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Healthcare providers’ and deaf patients’ interpreting preferences for critical care and non-critical care: Video remote interpreting
Disability and Health Journal xxx (xxxx) xxx
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Original Article
Healthcare providers’ and deaf patients’ interpreting preferences for critical care and non-critical care: Video remote interpreting Manako Yabe University of Illinois at Chicago, Department of Disability and Human Development, 1640 West Roosevelt Road, Chicago, IL, 60608, USA
a r t i c l e i n f o
a b s t r a c t
Article history: Received 4 January 2019 Received in revised form 2 November 2019 Accepted 13 November 2019
Background: While Video Remote Interpreting services provides prompt services for emergency care and is cheaper than in-person interpreting services, there have been several issues, such as poor connection and limited flexibility to maneuver. Objectives: This study proposes three research questions and four hypotheses to identify healthcare providers and deaf/hard of hearing (DHH) patients’ preferences for VRI and in-person interpreting on critical care and non-critical care. Methods: The study utilizes a mixed methods design incorporating both an online survey and qualitative interviews. A total of 103 participants responded to the online survey. This included 36 healthcare providers who worked with limited English proficiency (LEP) patients, 26 healthcare providers who worked with DHH patients, and 41 DHH patients. Qualitative interviews were also conducted with eight healthcare providers and eight DHH patients to explore the online survey findings. Results: In the Part I study, healthcare providers (n ¼ 62) included 16 males and45 females; most professions were dentists, nurse practitioners, and students. DHH patients (n ¼ 41) included 17 males and22 females; most education was graduate or professional degrees. There was no statistical difference in their preference uses for critical care (p ¼ 1.000), but there was a statistical difference for non-critical care (p ¼ .035). In the Part II study, both healthcare providers and DHH patients preferred in-person interpreting for critical care to obtain effective communication, translation accuracy, and better treatment. Conclusions: Recommendation to improve VRI equipment and training with healthcare providers, hospital administrators, VRI companies, VRI interpreters, and DHH patients to improve healthcare communication. © 2019 Elsevier Inc. All rights reserved.
Keywords: Video remote interpreting In-person interpreting Deaf/hard of hearing patient Healthcare providers Patient-provider communication
Introduction The popularization of using Video Remote Interpreting (VRI) has become a concern for the Deaf community.1 VRI uses a video camera on a computer or a tablet screen to connect healthcare providers and patients with remote interpreters to assist with interpretation needs.2 In recent years, VRI has emerged as a popular communication tool used by healthcare providers when working with Limited English Proficiency (LEP) and DHH patients.3 The widespread use of VRI has become increasingly popular because it is less expensive, and it makes it easy to contact an interpreter at almost any time. As a result, many hospitals no longer hire inperson interpreters.4 This study targeted healthcare providers who have experienced
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using VRI with LEP patients and DHH patients, and DHH patients who have identified as American Sign Language (ASL) users and who have experienced using VRI. Most ASL users have been deaf since birth or early childhood.5 In the United States, an estimated 100,000 to one million people use ASL as their primary language.5 The Americans with Disabilities Act of 1990 and Section 504 of the Rehabilitation Act of 1973 have provided legal protections for DHH patients’ rights.6 Yet, healthcare providers often do not provide ASL interpreters.7 The reasons vary: Time constraints, little knowledge about the availability of professional interpreters, and high costs for interpreting services.8 Overview on healthcare communication barriers with deaf/hard of hearing patients Previous studies highlight the impact of communication barriers on the health outcomes and health experiences of DHH
https://doi.org/10.1016/j.dhjo.2019.100870 1936-6574/© 2019 Elsevier Inc. All rights reserved.
