multimedia, smartphones, hospitals, children, nursing staff and communication. This literature search (see Prisma, Figure 3) was carried out by one author (author five), along with all of the other steps, including completion of a summary of the included studies (n = 10). This summary was read by two authors (authors one and two).

Figure 3.

Prisma literature search two.

Focus group interview with PNs

Five PNs from the unit where the shadowing took place, were interviewed as a group by three authors (authors one, two and three). Verbal consent was obtained and recorded at the beginning of the interview. In regard to the research questions, the interview focused on: (a) what are the main communication problems in your everyday work and how do you deal with them, and (b) what must a digital communication aid be able to do to support your work with MPPs and where would a digital aid not be helpful? These questions were developed collaboratively by the three authors and sought to gain the perspective of the nurses. The focus group interview was transcribed by one author (author one).

Shadowing and short interviews

Verbal consent to shadow the PNs during their daily work (when MPPs with language barriers were present on the unit) was obtained from both the nursing unit manager and from the nursing team (PNs = 10, MPPs = 14). The researchers strictly adhered to the ethical permission obtained and did not engage in any contact with the patients; the role of the researchers was to shadow the PNs. Time permitting, short interviews (between 1 and 15 minutes long) were conducted with the PNs to better understand the observed situations. The questions in the short interview followed a topic guide and were focused on the observed situations, as well as on the challenges present when caring for MPPs. During the shadowing, field notes and individual interviews with PNs were immediately recorded in writing, using a collaboratively developed observation protocol. The protocol included the communication process, the actors, the language used, any communication problems, strategies or aids used, as well as subjective comments. The documented observations were transcribed by the same author who had undertaken the shadowing.

Focus group interview with experts

Nine Swiss experts were invited to a presentation regarding the preliminary study results to validate and enhance the findings. They were chosen as they either held functions for diversity management, equal opportunities or intercultural communication in Swiss hospitals or federal offices, or had expertise in health communication related to migration. Recruitment was via personal networking. The interview focused on the following points: (a) discussion of study results, (b) documentation of further communication challenges, and (c) documentation of experts' ideas regarding the main criteria or requirements for a digital communication aid. The discussion was recorded and key points noted on flip charts. Verbal consent was obtained and recorded at the beginning of the interview. Subsequently, the flip charts were transcribed (author one).

Ethical permission

In accordance with Swiss legislation, it was not necessary to submit the study to the local Swiss Ethics Commission, as shadowing did not include any researcher involvement with the patients. According to the Clarification of Responsibility from the Swiss Ethics Commission, the study did not fall under the Human Research Law. The head of the clinic and the head of nursing approved the study in written form, prior to initiation of the interviewing and shadowing. Verbal informed consent was obtained from the nursing unit leader, as well as from the nurses on the unit prior to their participation in the study. The PNs and the MPPs were coded numerically (anonymously) upon entry into a data-management system.

Data analysis

This study used thematic analysis qualitative research methodology. This was undertaken in accordance to Braun and Clarke’s six-step framework (Braun and Clarke, 2006). Thematic analysis was viewed as being most suitable for this study, as we aimed to identify patterns as well as to interpret and make sense of them (Maguire and Delahunt, 2017). The following steps were undertaken to analyse the data: (a) identifying themes from literature search one; (b) using the identified themes from literature search one for the initial coding in MAXQDA of the focus group interview with PNs, shadowing field notes and short interviews with PNs; (c) adapting/supplementing the coding system with new emerging themes from the focus group interview with PNs, shadowing field notes and short interviews with PNs; (d) reviewing themes from the focus group interview with experts; and (e) defining and naming the final themes based on these previous steps. The first five of the six steps occurred during this stage. Step 6 (producing the report) was completed after the results were obtained.

Results

Emerging themes were extracted based on the above data analysis process (see Figure 4). This process allowed conclusions to be drawn to answer the two research questions described in the introduction. Both research questions will be addressed in the following results.

Figure 4.

Thematic map – an overview of results.

Communication needs

The communication needs of the PNs were sought during the focus group interview. The needs of all primary stakeholders were included during the coding of the field notes. The most important need identified in the hospital was mutual understanding and it appeared frequently in all analysed data. Nevertheless, the various stakeholders did have differing needs. PNs depended on good communication for the professional undertaking of their work, as the following quote reveals: “It is important to reach the goal of achieving a good quality of care, despite the language barrier – care does not work without communication” (nursing student, short interview). In general, the key identified needs of MPPs and their parents were understandable information, the possibility to express needs and feelings and having contact with hospital staff with whom they could build trust. Jaeger discussed that MPPs are foremost children, so many of their basic needs are the same as that of other children (Jaeger et al., 2013). Diversion and entertainment help them to deal with emotions such as fear, homesickness and boredom.

