A high-quality health care experience involves trust and good communication with health care providers, as well as safe, timely, and effective care. However, the nearly 10% of U.S. residents who do not speak English well often do not receive such ideal care.1 Compared with those who speak English proficiently, people with limited English proficiency (LEP) are more likely to misunderstand their diagnosis, treatment, and follow-up plans,2–6 use medications incorrectly,7 lack informed consent for surgical procedures,8 suffer serious adverse events,9–12 and report a lower-quality health care experience.13–17 Being ill can be a dehumanizing experience for anyone, but a language barrier may make it harder for clinicians to provide high-quality care to patients with LEP.
Unfortunately, health professions students do not receive effective training for ensuring clear communication with, and providing high-quality care for, patients with LEP. To illustrate, at Harvard Medical School (HMS), 70% (N = 58) of the fourth-year students we surveyed felt inadequately prepared to care for patients with LEP,18 and one-third of residents nationally admitted to having used a child under the age of 12 as an interpreter.19 Moreover, 60% of HMS students reported that a lack of role models for cross-cultural care was a problem, and more than half reported problems with dismissive attitudes about cross-cultural care among attending physicians and fellow students.20 Anecdotal evidence suggests that nursing students are similarly unprepared. To help fill this gap in training, we developed an innovative interprofessional (IP) mini-course on providing high-quality, safe, humanistic care for patients with LEP (the Macy IP/LEP curriculum). We piloted the curriculum with eight medical students and eight advanced practice nursing students and reported our findings previously.21
While the Macy IP/LEP curriculum has filled an important gap in students’ educational experience (the formal curriculum), we were particularly interested in these students’ perspectives several months after the training. We wanted to understand their experiences with the care of LEP patients during their actual clinical training when the hidden curriculum could potentially challenge their ideals. The hidden curriculum has been defined as “the set of influences that function at the level of organizational structure and culture including, for example, implicit rules to survive the institution such as customs, rituals, and taken-for-granted aspects.”22 In addition, an aspect of the hidden curriculum, which has yet to be fully explored, is that of the null curriculum, or that which is taught through passivity or omission.23 Although hidden and null curricula are not necessarily negative, educators often focus on their detrimental effects such as loss of idealism, emotional neutralization, degradation of ethical integrity, and acceptance of hierarchy22—all of which are particularly dangerous in the care of patients with LEP. We could find nothing published in the literature that specifically explores the hidden curriculum for medical students or nursing students caring for patients with LEP; however, the literature on cross-cultural education describes negative elements of a hidden curriculum.24 To explore and characterize the hidden curriculum that medical and nursing students experience regarding the care of patients with LEP and to understand the mechanisms of its transmission, we conducted interviews with students who were immersed in their clinical rotations and who had completed the Macy IP/LEP curriculum several months earlier.
We invited, through e-mail, 16 students (8 medical and 8 nursing students) from HMS and the Massachusetts General Hospital Institute of Health Professions to participate in interviews. These students had previously (6–10 months earlier) participated in an IP pilot curriculum focused on providing safe, effective, and humanistic care for patients with LEP called the Macy Curriculum on Safe, Effective, and Humanistic Care for Patients with LEP.21 They were invited to participate in this curriculum semirandomly based on whether they happened to be on one of a few rotations with a relatively light workload. The pilot curriculum focused on three major themes and learning goals: (1) understanding disparities in care for patients with LEP and the need to address them, (2) developing skills to work effectively with interpreters, and (3) understanding how improving systems can lead to safer and more effective care for patients with LEP.21
Considering the implicit nature of the hidden curriculum, we theorized that these students would be primed, through their participation in this structured training, to think about the care that patients with LEP receive and to recognize and recall more aspects of the hidden curriculum pertaining to such patients. Between the time of the training (July 2013) and the interviews (January through May 2014), the students participated in both inpatient and outpatient clinical experiences in various settings from primary care to tertiary services.
