The United States has a large and growing population with limited English proficiency (LEP). In 2010, 9% of individuals over the age of 5 were identified as having LEP,1 which is commonly defined as speaking English less than very well. This population faces many obstacles to health care,2–4 including providers who are not equipped to care for them.5,6 Studies have shown that patients with LEP are more likely than English-proficient individuals to suffer adverse health outcomes, in part due to communication barriers.7–9 Improving communication between patients and providers may help reduce such disparities.6,10
For patients and families with LEP, provider use of professional interpreters is one method of diminishing language barriers. Studies have consistently shown that interpreter use is associated with enhanced communication between patients and providers as well as improved health processes and outcomes.11–14
Providing training during residency on the use of interpreters would allow for the development and assessment of competency in this essential professional skill before residents start their independent careers. Currently, residency programs lack frameworks from which to teach appropriate interpreter use. Such training could be important in enhancing residents’ ability and self-efficacy in the use of interpreters. Self-efficacy is a construct used within social cognitive theory to help understand human behavior. As described by Bandura,15 self-efficacy is a measure of an individuals’ confidence that he or she can undertake a behavior or accomplish a task. Self-efficacy is an important prerequisite to implementing a behavior or task because it strongly influences whether an individual chooses to enact the behavior, the level of effort put forth to accomplish the behavior, and overall performance.16 Physician self-efficacy has been shown to be associated with positive practices.17 For example, a study by Thompson et al17 demonstrated that physicians with a high level of self-efficacy in counseling patients on lifestyle changes were more likely than those with a low level of self-efficacy to counsel patients on these topics. Enhanced self-efficacy in the use of interpreters could therefore lead to increased and/or more appropriate use of interpreters by providers.
To our knowledge, there are no current studies of residents’ self-efficacy in the use of professional interpreters. In a study of resident training in the use of interpreters conducted in 2003–2004,5 35% of residents reported receiving little or no structured education on interpreter use, and approximately 20% reported feeling generally unprepared to care for patients with LEP. A current description of resident skill level and self-efficacy in this area is essential to inform the development of future training curricula to effectively address the health needs of patients and families with LEP.
We therefore conducted a cross-sectional study of pediatric residents to provide a more current description of residents’ experiences and training in the use of professional interpreters, their perception of the value of such training, and their self-efficacy in two domains: (1) determining whether an interpreter is needed and (2) using a professional interpreter when caring for patients and families with LEP. Our main objective was to evaluate predictors of resident self-efficacy in these two domains, including whether having formal training in and experience with the use of professional interpreters is associated with self-efficacy.
Study design and population
We conducted this cross-sectional study in spring 2010. We invited directors of 12 pediatric residency programs that subscribe to the Johns Hopkins Internet Learning Center Pediatric Curriculum—which provides interactive, Web-based instruction in primary care pediatrics—to offer participation in this study to their residents. We selected these 12 programs because they were located in cities known to have established or growing populations with LEP. We recruited programs using this curriculum because our study was part of a project to develop a new educational module on caring for patients with LEP for use in this curriculum.
The directors of seven pediatric residency programs agreed to participate; those at five programs did not respond or did not want to participate. The participating programs were medium (n = 3; 31–49 residents) and large (n = 4; > 50 residents) programs located in midwestern, southern, and mid-Atlantic locations. All residents training in these pediatric programs were eligible, including those in pediatric/emergency medicine, pediatric/psychiatry, or pediatric/internal medicine programs at some sites.
In May 2010, residents at each of the seven sites received an e-mail with a description of the study opportunity and an electronic link to our online survey. The survey was administered using the WebQ platform.18 Nonresponders received reminder e-mails. The survey introduction indicated that completion of the survey would serve as consent. Respondent identity was known for those residents who opted to receive a $5 gift card as remuneration for responding. The Johns Hopkins Medicine institutional review board approved this study.
Survey and measures
We developed a 29-item survey on resident training, experiences, self-efficacy, and perceptions about caring for patients and families with LEP during residency. Because pediatric providers care for children and therefore interact with both patients and their families, the survey introduction stated that the survey’s focus was on the resident’s experiences as a health care provider in caring for both patients and families with LEP. We developed the survey items based on a review of the literature, social cognitive theory, and discussions among study team members. Our team’s expertise includes the areas of postgraduate medical education and caring for patients with LEP. The survey development process included piloting the survey with a few residents at two of the sites. Their feedback was positive, and we therefore made no changes to the survey. We included data from these few residents in this study’s analyses.