Influencing factors and communication challenges during the hospital stay

In an inductive process, the influencing factors and the communicative challenges in hospital care that were identified in the literature, were supplemented with the following: (a) the results of the focus group interview, (b) short interviews with the PNs, and (c) shadowing. The factors that could have a negative impact on communication were grouped into six thematic categories: language barriers, culture, health literacy (MPPs or parents), emotions, diagnosis and working conditions. Communication problems could arise at different points during the hospital stay. Figure 5 depicts the factors that influenced communication and where the problems occurred during the hospital stay.

Figure 5.

Influencing factors and communication challenges in hospital stay.

Influencing factors

Language barriers were by far the most common influencing factor according to the literature and the frequency of codes. Communication problems were mainly caused by a lack of language competency with patients. The inability to communicate had a direct effect on the daily work of the nursing staff, which could lead to feelings of helplessness and frustration, as the following quote highlights: “And then they talk to a wall and we talk to a wall – I find that very difficult” (person five, focus group interview with PNs). Incorrect or insufficient use of communication strategies or aids, were also considered a language barrier. Additionally, other factors such as time or culture could be influenced by the lack of language competency.

In all areas of data collection, the cultural background had a major influence on the communication between nurses, MPPs and their parents. Influencing factors included beliefs and values, different role models or the perception of the disease (Siefen et al., 2015). Parents sometimes interpreted the child's illness as ‘witchcraft’ or ‘an examination of God’ (Jaeger et al., 2013: Karabudak et al., 2013). Different habits, values or education were rarely present in literature, but were often observed in shadowing. During a hospital stay, the different value systems between school and home were sometimes difficult for MPPs to manage (Jaeger et al., 2013). Regarding culturally determined role models, fathers sometimes found it difficult to accept the competence of female nurses (Jaeger et al., 2013; Festini et al., 2009): “According to a nurse, some fathers don't accept women in nursing or female doctors, and language can also then affect these cultural differences” (nurse seven, short interview).

Identified influencing factors in the health literacy category were a lack of understanding of medical conditions, poor compliance or inadequate disease management. Such challenges in patient education led to difficulties for patients and relatives in coping with the disease. Giving instructions could be especially difficult: “Regarding diabetes, we have photos about the daily schedule. But they have to be able to do it themselves afterwards. We then need to check again to make sure they understand. Why are they injecting now? How much? When? Why?” (person four, focus group interview with PNs). Compliance upon discharge was affected because the therapy or medication was not understood, or there was no understanding that it must be continued (Jaeger et al., 2013; Karabudak et al., 2013). Additionally, informed consent was unattainable when adequate health literacy was not present. Moreover, parents from certain cultures may not have wanted to make shared decisions. They preferred instead that the doctor decided (Jaeger et al., 2013). Accessing health services after discharge from the hospital was also difficult.

The most mentioned issue in individual interviews and in the focus group interview concerning the category of working conditions, was the ‘lack of time’. This was obvious during shadowing because the care of MPPs was more time consuming: “Nurses need enough time for MPPs and their parents, to generate access and success in treatment” (nurse 5, short interview).

In the category of emotions, the importance of trust was essential in all data analysed (Fields et al., 2016). However, without the ability to communicate in the given language, it was much more difficult to build a relationship: “Well, I think I really come to the linguistic limit when it comes to emotions. When I have a mother, who cries and I can't comfort her … I can only hold her in my arms when she's in a bad situation” (person four, focus group interview with PNs). The changing of confidants (e.g. ending of shifts) was emotionally stressful, especially for the MPPs.

The diagnosis also largely determines what needs to be communicated. In the literature search as well as in all other areas of data collection, it was evident that the more complex the medical diagnosis and therapy was, the more instruction was required. This resulted in further challenges in communication: “The problem was that the whole manual for diabetes, the whole handling of it and so on, was sluggish because she just didn't understand it. So, the instructions had to be explained over and over again” (person two, focus group interview with PNs).