Please cite this article as: Yabe M, Healthcare providers’ and deaf patients’ interpreting preferences for critical care and non-critical care: Video remote interpreting, Disability and Health Journal, https://doi.org/10.1016/j.dhjo.2019.100870
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patients. For instance, DHH patients who are ASL users struggle to understand spoken English due to a lack of proficiency in written English. They may experience a lack of general knowledge about cancer, preventive health, and cardiovascular disease.9 Previous studies have found that language barriers have been shown to decrease the quality of care, and communication issues are associated with an increased risk of preventable adverse events.10,11 Communication strategies for deaf/hard of hearing patients Healthcare providers need to be trained to understand the advantages and disadvantages of interpreting services, as well as to be aware of their legal obligation to provide accommodations.12 Healthcare providers need to understand Deaf culture, such as differences between spoken English and ASL, and the fact that DHH patients have different types of communication styles.12 Healthcare providers need to consider various communication strategies, such as speaking to the DHH patients directly rather than directing communication at the interpreters.13 Due to the populations of VRI, healthcare providers also need to understand pros and cons of VRI versus in-person interpreting and provide appropriate interpreting services for clinical situations.1 Gaps in video remote interpreting research Few studies have discussed DHH patients’ healthcare communication through VRI. Kuenburg, Fellinger, and Fellinger11 examined the topic of healthcare access for the deaf population within the United Nation Convention on the Rights of People with Disabilities. The researchers reviewed literature published between 2000 and 2015 and found that the deaf people still experienced barriers to healthcare, yet, the literature had not addressed VRI issues. Kushalnagar, Harris, Paludneviciene, and Hoglind14 created an ASL version of the Health Information National Trends Survey and gathered information about health information seeking behaviors of DHH patients in the United States across technology-mediated platforms.14 The researchers found that some items from the survey required cultural adaptation for use with DHH patients who use technology,14 but they did not discuss DHH patients’ preferences regarding VRI for critical care and non-critical care. Sheppard15 collected Deaf adults’ stories about their lifelong experiences with health care. The researcher found that communication barriers between DHH patients and healthcare providers were attributed to healthcare providers’ lack of understanding of Deaf culture and inadequate communication.15 However, the study did not discuss communication issues from the use of VRI. Pendergrass, Nemeth, Newman, Jenkins, and Jones16 examined nurse practitioners’ perceptions of barriers and facilitators in providing healthcare for Deaf ASL users. The researchers found that nurse practitioners preferred to use ASL interpreters, but they often choose them as a last resource after the failure of attempting all other communication methods.16 However, this study did not discuss their experiences with VRI. Objectives of the study The above literature has discussed that healthcare providers and DHH patients experience communication barriers. However, VRI research is still scant. Therefore, this study proposes to identify healthcare providers’ and DHH patients’ interpreting preferences for VRI and in-person interpreting during critical care (e.g., surgery, urgent care) and non-critical care (e.g., follow up, non-urgent care). Based on study findings, recommendations are offered to identify appropriate interpreting solutions for specific clinical situations.
Methods Research questions This study proposes three research questions: 1. What are the perspectives of healthcare providers and DHH patients regarding the use of VRI and in-person interpreting? 2. Are there differences in healthcare provider and DHH patient preferences for VRI versus in-person interpreting based on critical care and non-critical care? 3. Are there differences in perspectives related to VRI and inperson interpreting between healthcare providers who primarily work with LEP patients and those who primarily work with DHH patients? In this study, a mixed methods approach using a sequential exploratory design was used, using a two-phase design where the quantitative data was collected first, followed by qualitative data collection. Both datasets were analyzed separately and compared.17 Collecting both quantitative and qualitative data allowed comparison of the preferences of healthcare providers and DHH patients, using two forms of data to understand the topic more comprehensively than would be possible with either type of data collected separately.18 Part I quantitative data were used to test hypotheses related to healthcare providers’ and DHH patients’ interpreting preferences for critical care and non-critical care. Hypotheses testing was conducted through SPSS 25 version software.19 Part II qualitative data explored in-depth findings from the Part I quantitative data collection. Qualitative content analysis in a direct approach was used,20 establishing the interview themes first and coding the data through Dedoose software.21 Questionnaires In Part I, the online survey questionnaires consisted of three parts regarding the participants’ interpreting preferences, their recommendations for improving VRI services, and their demographic backgrounds. Questions included in Part 1 and Part 2 were similar for two groups; however, questions in Part 3 were designed to fit each group’s demographic backgrounds. The survey for DHH patients included 15 questions and the survey for healthcare providers included 16 questions. In Part II of the study, semi-structured 1:1 interviews were done and explored the following questions: Q1. Please describe your experiences with video remote interpreting and in-person interpreting during healthcare appointments. Q2. If you see a patient (or a doctor) for critical treatment, which interpreting method would you prefer to use? Q3. If you see a patient (or a doctor) for non-critical treatment, which interpreting method would you prefer to use? Q4. How do you determine what interpreting method is appropriate for different appointments with your patient (or your healthcare provider)? Q5. What are your suggestions or ideas for improvement of video remote interpreting?