The survey collected information on respondent demographics, experiences caring for patients and families with LEP, use of interpreters, and training and self-efficacy in using interpreters. Demographic items included postgraduate year (1–4+), self-reported race/ethnicity, and first spoken language.
Regarding individual experiences caring for patients with LEP, the survey asked residents to report the proportion of the patients/families they care for who have LEP, the proportion of patients/families with LEP with whom they communicate using their own non-English language skills, and how often they communicate in English with patients/families with LEP when no professional interpreter is available. Response options were< 10%, 10%–30%, 31%–50%, 51%–75%, and > 75%. The survey also asked participants about the availability of interpreters where they train (yes/no) and their level of experience with using interpreters (response options: none, a little, moderate experience, a lot of experience).
Related to their training, the survey asked residents how many organized educational sessions on using professional interpreters they had received during residency (response options: none, 1–2, 3–5, > 5). Because feedback is an important aspect of training, the survey specifically asked participants whether they had ever received feedback regarding communication when using a professional interpreter (yes/no). Finally, the survey asked residents to indicate the value they placed on educational sessions on the use of professional interpreters (response options: of no value, somewhat important, very important, essential to my training).
The survey asked participants to indicate how confident they were in their ability to assess when an interpreter is needed and to use a professional interpreter for patient care (response options: not at all, somewhat, moderately, very, extremely). We used these items to assess residents’ self-efficacy in these domains. Self-efficacy is a measure of confidence in one’s ability to accomplish a task.15
We used descriptive statistics to assess the study population. We collapsed responses for some variables to ease interpretation. Responses about experience with interpreters were combined into two categories: low experience = 1 (none, a little) and high experience = 2 (moderate experience, a lot of experience). Data on the proportion of residents’ patients with LEP were collapsed into three categories: < 10% = 1; 10% to 30% = 2; and > 30% = 3. Data on the proportions of patients with LEP with whom residents communicate using their own non-English language skills and of patients with LEP with whom the resident uses English if no interpreter is available were collapsed into two categories: < 10% = 1; and ≥ 10% = 2. Data on having received educational sessions on the use of interpreters were collapsed into two categories because there were very few responses over “1 to 2”: no = 0 sessions; and yes = 1 to 2, 3 to 5, and > 5 sessions.
We conducted multiple regression analyses. The three dependent variables in these analyses were the value residents placed on organized educational sessions on professional interpreter use and resident self-efficacy in two domains: (1) determining when an interpreter is needed and (2) using a professional interpreter. Because we aimed to evaluate predictors of placing high value on such training, responses related to value were dichotomized for analysis into low value = 0 (of no value, somewhat important) and high value = 1 (very important, essential to my training). Similar to a separate study on physician self-efficacy,19 responses related to self-efficacy in this study were dichotomized for analysis: responses of “very” and “extremely” confident were labeled as high self-efficacy (1), and responses of “not at all,” “somewhat,” and “moderately” confident were labeled as low self-efficacy (0).
We used binary logistic regression to evaluate the relationship of independent variables with the three dependent variables. We performed multivariate logistic regression analyses to identify factors associated with placing high value on organized educational sessions on interpreter use with the covariates of postgraduate year, first language, proportion of residents’ patients with LEP, proportion of patients with LEP with whom residents use their own non-English language skills, and having attended a previous organized educational session on interpreter use.
We conducted two additional multivariate logistic regression analyses to identify factors associated with high self-efficacy in determining when an interpreter is needed and in using professional interpreters when caring for patients and families with LEP. These analyses included the same covariates as above, in addition to resident report of experience with using interpreters. We accounted for clustering in all regressions because of the possible lack of independence of observations within residency programs. We performed all statistical analyses using Stata software version 11.0 (Stata Corp, College Station, Texas). Statistical significance was set at P < .05.