We developed a structured interview guide, which was informed by an extensive literature review on the hidden curriculum, informal in-person and telephone-based meetings with several experts, and our own expertise in the field of language barriers in health care. Two of us (A.R.G. and T.C.K.) conducted test interviews with two students to determine the pace and effectiveness of the interview guide. We made no major substantive changes to the guide based on these two pilot interviews, and we included the data from these pilot interviews in our results.
After obtaining informed consent and guaranteeing anonymity and confidentiality, two of us (A.R.G. and T.C.K.) conducted semistructured interviews with the students about their clinical experiences caring for patients with LEP. Together, we (A.R.G. and T.C.K.) conducted all the interviews in person (n = 9) or via phone (n = 4). We began each interview by asking the participants to share an impactful personal story about the care delivered to a patient with LEP, how the incident affected them, and how it compared to an ideal interaction. We then asked about the direct messages (specifically stated) and the indirect messages (implied through attitude or nonverbal communication) that students received from their peers and their supervisors (generally residents, attending physicians, and practicing nurses) about patients with LEP. Additionally, we asked about students’ overall experiences caring for patients with LEP in the clinical sites where they had worked, whether or not their initial story was broadly representative, and if/how their perspective on caring for patients with LEP had changed during their clinical experiences.
After each interview, two of us (A.R.G. and T.C.K.) discussed and documented key themes. One of the interviewers (T.C.K.) recorded and transcribed each interview verbatim and assigned a unique identifier. We applied qualitative content analysis by systematically coding and identifying categories and themes. The two interviewers (A.R.G. and T.C.K.) worked together to develop a set of themes while an independent investigator (L.T.) did the same. Then, the three of us used an iterative process to compare, compile, and consolidate the themes into a coding scheme. We coded the data from nursing and medical students together because of the similarity in themes. Next, one of us (T.C.K., one of the interviewers) coded all of the interview transcripts, while another of us (A.R.G., the other interviewer) coded sample sections of the interviews and reviewed all the coded material. We discussed and reconciled our few initial disagreements.
We used ATLAS.ti 7.1.8 (Berlin, German) to code and analyze the data. We received approval for the study from both the Partners HealthCare and HMS institutional review boards. Students received no compensation for participation in this study.
Study participants and interviews
Of the 13 students we interviewed, 7 were medical students and 6 were nursing students; 4 were men and 9 were women. On average, they were 27 years of age. Members of some race/ethnicity groups numbered too small to report.
Each interview lasted between 35 and 50 minutes. We identified no major new themes after 7 interviews, and no new subthemes after 10 interviews.
We identified four overarching themes that represent the informal teaching mechanisms that help to define and characterize the hidden curriculum for the care of patients with LEP in medical and nursing education: (1) role modeling, (2) systems factors, (3) learning environment, and (4) organizational culture. We describe each of these overarching themes and several subthemes in detail below.
All of the interviewees readily discussed the role modeling of the care of patients with LEP that they experienced in the clinical setting (see Table 1). All 13 students described indirect negative experiences in their opening story. They described peers or supervisors who, when discussing patients with LEP, expressed an attitude of frustration. To illustrate, one student said, “I don’t think this is unusual, per se, because I mean I’ve even taken my mom to the primary care clinic and I see it. I see the rolling of the eyes.”
Three interviewees described more direct negative role modeling, including supervisors who clearly disregarded the needs of patients with LEP during clinical encounters. For example, supervisors communicated with patients with LEP without an interpreter when it was obviously necessary or they made assumptions based on stereotypes. One student commented, “I think that there are some ignorant comments that come with that as well: ‘Because he doesn’t have insurance, he is here illegally.’”
No student identified a specific positive role model for the care of patients with LEP even when prompted; however, six interviewees described some generally positive practices. One student reported: “People are willing to call interpretation services in a timely fashion. Calling in advance, knowing that they will need them.”