Inclusion criteria This study focused on: a) healthcare providers who had used VRI in clinical settings in the past 10 years, were 18 years or older, and
Please cite this article as: Yabe M, Healthcare providers’ and deaf patients’ interpreting preferences for critical care and non-critical care: Video remote interpreting, Disability and Health Journal, https://doi.org/10.1016/j.dhjo.2019.100870
M. Yabe / Disability and Health Journal xxx (xxxx) xxx
who spoke English; b) DHH patients who had used VRI in clinical settings in the past 10 years, were 18 years or older, and who used ASL. Healthcare providers were authorized to practice medicine or surgery in clinical settings, and included: Assistant practitioners, dentists, nurse practitioners, occupational therapists, physicians, physical therapists, pharmacists, speech-language pathologists, and students who practiced in clinical settings under supervision. Recruitment The researcher contacted healthcare professional associations and deaf agencies from the midwestern state asking permission to send a recruitment letter to their member list. Upon approval, participants were recruited via mass mail. The researcher posted flyers at a university’s hospital and health colleges, and deaf agencies. The researcher used snowball sampling22 through emails and national organizations’Facebook groups. Most of the survey data and the interview data were collected from Illinois. Procedures Interested participants who completed Part I were asked to enter their email addresses at the end of the online survey if they would also like to participate in Part II. They were provided a screening questionnaire via email to confirm their eligibility for qualitative interviews. Eligible participants were scheduled for a 20 to 30-min interview appointment in person, via videophone, Skype, or Google Docs. During interviews with healthcare providers in person and via Skype, the researcher used an ASL interpreter to facilitate communication. Audio-recording was used for transcription. The researcher completed the interview with one participant using Google Docs, which became a transcript of the interview. During the interviews with DHH patients, the researcher interviewed DHH patients via videophone in an interview location which provided a large screen for videophone and the space to set up a video-camera to record the interviews on the screen. The researcher used an ASL interpreter team, audio-recording, and video-recording for translating content from ASL into spoken English. Audio-recorded files were transcribed, and the researcher double-checked the accuracy of the transcription by reviewing video-recordings. All participants who completed both Part I and Part II were given $25 Target gift cards. Results Part I study One hundred and three respondents completed the online survey, including 36 healthcare providers who primarily worked with LEP patients, 26 healthcare providers who primarily worked with DHH patients, and 41 DHH patients. Incomplete and duplicate surveys were omitted from data analysis. Regarding demographic characteristics, healthcare providers (n ¼ 62) included 16 males and 45 females. The majority were between 20 and 39 years of age, and sixty-six percent of respondents were White. The majority of professions were dentists, nurse practitioners, and students. Eighty-four percent of respondents were from Illinois. DHH patients (n ¼ 41) included 17 males and 22 females. The majority were between 40 and 60 years of age, and sixty-eight percent of respondents were White. The majority of education levels were graduate or professional degrees. Seventy-three percent of respondents were from Illinois (See Table 1). This study proposed four hypotheses analyzed through chi-
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square testing to examine differences in interpreting preferences among the three groups based on critical care and non-critical care. Statistical differences were double-checked by using Fisher’s Exact Test for accuracy.23 Hypothesis 1. The study examined whether there were differences in interpreting preferences for critical care between healthcare providers who primarily worked with DHH patients and DHH patients. A chi-square test found no difference in preferences, c2 (1, N ¼ 58) ¼ .011, p > .05 (Fisher’s Exact Test, p ¼ 1.000). Both groups preferred in-person interpreting for critical care. Hypothesis 2. The study examined whether there were differences in interpreting preferences for non-critical