Of the 449 eligible residents at the seven pediatric residency program sites, 271 (60%) responded to the survey. Respondents were mainly in postgraduate years 1 to 3 (Table 1). Most (n = 224; 83%) reported English as their first language. Over three-quarters (n = 221; 82%) reported that ≥ 10% of their patients have LEP. About a third (n = 86; 32%) indicated they use their own non-English language skills to communicate with ≥ 10% of their patients with LEP. Over half (n = 161; 59%) reported using English to communicate when no interpreter is available with ≥ 10% of their patients with LEP.
Availability of and experience with interpreters
Almost all respondents (n = 269; 99%) reported that professional interpreters are available at their residency program site. More than half (n = 143; 53%) reported having “a lot” of experience with interpreters.
More than half of the respondents (n = 146; 54%) reported that they had never attended educational sessions on the use of professional interpreters. This varied by residency location: At four of the sites, over 60% of respondents (range: 63%–78%) reported that they had never received such training, whereas 30% to 50% of respondents at the other three sites reported never having received this training. There was no significant variation by postgraduate year (P = .32).
A large proportion of respondents (n = 124; 46%) indicated that they placed high value on organized educational sessions on the use of professional interpreters. Bivariate analyses demonstrated that respondents whose first language was not English (P < .01) and those who reported that > 30% of their patients have LEP (P < .05) were significantly more likely than others to place a high value on such formal training. Multivariate logistic regression showed that respondents whose first language was not English were more likely than native English speakers to place high value on such training (odds ratio [OR] = 2.72; 95% confidence interval [CI] = 1.83–4.05; P < .001; Table 2).
More than three-quarters of respondents (n = 210; 77%) reported that they had never received any feedback on their use of interpreters. In bivariate analyses, individuals who reported having received educational sessions on the use of professional interpreters were more likely to report that they had received feedback than were those who had not attended such a session (OR = 2.54; 95% CI = 1.31–4.91). Postgraduate year, first language, and percentage of resident’s patients with LEP were not associated with receiving feedback.
More than two-thirds of the responding residents (n = 186; 69%) reported high self-efficacy in knowing when an interpreter is needed: 37 (14% of all respondents) indicated they were “extremely confident,” and 149 (55%) replied “very confident.” Among the remaining 85 (31%), 69 (25% of all respondents) indicated they were “moderately confident,” and 15 (6%) reported being “somewhat confident.” Similarly, 68% of the residents reported high self-efficacy in using a professional interpreter (n = 185): 50 (18% of all respondents) responded “extremely confident,” and 135 (50%) marked “very confident.” Among the 86 residents (32%) in the low self-efficacy category, 51 (19% of all respondents) responded “moderately confident,” and 35 (13%) responded “somewhat confident.” The correlation between self-efficacy in these two domains was low (r = 0.34).
Bivariate analyses demonstrated that having a non-English first language was significantly associated with high self-efficacy in determining the need for an interpreter (P = .02). Multivariate logistic regression showed that residents whose first language was not English were more likely to report high self-efficacy in this area than were native English speakers (OR = 2.47; 95%CI = 1.36–4.47; P = .003); similarly, those reporting a high level of experience with professional interpreters were more likely to report high-self efficacy compared with those reporting a low level of experience (OR = 1.85; 95% CI = 1.03–3.32; P = .04; Table 3).
Our bivariate analyses demonstrated that receipt of educational sessions onthe use of professional interpreters (P < .01) and a high level of experience using interpreters (P = .04) were significantly associated with high self-efficacy in using a professional interpreter. These associations persisted in our multivariate logistic regression model controlling for all other variables: Report of receipt of educational sessions on the use of professional interpreters (OR = 1.62; 95% CI = 1.22–2.14; P = .001) and report of a high level of experience with professional interpreters (OR = 3.97; 95% CI = 1.19–13.31; P = .03) were associated with high self-efficacy in interpreter use (Table 3).
As the U.S. population of individuals and families with LEP continues to expand,1 residents will need to be prepared to care for growing numbers of patients with LEP. With the forecasted increase of insured members of racial and ethnic minority groups following implementation of the Affordable Care Act,20 ensuring that future physicians are able to care for greater volumes of racially and linguistically diverse patients will be critical to the success of health care in the United States. More than three-quarters of the pediatric residents in this study reported having higher proportions of patients and families with LEP in their training practices than the 9% prevalence of individuals with LEP in the United States.1 Most also reported having at least moderate experience in working with professional interpreters during their residency.