Seven students described role modeling that we labeled as either “indifferent” or “mixed.” Indifferent role models gave no special attention to ensuring optimal communication for patients with LEP, but would involve interpreters when convenient or obviously necessary. These supervisors appeared to tacitly accept limited communication with LEP patients but never directly or indirectly expressed negative attitudes towards them. To illustrate, one student remarked, “It was mostly the way they acted. I don’t think I ever heard, ‘Oh, don’t get the interpreter.’ It was more, ‘Let’s just get this done.’” Indifferent role models appeared to contribute directly to the null curriculum by not demonstrating a commitment to optimizing care for patients with LEP.
Mixed role modeling occurred when supervisors demonstrated good patient communication skills and a dedication to high-quality care in general, but seemed frustrated and less effective when providing care to patients with LEP. An interviewee commented: “He definitely was someone who had really good relationships with all of his patients.… So I was a little surprised that he would’ve just said, ‘Okay. Well, this is the best that we can do.’”
Student reactions to indifferent and mixed role modeling varied, but they were not critical of their supervisors in general. Instead, they tended to attribute their supervisors’ behavior to limitations imposed by the system and lack of structural support for working with patients with LEP (described below). This made it difficult for students to make value judgments on the quality of the care delivered. The mixed messages from otherwise-respected role models seemed to conflict with students’ ideals and with explicit teaching in their preclinical years. To illustrate, one student commented:
Part of it is, if this can happen to someone that I see as such a model.… I’m sure it happens across the board, regardless of how cognizant you are of all of these limitations. You know part of it is, he does such a great job on a typical case but part of it is that he did the best that he could. Part of it … some of the problems leading to this are basically a systemic issue of why did no one give him a heads-up about this is what’s going to be happening, this patient is going to be coming to your clinic.
All 13 students identified examples of substandard care for patients with LEP that resulted from inefficient and/or ineffective systems in the clinical environments where they trained (see Table 2). Many of the inefficiencies and ineffective practices were actually part of the systems in place for addressing language barriers. These included inadequate interpreter services, lack of staff training or knowledge of how to access and work with interpreter services, and inadequate identification of patients requiring language assistance.
Inadequate interpreter services.
According to our data, the most common structural barrier was inadequate interpreter services. Students recalled long wait times for interpreters, limited on-site interpreters for some languages, too few interpreters in the outpatient setting, and no on-site or phone interpreters at all.
Lack of staff knowledge regarding interpreter services.
Eleven students also identified lack of staff knowledge as a major barrier. They reported knowledge gaps in how to access on-site interpreters, poor ability to find and use interpreter phones, and poor technique when using interpreter services. Interestingly, students did note that interpreter services were involved more appropriately in the outpatient setting, particularly when patients with LEP were preidentified appropriately. Students reported that in the inpatient setting, the patient’s primary team was more likely than specialists to routinely involve an interpreter. Overall, students observed that supervisors were not knowledgeable on when to involve interpreter services; some supervisors used such services only for eliciting consent for procedures or discussing important diagnoses. Students noted that interpreter services were often absent during resident and student prerounding, day-to-day nursing interactions, and when patients had a prolonged inpatient stay. Five students also noted that some of their supervisors, impatient with the timing of interpreter services, were unwilling to wait for the interpreter services to be arranged.
The students noted a difference in knowledge between nurses and doctors when using interpreter phones. They observed that attending physicians and residents may not always work in the same setting, so floor nurses or a secretary may know more about accessing interpreter services or how to use the phone than the physicians. Nursing students also reported that they observed nurses coordinating interpreter phones or video systems in patients’ rooms if the resources were available. Notably, medical students did not report their supervisors—attending physicians or residents—arranging interpreter phones or videos, which sent a message that such tasks are not important to the way a physician might address a language barrier—an example of the null curriculum at work.
Identification of patients with LEP.
Students noted that providers in the most language-supportive environments successfully identified patients with LEP ahead of time and arranged interpreters in advance. Although this practice happened most in the outpatient setting, even there, according to students, it was not the norm.
Overall, students recognized that lack of effective systems for caring for patients with LEP led to delays, frustration, and difficulties in providing high-quality care. They highlighted a strong link between these structural barriers and “indifferent” or “mixed” (our terms) role modeling.