care between healthcare providers who primarily worked with DHH patients and DHH patients. Statistical testing found a significant difference. Healthcare providers and DHH patients had different preferences for non-critical care, c2 (1, N ¼ 53) ¼ 5.014, p < .05 (Fisher’s Exact Test, p ¼ .035). It appeared that healthcare providers had no preferences between VRI or in-person interpreting for non-critical care, while DHH patients tended to prefer in-person interpreting for non-critical care (See Table 2). Hypothesis 3. The study examined the differences between interpreting preferences of healthcare providers who primarily worked with LEP patients and healthcare providers who primarily worked with DHH patients for critical care and found no significant difference, c2 (1, N ¼ 54) ¼ .351, p > .05 (Fisher’s Exact Test, p ¼ 1.000). Both groups preferred in-person interpreting for critical care. Hypothesis 4. The study examined differences between interpreting preferences of healthcare providers who primarily worked with LEP patients and healthcare providers who primarily worked with DHH patients for non-critical care and found no significant difference, c2 (1, N ¼ 49) ¼ .007, p > .05 (Fisher’s Exact Test, p ¼ 1.000). Both groups did not have a strong preference for either VRI or in-person interpreting for non-critical care (See Table 3). Training experience. The study examined whether healthcare providers had training experiences in using VRI or for treating DHH patients. More than 50% of both healthcare providers who primarily worked with LEP patients and healthcare providers who primarily worked with DHH patients had no training in using VRI. Similarly, more than 40% of both groups had no training in treating DHH patients. The researcher tested to see whether there was a statistically significant difference between the two groups related to their training experiences using a chi-square test. The test revealed no difference for VRI training, c2 (3, N ¼ 62) ¼ 2.726, p > .05 (Fisher’s Exact Test, p ¼ .441), and for treating DHH patients, c2 (3, N ¼ 62) ¼ 0.569, p > .05 (Fisher’s Exact Test, p ¼ .857). (See Table 4). Recommendations. A chi-square test was used to assess whether there was a statistically significant difference related to recommendations for VRI training among the three groups. The test revealed that there were no statistically significant differences among the three groups, c2 (2, N ¼ 103) ¼ 3.455, p > .05 (Fisher’s Exact Test, p ¼ .221). (See Table 5). Part II study In Part II of the study, 21 of 26 healthcare providers and 33 of 41 DHH patients were interested in participating in the qualitative interviews. A sample size of 12e15 participants is a minimum for qualitative interview studies conducted in homogeneous groups.24 For this study, recruitment of 12 healthcare providers and 12 DHH patients would have been adequate to achieve data saturation.
Please cite this article as: Yabe M, Healthcare providers’ and deaf patients’ interpreting preferences for critical care and non-critical care: Video remote interpreting, Disability and Health Journal, https://doi.org/10.1016/j.dhjo.2019.100870
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Table 1 Characteristics of survey respondents. Healthcare Providers (n ¼ 62)
Total
Gender
Age
Race
Profession
DHH Patients (n ¼ 41) Gender
Age
Race
Education
N
%
Male Female Not Answered 20e29 30e39 40e49 50e59 Over 60 Not Answered White Black Hispanic Asian Other Assistant Practitioner Dentist, Dental Hygienist Nurse, Registered Nurse, Nurse Practitioner Occupational Therapist Physician Physical Therapist Pharmacist Speech-Language Pathologist Student Other
16 45 1 25 15 8 6 1 7 41 2 4 11 3 1 13 16 2 5 3 3 6 12 1
25.8 72.6 1.6 40.3 24.2 12.9 9.7 1.6 11.3 66.1 3.2 6.5 17.7 4.8 1.6 21.0 25.8 3.2 8.1 4.8 4.8 9.7 19.4 1.6
Male Female Other 20e29 30e39 40e49 50e59 Over 60 Not Answered White Black Hispanic Asian Other Less than High School High School Graduate Some College, No Degree Associate Degree Bachelor’s Degree Graduate or Professional Degree
17 22 2 5 6 9 8 9 4 28 5 4 3 1 1 6 4 9 8 13
41.5 53.7 4.9 12.2 14.6 22 19.5 22 9.8 68.3 12.2 9.8 7.3 2.4 2.4 14.6 9.8 22 19.5 31.7
After reviewing the participants’ demographic backgrounds, the researcher contacted 12 healthcare providers who were the midwestern state residents, including six males and six females. Four participants did not respond to the invitation. As a result, the researcher was able to recruit eight participants, including two males and six females.