Communication challenges during the hospital stay

During admission, the need for linguistic support of MPPs was not systematically screened and documented; consequently, PNs were not prepared for potential communication problems, as in the following situation: ‘Nurse 1 gets the scales in the corridor, asks the present PN if anybody speaks Italian. She looks a bit stressed, says that she didn't even know that the mother speaks Italian’ (field-note shadowing, 24 July 2018). The obtainment of information from patients regarding their medical history was also difficult: “Finding out a patient’s medical history without language is of course really difficult. They [the patients] can hardly SHOW me their story” (person four, focus group interview with PNs). It was also revealed from the focus group interview with PNs and from shadowing, that obtaining information about the medical history from MPPs often did not occur at the beginning of the hospital stay, but instead it took place gradually after admission. A frequent issue regarding the provision of daily care was patients having difficulties in expressing their needs or asking questions. Culturally determined eating habits and preferences, or a differing approach to personal hygiene, could also lead to problems (Calza et al., 2016). The following example from a PN depicts this: “My experience with the West African children is that I put them in the shower because it looks like a latrine and then they pee in the cup. I do this because a toilet doesn't mean anything to them” (person four, focus group interview with PNs).

Regarding medical care, explaining interventions (e.g. blood collection), diagnostic procedures (e.g. magnetic resonance imaging) or instructions (e.g. diabetes), was the most problematic: “The administration of medications and injections is difficult if you can't explain to the child what you're doing” (nurse eight, short interview). Problems with pain management were only minimally present in the analysed data, although in the opinion of the authors, it was an important topic. Regarding the care plan, the literature recommended that written information for informed consent be translated into the foreign language (Dunlap et al., 2015; Langer et al., 2017). In one situation during shadowing, the declaration of consent was only available in German. It was apparent that the attending doctor assumed the mother spoke the language sufficiently to give informed consent. Discharge was also sometimes challenging for the PNs: ‘The nurse says that the discharge was very exhausting for her, because she is responsible for ensuring that everything works afterwards, and that the patient takes the medication correctly. With a language barrier, this is very difficult’ (nurse six, field-note shadowing, 12 July 2018).

Communication strategies

Numerous strategies were used to overcome difficult communication situations, which were observed during shadowing and discussed during the focus group and individual interviews. Important findings on the applied strategies used in everyday care, were that many things can be communicated very effectively by ‘showing’. However, important and complex topics often required a professional interpreter: “I think an interpreter is needed for instructions. In our diabetes instructions an aid [an application (app)] is not enough” (person two, focus group interview with PNs). If no interpreter was available, although contrary to recommendations from the literature (Bracht et al., 2012) and practice, relatives or employees were often used for such topics. It was observed that in many cases, a simple form of German was used by the nurses for communicating with the MPP and parents. In addition, proven aids (e.g. magnetic day plan) were often used. There were numerous aids available on the observed unit. However, not all of them were known to all PNs and were then not used to their full potential. Moreover, existing tools and ad hoc solutions such as spontaneous sketches or notes, were frequently applied: “With children it was sometimes helpful to draw sketches” (nurse eight, short interview). Strategies that were effective for children in general were also helpful in the hospital setting.

An approach frequently described in the literature was the inclusion of interpreters (certified, ad hoc, live or via telephone). Additionally, the development of an iPad app (Jackson and Mixer, 2017), or the development of a specific communication model (Karabudak et al., 2013), were among the tools that were discussed to overcome such communicative challenges. Translated information was also considered helpful (Jaeger et al., 2013; Dunlap et al., 2015).

Requirements for a digital communication aid

Based on the previously outlined communicative challenges and their applied strategies, requirements for a digital communication aid in a paediatric hospital setting were formulated, along with their associated limits and challenges.

The focus group interview with experts resulted in four categories of requirements: target group, functionality, content and accessibility (see Figure 6). The most frequently mentioned requirement from all data analysed was that a digital communication aid needed to be very simple, self-explanatory and user friendly. Furthermore, it should be easily accessible. In many cases, the wish for speech recognition and correct translation was expressed. Visual elements (pictures, videos) were very important. Conflicting recommendations were made as to whether a tool should be language based (translations) or language free (explanatory visual images). It was expressed that the quality of existing translator apps was often poor. This was a concern with Google Translate, as it did not accurately translate medical topics. Therefore, it should not be used in the healthcare sector due to safety reasons (Haith-Cooper, 2014; Day and Song, 2017). During shadowing, however, it was discovered this app was often used due to lack of time and its ease of easy access: ‘On days when time is short, the nurse often uses Google Translate. Even if the translation is bad, it is better than nothing’ (field-note shadowing, 24 July 2018).

Figure 6.

Key requirements for a digital communication aid.