Nevertheless, less than one-half of the residents in this study reported receiving an organized educational session on the use of interpreters, and more than three-quarters reported never receiving any feedback on their use of interpreters during their residency. This is notable given that patient communication is one of the six core competencies defined for all residents by the Accreditation Council for Graduate Medical Education (ACGME)21 and is also an important focus of the Joint Commission.22 Working effectively with interpreters is critical to communicating with individuals with LEP. In a study conducted in 2003–2004, Weissman et al5 found that about one-third of the residents in their national sample reported very little or no additional instruction during residency on working with an interpreter. Differences between their findings and ours may be due to differences in survey wording and the number of programs included in the study. However, the proportion of residents who lack training on working with interpreters is unacceptably low in both studies.
Various training programs on working with interpreters that target medical students and residents have been described in the literature.23–29 In our opinion, provider training in the appropriate use of interpreters should include such topics as the health impact of language barriers, optimal positioning of the interpreter, and maintaining eye contact with the patient during the encounter. Training has been shown to be associated with improved knowledge and attitudes,24 higher self-assessed skill levels in working with interpeters,5 improved patient satisfaction,23 increased use of interpreters by providers, and increased provider satisfaction with care.30 We found that residents who have received training (in the form of educational sessions) on interpreter use were more likely than those who have not to report high self-efficacy in the use of an interpreter. Having a high level of experience with interpreters was also associated with high self-efficacy. Social cognitive theory shows that individuals with high self-efficacy in a specific task approach that task with confidence instead of avoidance.15 Because there are many real and perceived barriers to using interpreters in medical settings, high self-efficacy in interpreter use may be especially important for providers when caring for patients and families with LEP. Although further work is needed to link self-efficacy in these domains to actual changes in provider behavior and improved patient outcomes, our findings support making training on working with interpreters a standard expectation for residency programs. Doing so would help ensure that future providers are equipped with skills to communicate with patients and families with LEP. Like other professional skills, working effectively with interpreters needs to be taught and evaluated.
Our findings suggest two additional important areas of focus when developing training for residents on the use of interpreters. First, more than half of the residents in our study reported that they communicate in English with patients and families with LEP when no interpreter is available. This finding underscores the importance of both improving residents’ knowledge of the impact of poor communication on the health outcomes of patients with LEP and ensuring that residents learn how to access and use professional interpreter support at all times and through different means (e.g., in person, on the telephone). Such knowledge may decrease the well-described “getting-by” phenomenon.31 Second, attention in training should also be given to residents’ use of their own non-English language skills. We found that almost one-third of residents in our study reported using their non-English language skills to communicate with patients with LEP. Lion et al32 recently found that 63% of residents who tested as nonproficient in Spanish reported communicating in varying clinical scenarios using their Spanish language skills. Testing language skills may play a part in reducing providers’ use of languages in which they are not proficient.33 This issue could be addressed within a training course on the use of interpreters.
Interestingly, only about one-half of the residents in our study placed a high value on educational sessions on the use of interpreters. This was more common among respondents whose first language was not English. It is possible that this group of trainees is more likely to have personally witnessed language barriers in the health care system through family experiences, but we did not evaluate this in our study. Respondents with a high proportion of patients or families with LEP also placed a high value on such training. Two other studies reported more encouraging results. In a qualitative study, Macdonald et al34 reported that residents have a desire to learn to be better at communicating with people from different cultures. Karliner et al30 found that over 80% of providers caring for patients with LEP are willing to get additional training in the use of interpreters. Possible reasons why many of our participants did not place a high value on this type of training may include the lack of value institutions place on such training and/or a lack of role models. Park et al35 noted that residents in their study reported that cross-cultural care was not prioritized by their institutions. In addition, many studies have found a high prevalence of not using professional interpreters when communicating with LEP families among both residents and attendings.25,36–38
We encourage medical educators to look for ways to incorporate training on interpreter use into residency programs. The Next Accreditation System39 encourages the implementation of entrustable professional activities (EPAs) to more accurately measure whether residents are achieving newly proposed milestones within the six ACGME core competencies. EPAs are the routine, everyday skills of physicians and can serve as the central anchors by which milestones and competencies in training can be reported on by faculty.40 For example, “care of the acutely hospitalized child,” as proposed by Carraccio and Burke,41 could be a pediatric-focused EPA that would speak to various milestones and competencies including patient care, medical knowledge, and interpersonal communication. We propose that all residency programs incorporate “use of medical interpreter to provide care for patient with limited English proficiency” as an EPA by which to measure achievement of key milestones. Residents “entrusted” with this skill would need to demonstrate that they can appropriately identify the need for an interpreter (medical knowledge), effectively work with the interpreter (interpersonal communication), and provide the necessary care for the patient (patient care).