For DHH patients, the researcher reviewed participants’ demographic backgrounds and contacted 12 DHH patients who were the midwestern state residents, including six males and six females. Four participants withdrew from participation. As a result, the researcher was able to recruit eight participants, including four males and four females. (See Table 6).
Table 2 Healthcare providers’ and DHH patients’ interpreting preferences. Critical Care
Healthcare Providers DHH Patients N
In-Person
VRI
N
p
Fisher’s exact test
20 35 55
1 2 3
21a 37b 58
1.000
1.000
Non-Critical Care Healthcare Providers DHH Patients N
In-Person
VRI
N
p
Fisher’s exact test
11 26 37
10 6 16
21c 32d 53
0.035
0.035
Note. a, b, c, d healthcare providers who preferred telephone interpreting or had no preference and DHH patients who had no preference were omitted for data analysis.
Please cite this article as: Yabe M, Healthcare providers’ and deaf patients’ interpreting preferences for critical care and non-critical care: Video remote interpreting, Disability and Health Journal, https://doi.org/10.1016/j.dhjo.2019.100870
M. Yabe / Disability and Health Journal xxx (xxxx) xxx
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Table 3 Healthcare providers’ interpreting preferences. Critical Care In-Person Healthcare Providers who worked with LEP Patients Healthcare Providers who worked with DHH Patients N
VRI
N a
p
Fisher’s exact test
30 20 50
3 1 4
33 21b 54
0.649
1.000
In-Person
VRI
N
p
Fisher’s exact test
1.000
1.000
Non-Critical Care Healthcare Providers who worked with LEP Patients Healthcare Providers who worked with DHH Patients N
15 11 26
c
13 10 23
28 21d 49
Note. a, b, c, d healthcare providers who preferred telephone interpreting or had no preference were omitted for data analysis.
The researcher established five themes: 1) experiences, 2) preferences, 3) opinions, 4) suggestions, and 5) other concerns for coding all interview transcripts. The researcher then divided the data into subthemes for each theme, including the following: the two groups’ positive and negative experiences with VRI and inperson interpreting; their interpreting preferences for critical care and non-critical care; their positive and negative opinions toward VRI and in-person interpreting; their suggestions for improving VRI services; and comparisons between LEP and DHH patients. Both groups mentioned positive and negative opinions based on their own experiences, the results of which were moved to opinions.
VRI, such as the VRI technology working and their providers’ comfort with using VRI. Seven patients (BU, DE, ED, IK, JA, RM, and RP) shared negative experiences with the use of VRI, such as poor connectivity, limited placement and positioning, lack of patientprovider relationship, and providing VRI without notification. Seven patients (DE, ED, IK, JA, ML, RM, and RP) expressed positive experiences with the use of in-person interpreting, including better patient-provider communication, promptness, and in-person interpreter’s professionalism. One patient (BU) had a negative experience with in-person interpreting due to limited availability (Appendix, Table A).
Experiences
Preferences
Six providers (EP, EK, GO, MN, TY, and WD) expressed positive experiences with use of VRI, such as the convenience of using VRI, comfort for patients, and providing a communication tool. Six providers (BE, EP, GJ, GO, KS, and TY) shared negative experiences with VRI, such as technology issues, lack of VRI training, lack of patient-provider relationship, and VRI interpreter’s unprofessionalism. Two providers (GO and KS) shared positive experiences with the use of in-person interpreting service, such as better patientprovider communication and better treatments. One provider (MN) shared a negative experience with in-person interpreting services due to limited availability. Three patients (BU, ED, and ML) had positive experiences with
Two providers (EP and TY) preferred using VRI for critical care because of its promptness. Three providers (GJ, KS, and WD) preferred using in-person interpreters for critical care because of the demands of surgery care. Two providers (GO and TY) preferred VRI for non-critical care for specific reasons, such as that VRI was already available in GO’s office and that in-person interpreter was not often available in TY’s office. Four providers (EP, KS, TY, and WD) preferred in-person interpreters for non-critical care because of better patient-provider relationships and communication. Four patients (BU, DE, ED, and RP) did not prefer VRI in general, but they would accept using VRI for a specific reason because of promptness. DE and ED would accept VRI for emergency care