Students described a learning environment that emphasizes an implicit hierarchy of values in the clinical setting (see Table 3). This hierarchy places much higher value on efficient completion of defined clinical tasks than on ensuring either effective communication or excellent care. Working with interpreter services adds another layer of complexity that could prevent health care providers from completing more highly valued tasks (e.g., checking blood test results). Students observed that during less-critical interactions with patients with LEP, supervisors would not involve interpreter services. The hierarchy extended to roles as well. One student noted that when a supervisor asked her to do even mundane tasks (e.g., finding a pair of socks), these took precedence over tasks that the student considered more clinically relevant (e.g., finding an interpreter).
The students perceived the hierarchy and the conflicts it created in different ways. Six students felt that competing priorities were inevitable and that the practical limitations justified different standards of care for patients who required more effort, such as patients with LEP, lower socioeconomic status, or with less education. Students noted that tending to patients with LEP had lower value on the hierarchy of tasks, comparable to tending to patients who frequently complained. Other students did not believe that patients with LEP received a significantly different level of care.
Another aspect of the learning environment that 12 students described was their limited role and low status in the clinical setting. When they observed behaviors that conflicted with their values, such as providing lower quality of care to patients with LEP, they did not feel empowered to express their views or change the situation—even if it impacted clinical care. Both nursing and medical students expressed this conflict; however, a medical student noted that the role of medical students is focused much more on data collection than on skillful communication. Although no students noted receiving negative feedback for spending time or effort on patients with LEP, they did note that they received no positive feedback either. This lack of positive feedback for providing good care for patients with LEP is another example of the null curriculum.
Students described a learning environ ment in which poor communication is considered appropriate and acceptable—the norm. Even when students had received more training in the use of interpreters than their supervisors had, they did not feel that they could intervene or advocate for patients.
Peer interactions did not seem to have much influence on the care of patients with LEP. Only four interviewees mentioned any peer interactions. Two noted peers expressing frustration about working with patients with LEP, and two reported negative comments from peers about participating in curricula related to cross-cultural care.
We asked students to describe aspects of organizational culture with respect to care of patients with LEP and how this culture was established, but the students often paused and seemed to struggle to describe the culture (see Table 4). They recognized that the culture changed from setting to setting (e.g., floor to floor and hospital to hospital). They also recognized that attending physicians and nursing faculty were not necessarily around enough to establish the local culture, so culture depended more on the residents and floor nurses. One student stated that it took only a few staff members to create a negative culture around providing care for patients with LEP; such staff members seemed to communicate that actions like procuring an interpreter went above and beyond the normal standard of care. Students clearly indicated that the prevailing practices of the staff present at the time seemed to determine culture—more than any regulations established in the hospital by higher-level administration. Students did not identify any institutional measures reinforcing a high standard of care for patients with LEP. This notable want of institutional policies further demonstrates the strength of omission and pervasiveness of the null curriculum even on an organizational level. One student explicitly mentioned that he felt that hospitals could strengthen the organizational culture by instituting a campaign, similar to the focus on hand washing, to provide consistent high-quality care for patients with LEP.
On the basis of our interviews with medical and nursing students, we have described four domains that influence the powerful hidden curriculum regarding care for patients with LEP in the clinical setting: role modeling, systems factors, learning environment, and organizational culture. We found each of these domains to be highly intertwined with the others such that they were sometimes difficult to separate. Most notably, systems factors had a huge impact on all of the other domains. Even the best of role models, for example, could be quickly frustrated in caring for patients with LEP if the systems were not adequate to allow for efficient access to interpreter services.
Overall, students perceived this hidden curriculum negatively; their responses ranged from neutral to highly disturbed. The students that were most negatively affected seemed to be disillusioned by the dissonance between their ideals and the realities of clinical care (at least in these settings). For example, the hidden curriculum they experienced in clinical settings with LEP patients often taught them that working with interpreters to ensure effective communication was not important and could be overlooked whenever time was limited, while the formal teaching in their patient–doctor course emphasized the importance of effective communication with all patients in all settings. This dissonance is not unlike other descriptions of hidden curricula regarding ethics, patient centeredness, and other aspects of clinical practice.25–28 Although students made little reference to any positive elements of the hidden curriculum, five described some generally positive behaviors around working with interpreter services, and some indicated that certain rotations provided better care to patients with LEP than others.