Although the mapping out of this proposed EPA relative to the current milestones and identification of appropriate subcompetencies would benefit from larger group discussions, an effort to implement it across residency programs would lead to more effective evaluation and targeting of the critical skills residents need to care for patients with LEP. Creating this EPA would also heighten the need for training on this topic. Other studies’ findings emphasize that training on interpreter use should be both formal and informal; it should include hands on training5,27 as well as simulated encounters with patients with LEP.24 Our results suggest that clinical exposure to and experience with interpreters is highly predictive of resident self-efficacy, perhaps even more so than receipt of formal educational sessions. Thus, the most effective methods to update residency training curricula may be standardizing training expectations related to patients with LEP through the creation of a specific EPA and implementing interactive training opportunities.
Inclusion of professional medical interpreters in training sessions on interpreter use has been viewed positively by residents.23 Medical interpreters have an in-depth understanding of communication in the health care setting and of the potential for miscommunications between patient and provider. Their sharing of their knowledge and experience could contribute to residents’ awareness and skill by enhancing awareness of common sources of misunderstanding and inherent challenges of interpretation.42 Additionally, some evidence suggests that residents often view the skills needed to overcome language barriers as separate and different from other aspects of providing cross-cultural care.43 Sessions on this topic should emphasize the interconnectedness of language and culture. The influence of culture on communication with families with LEP cannot be overlooked.44 Other work on cultural competency training suggests that education on the importance of quality communication with patients with LEP may be better received if it is woven throughout the curriculum instead of presented as a one-time, formal program.45 Finally, faculty may be unsure of their ability to teach about or provide care for patients with LEP. Their lack of confidence may limit their desire to educate trainees on this topic. Faculty development efforts should incorporate topics related to the care of patients with LEP.34
There are important limitations of this study that warrant mention. Our response rate of 60% may introduce bias. We do not have any information on nonresponders. Nevertheless, our response rate is similar to those of other studies involving residents.5,46 The generalizability of our findings is also limited in that we included only pediatric programs. Additionally, our sample consisted of predominantly non-Hispanic white individuals, and because of small numbers of respondents in the other racial and ethnic categories, we were unable to evaluate the influence of race and ethnicity on resident self-efficacy. Lopez et al47 found differences in residents’ perceived preparedness for delivering cross-cultural care by race/ethnicity in their 2008 study. Additionally, our measure of training on the use of interpreters is based on resident report, which introduces reporter bias, rather than on a measure of the actual training they received.
Despite these limitations, our findings have numerous implications for policy and for future research. Pediatric residents in many parts of the United States are caring for a large number of patients and families with LEP. Standardizing residency training on how to work effectively with interpreters is needed, as is work to structure EPAs related to communicating with patients with LEP to align residency programs in the Next Accreditation System. Additionally, our findings act as a reminder of the continued importance of diversifying the health care workforce in order to help overcome culture and language barriers. Finally, it is important to remember that knowledge, experience, and competency are not the only important factors in working with interpreters. Other issues such as cost, time, and habit need to be addressed as well.
In conclusion, our study demonstrates that many residents are not receiving educational sessions on interpreter use during residency and that this lack of training is associated with low self-efficacy in the use of interpreters. Low self-efficacy may influence a provider’s decision to use interpreters or even to pursue future work with populations with LEP. Future physicians must be equipped with the skills necessary to confidently care for patients and families with LEP to help reduce health disparities. Standardizing and updating residency training curricula in the use of interpreters is one way to achieve this important goal.
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