Discussion

Valuable information was extracted during answering the research questions: (a) which communicative challenges do nurses face in situations with MPPs along with their parents, and how do they cope with them, and (b) what requirements do the nurses (and other stakeholders) have for a digital communication aid? It became apparent that communicating with MPPs is a large and complex topic. Many findings from the literature could be confirmed by this study. Additionally, this study identifies, summarises and thematically organises key areas and provides new and relevant insights to everyday nursing practice. It also reveals where a digital communication aid would be feasible in improving the quality of care for MPPs and in promoting the therapeutic communication between PNs and MPPs.

Communication needs, influencing factors and communication challenges

The results of this study concur with literature (Jaeger et al., 2013), in that mutual understanding is one of the most important needs of all defined stakeholders. It is evident that language barriers are one of the largest challenges, as they influence many other factors and thus impede the care of MMPs. There are additional factors affecting the communication with MPPs, such as cultural background. People from other countries bring not only their native language to their host country, but also their values, habits, religious beliefs and traditional role models. Cultural differences can also sometimes arise during hospitalisation, making communication more difficult. Faith can be an essential support for MPPs and their parents, it is therefore important to support religious beliefs (Jaeger et al., 2013). However, this can be difficult to manage in everyday care, for example, with the adherence to prayer times or eating rules (Calza et al., 2016; Festini et al., 2009).

Another important factor is nurses’ working conditions and organisational structures within the hospital or unit. They form the framework in which nurses can do their work. This was very evident during the shadowing of the PNs, even though they did not mention it as an influencing factor. An important finding relating to this, is that the provision of care to MPPs takes time, which is not in abundance in a hospital setting. Moreover, diagnosis has a major influence on the need for communication: the more complex the diagnosis is, the more complex the information must be.

Critical points during the hospital stay in which PNs were often confronted with demanding communication, were identified as follows:

• – when obtaining medical history, as it is necessary to retrieve important information from the patients;

• – during education, counselling or training, as complicated information often needs to be communicated (e.g. with complex or chronic diseases);

• – when discussing the care plan, as it is important to be sure patients have understood key information (e.g. medication plan, informed consent);

• – during discharge, as it is necessary to ensure that the patient continues the therapy correctly.

Communication strategies

The PNs applied a variety of communication strategies, depending on the situation. An important finding is that ‘showing’ is an efficient strategy in everyday communication. Pictures and sketches can also be quite effective. However, with important and complex topics, professional interpreters are indispensable. Due to time and cost factors, interpreters are often only booked for doctors. Contrary to the recommendations in the literature, hospital staff and relatives are often involved in translations. This may be partly due to the situation in Switzerland. In most of the publications included in this study, the country of origin of the study described only one main foreign language (e.g. Hispanics in the United States of America). The patients treated in Swiss hospitals are often linguistically heterogeneous. Due to this, not all informational materials can be translated into all of the languages required. Moreover, foreign-language staff cannot be hired specifically for all patient groups, in contrast to the recommendations from Dunlap (Dunlap et al., 2015).

In addition to existing and proven aids, ad hoc solutions were also often used to address such language problems. It can be assumed that ad hoc solutions are effective in responding specifically to individual situations. Existing tools, in contrast, are probably not used if they are unknown, not easily accessible or if they are unspecific. According to an expert in the focus group interview, a statement often heard by nursing professionals is that, ‘it somehow worked in the end’. This describes very well that there are no standardised or systematic procedures available to nursing staff for dealing with language barriers. Rather, they constantly strive to overcome language barriers as best as possible in a context-based, ad hoc manner. However, sometimes strain and a sense of resignation are present (Calza et al., 2016). Personal experience and intercultural competence play an important role in dealing with such challenges.

Based on this study, the requirements for a digital communication aid are very broad, as they reflect the needs of a variety of stakeholders. The results partly contradict each other, as they reflect varying individual preferences. It is obvious, however, that a digital communication aid cannot meet all requirements. Nevertheless, these requirements are an important indicator of the priorities that need to be considered in developing an aid. It is important that such an aid not be too specific and that it allows for the possibility of individual customisation. Moreover, it should be user friendly and functional for the entire treatment team. It should also be designed for all age groups of children and adolescents. Additionally, its main features should be quick availability and intuitive handling. There is a substantial demand for the aid to have speech recognition and to provide accurate translations. We believe that soon there will be rapid technical development in this area; from a technological perspective, a lot will be possible. Presently, translation software focuses mostly on common languages. They seldom focus on languages that are repeatedly used in Swiss hospitals (e.g. Tigrinya or Urdu), or if they do, the translations are poor quality. Therefore, there is demand for an image-based, non-verbal digital communication aid. Whether language or image based, it should offer two-way instead of one-way dialogue.