As we expected, the students experienced negative role modeling—both during direct patient care and through indirect discussions about patients with LEP. Although students clearly disapproved of negative role modeling, what struck us was the power of passive indifference and the null curriculum. Many students described supervisors who simply did not pay much attention to ensuring effective communication with patients with LEP and supervisors who often did nothing to explicitly address any communication gaps. We thought that this passivity sent a very strong message to students that not involving professional interpreters, struggling through interactions with patients with LEP, or using family members to interpret was considered acceptable and unavoidable. Although faculty would not be likely to directly advocate any of these actions, they endorsed all of them through their actual behavior. This observation is consistent not only with the literature on the null curriculum23 but also with literature on implicit (and unconscious) bias, which has been shown to be prevalent in health care, and more likely to impact care than conscious discrimination.29–31 The prevalence of passive inaction stood in contrast to the fewer examples of direct and blatant negative role modeling, which students easily wrote off as aberrant behavior to be avoided. Although the concepts of passive indifference and the null curriculum appear in the hidden curriculum literature,23 they deserve deeper exploration as to their impact on students.
What we referred to as “mixed role modeling”—the mismatch between supervisors’ previously demonstrated dedication to high-quality care and their apparent unwillingness or inability to deliver this same level of care to patients with LEP—was particularly disturbing for students. Students often attributed inconsistent care to factors outside the supervisor’s control, thereby protecting their image of these role models, and perhaps accepting that high-quality care for patients with LEP is not possible in the “real” world. The prevalence of such seeming unwillingness or inability among supervisors to deliver consistent high-quality care to patients with LEP, along with the apparent absence of positive role models, indicates a need for extensive faculty development in caring for such populations. We have developed and piloted an IP training curriculum involving medical students, nursing students, and professional interpreters that is adaptable for clinical faculty and staff and is freely available.21 We also previously collaborated with the Agency for Health Care Research and Quality to develop a TeamSTEPPS training module on caring for patients with LEP that has been used in several institutions nationally.32
The systems issues that students continually cited align with those described in other reports on hidden curricula but have not been emphasized regarding patient–provider communication in particular. These systems issues related to the care of patients with LEP are somewhat unique given that effective communication is closely linked to the coordination of an ancillary clinical service (professional interpretation). One possible parallel is the teaching of patient safety, which also relies heavily on effective systems. When systems do not work well, they prevent effective role modeling, negatively impact the learning environment and organizational culture, and encourage the omission of important actions, thereby reinforcing a negative null curriculum. Training in a system wherein dysfunction eclipses individual clinicians’ values can lead to disillusionment, frustration, a belief that substandard care is inevitable for patients with LEP, and ultimately, an erosion of values.
Our findings about the learning environment and the hidden curriculum related to patients with LEP are very consistent with those from other studies about the hidden curriculum for topics like patient centeredness and ethics.25,27,28,33 Namely, supervisors place lower value on the humanistic aspects of care in favor of medical knowledge and efficiently accomplishing clinical tasks, and they reinforce this hierarchy when they fail to provide positive feedback for students who do offer or advocate higher quality of care. Students have internalized this hierarchy of values and feel disempowered and unable to advocate for patients with LEP. Even suggesting something as basic as involving a professional interpreter would be difficult for a student because doing so could slow down the team. This tension is parallel to that in the field of patient safety in which hierarchical structures lead to inhibition among lower-ranked team members who do not feel free to speak, ultimately allowing errors to occur.