The potential for a digital communication aid lies in the gap between the communication situations that can be easily managed ad hoc, and those that require a professional interpreter. The possible contents of a digital communication aid could be explanations of interventions, instructions or information in different languages, or the clarification of medication plans and schedules (see Figure 7).

Figure 7.

Potential of a digital communication aid.

Patient-specific information, such as the patient’s medical history, preferences and language support needs, would also be feasible. For example, it was revealed that children preferred digital face-pain analogue scales rather than paper-version scales (Sun et al., 2015). Such digital communication aids could help paediatric cancer patients identify and express their symptoms (Baggott et al., 2015). Additionally, the inclusion of icons in a tablet could enable children to communicate directly with nurses (Crowley et al., 2017). Apps and mobile devices often could be used as ‘icebreakers’ (Goenka, 2016), or be viewed as modern technology (Anttila et al., 2017). The acceptance of digital devices was also confirmed in our focus group interview with PNs: “Usually a tablet is very interesting as a device in itself [for children]” (person three). However, to increase the acceptability and usability of an app, children’s and parents’ perspectives and priorities must be investigated and incorporated in the development of the app. Additionally, it would be vital to include both user groups (children and parents as well as the nurses) in a pilot testing phase of the app.

Limitations

Due to limited time and financial resources and the need to follow ethical regulations, no interviews with MPPs and their parents were conducted. This limitation may have partly been compensated for, through interviews with the PNs and through shadowing. Nevertheless, further research is needed to adequately include the children’s and parents’ points of view, which should occur before the development of an app. Additionally, due to the short time-span of the project, shadowing could only be carried out for a selective period in one paediatric hospital unit. The strengths of this study were the variety of data sources used along with its interdisciplinary approach. This enabled many different perspectives to be integrated into the study, which contributed to more comprehensive findings.

Conclusions

This study reveals the areas of hospital care in which a digital communication aid could be feasible. An implication for policy and practice is that the development of a digital communication aid could be a cost-effective measure in modern healthcare systems, especially as the employment of skilled interpreters is not always feasible or affordable. However, such a digital communication aid cannot and should not replace verbal communication between nurses, MPPs and their parents. Instead, it should support and enhance it. Many of the described communication challenges stem from issues that cannot be solved with a digital communication aid. Instead, training nursing staff and tackling such issues at the hospital management and/or the political level is necessary. In Switzerland, there are already various measures in place to support the provision of care for MPPs, along with their parents. However, it will require time before practical solutions are evident. In the development of valuable and sustainable solutions in the field of digital communication aids, interdisciplinary collaboration is important. Additionally, the involvement of users is crucial to incorporate in human-centred design. This study adds to the available literature concerning digital communication aids, as it reveals which challenges are present in the provision of care for MPPs.

Key points for policy, practice and/or research

• Interdisciplinary cooperation and user involvement are crucial in the development of digital communication aids.

• Training in the handling of digital communication aids for nurses is central to their acceptance (Jaeger et al., 2013).

• Digital communication aids must be user friendly and easily accessible, otherwise they will not be used.

• The various possible strategies and aids used when dealing with language problems must be embedded in and regulated by management of the hospital. It is important staff are aware of them and access to them must be easy (Suisse Office fédéral de la santé publique et al., 2007).

• Sufficient time must be available for the optimal care of migrant paediatric patientss and their parents (Jaeger et al., 2013).

Biography

Beatrice Kaufmann is a graduate designer and research associate at the Bern University of the Arts (HKB) in the Institute of Design Research and freelance designer/illustrator.

Tannys Helfer has a Masters of Public Health in Health Promotion, RN and research associate at the Bern University of Applied Sciences in the Department of Health Professions.

Dana Pedemonte has a master’s degree (MA) in Communication Design and an MA in Research on the Arts and is a freelance communication designer and design researcher in various social and cultural projects.

Marika Anja Simon has an MA in Design Research and MA in Research on the Arts and is a PhD student at University of Bern and a signage designer.

Sarah Colvin is a research assistant at the Bern University of Applied Sciences in the Department of Health Professions.

Declaration of conflicting interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethics

In accordance to Swiss legislation, it was not necessary to submit the study to the local Swiss Ethics Commission, as shadowing did not include any researcher involvement with the patients. According to the Clarification of Responsibility from the Swiss Ethics Commission, the study did not fall under the Human Research Law. Verbal informed consent was obtained from the nursing unit leader, and from the nurses on the unit prior to study participation. The PNs and the MPPs were coded numerically (anonymously) upon entry into data management system.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Beatrice Kaufmann https://orcid.org/0000-0003-2106-724X

Marika Simon https://orcid.org/0000-0001-8853-9059