Students had less to say about the broader organizational culture and what influence it had on them compared with the other three domains—perhaps as a result of their stronger link to the educational environment as established by their supervisors. Their weaker connection to the organization as a whole may reflect their transient roles. In general, hidden curriculum studies are challenging in that students can identify some of the more obvious influences but have more difficulty recognizing subtle aspects such as organizational culture. Similarly, students have difficulty recognizing the influence that even the more obvious aspects of the hidden curriculum have on their own developing values and behaviors. Most students in our study recognized a waning of idealism in general, but not specifically for the care of patients with LEP. In fact, 10 students stated that they felt a personal commitment to providing high-quality care to all patients and to effecting positive system-level change, and 11 students said they were willing to advocate for patients and system improvements in their future careers. Nonetheless, we were not able to define what unconscious impact this hidden curriculum had on students’ values and behaviors.
Comparing medical and nursing students
We found few differences between the experiences of medical and nursing students. Nursing students identified more structural changes that could be made in each setting and seemed to have a stronger role in how to access interpreter services (e.g., locating interpreter phone and relocating them to patient rooms). Nursing students seemed more hesitant to imply any lack of empathy on the part of their supervisors toward patients with LEP (regardless of the supervisor’s actions)—perhaps because empathy may be more highly emphasized as an integral part of nursing training than it is in medical training. As such, implicating supervisors as lacking in empathy may imply that they are not capable of doing their job. Otherwise, nursing and medical students had very similar experiences and observations across all four domains.
This study has several limitations. Although we are able to generate hypotheses about the hidden curriculum for the care of patients with LEP, our findings—the results of a qualitative study—cannot be taken as representative of the views of other medical and nursing students at HMS or Massachusetts General Hospital Institute of Health Professions more broadly. Students seemed to choose their words carefully at times when critiquing their supervisors (especially if the students respected them otherwise), so our findings may show a more positive view of these role models than what the students truly felt at the time. Their hesitation to criticize may have also led students to implicate structural factors more strongly as a way of protecting their image of their supervisors. Because the nature of the topic we are exploring is “hidden,” we are unable to know for sure whether we were able to delve deeply into the hidden curriculum regarding the care of patients with LEP or if we have just gained a preliminary view. The student interviewees had participated in a mini-curriculum on the care of patients with LEP, so although they were perhaps better prepared to recognize the hidden curriculum they were experiencing clinically, this exposure could also be a source of bias. Ultimately, we felt that 6 to 10 months between the interviews and the curriculum would limit this potential bias, and that it was more important for our study not to miss elements of the hidden curriculum that are particularly subtle.
To our knowledge, our study is the first to explore the topic of the hidden curriculum for the care of patients with LEP in medical and nursing education. The conceptual model proposed by Haidet and Teal34 to explore hidden curricula posits that educators should move beyond describing one general hidden curriculum and instead focus on hidden curricula that are specific to the content (e.g., care for patients with LEP), context (e.g., a specific clinical setting), and lens (e.g., medical and/or nursing students). We have used this approach to better understand an aspect of medical and nursing education, for which a powerful hidden curriculum is a likely driver—especially because it is underemphasized in the formal educational curriculum (and in health professions research). Although some limitations mitigate the application of our specific findings to other contexts, our study and discussion clearly uncovered three domains (role modeling, systems issues, and learning environment) in which the hidden curriculum, particularly the null curriculum, had a strong impact on how students learn about caring for patients with LEP in the clinical environment. We believe that the hidden curriculum within these domains—and in organizational culture—can be improved through trainee education and faculty development. Further, we think such training programs would likely be applicable to other contexts, trainees, and patient populations.
Ensuring safe, effective, and humanistic care for patients with LEP will require new educational approaches and a reinvigorated commitment to humanistic medical education. Such a commitment goes beyond simply teaching students how to work with an interpreter. It involves raising expectations for the level of care that is possible, speaking up when others accept (and even contribute to) suboptimal care, and seeing beyond the veil of language to understand the individual patient in the context of his or her culture.
Acknowledgments: The authors would like to thank Aswita Tan McGrory, Joseph Betancourt, Giselle Perez-Lougee, Elyse Park, Elizabeth Gaufberg, and Sigall Bell for their help with this study.
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