Table 4 Healthcare providers’ training experience. For Using VRI
A Significant Amount A Moderate Amount A Little Amount None at All N
Healthcare Providers who worked with LEP Patients
Healthcare Providers who worked with DHH Patients
N
%
N
%
p
Fisher’s exact test
1 3 11 21 36
2.8 8.3 30.6 58.3 100.0
0 4 11 11 26
0.0 15.4 42.3 42.3 100.0
0.457
0.441
For Treating DHH Patients Healthcare Providers who worked with LEP Patients
A Significant Amount A Moderate Amount A Little Amount None at All N
N
%
Healthcare Providers who worked with DHH Patients N %
1 2 13 20 36
2.8 5.6 36.1 55.6 100.0
1 2 11 12 26
3.8 7.7 42.3 46.2 100.0
p
Fisher’s exact test
0.926
0.857
Please cite this article as: Yabe M, Healthcare providers’ and deaf patients’ interpreting preferences for critical care and non-critical care: Video remote interpreting, Disability and Health Journal, https://doi.org/10.1016/j.dhjo.2019.100870
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Table 5 Healthcare providers’ and DHH patients’ recommendations for VRI training. Healthcare Providers who worked with LEP Patients
Need to be trained Not to be trained N
DHH Patients
Healthcare Providers who worked with DHH Patients
N
%
N
%
N
%
32 4 36
88.9 11.1 100.0
19 7 26
73.1 26.9 100.0
36 5 41
87.8 12.2 100.0
unless an in-person interpreter could come less than two hours later. Six patients (BU, DE, IK, RM, and RP) preferred in-person interpreting for critical care because of the ability to clarify information and an effective translation process. Two patients (ED and IK) would not prefer VRI but would accept VRI for non-critical care for a specific reason, such as follow-up. Two patients (BU and DE) preferred in-person interpreting for non-critical care, such as if an appointment is scheduled in advance, and they would not accept VRI (Appendix, Table B). Opinion Five providers (BE, GO, MN, TY, and WD) shared positive opinions about VRI, such as it was already available, it was helpful for communication, it was better than nothing to have an interpreter, and it was economically viable. Three providers (BE, EP, and GJ) shared negative opinions about VRI, such as a lack of patientprovider relationship and limited access. Four providers (GJ, EP, MN, and WD) shared a positive opinion that in-person interpreting provided better patient-provider communication. Three providers (BE, GJ, and WD) shared negative opinions about in-person interpreting, such as limited availability and economic loss. Seven patients (BU, DE, ED, JA, ML, RM, and RP) shared negative opinions about VRI, such as limited placement and positioning, poor connectivity, limited visual access, inappropriate use, limited language assessment, lack of patient-provider relationship, lack of medically trained interpreter, and economic loss. Five patients (BU, DE, ML, RM, and RP) shared positive opinions about in-person interpreting, such as full accurate translation, flexibility to move, language assessment, and developing patient-provider relationship (Appendix, Table C).
p
Fisher’s exact test
0.221
0.221
Suggestions Six providers (BE, DO, GJ, GO, KS, and MN) provided suggestions for improving equipment use, such as more flexibility, larger screen size, adjustable height, and better connectivity. They also suggested educating healthcare providers in how to interact with DHH patients through VRI and educating DHH patients for their rights. Hiring more bilingual providers was another suggestion. Eight patients (BU, ED, DE, IK, JA, ML, RM, and RP) provided similar suggestions such as improving equipment use, hiring more bilingual providers, and educating both healthcare providers and DHH patients. The patients also suggested educating hospital administrators to identify which clinical situations would be appropriate to use VRI, VRI interpreters advocating for DHH patients, and VRI companies and hospital administrators meeting legal obligations (Appendix, Table D). Comparison with limited English proficiency patients and deaf/hard of hearing patients Six providers (BE, EP, GJ, KS, MN, and WD) made comparisons between LEP patients and DHH patients. As a similarity, the providers shared that VRI was beneficial for trilingual interpreting held among a provider, a DHH patient, and an LEP family member. Interpreting was beneficial for all populations, yet it required some time for communication access. The same providers also had budget concerns about paying for interpreting services. As for differences in interpreting requirements, LEP patients could hear when they laid down or moved around, so it was less challenging to use VRI. But DHH patients were unable to see the VRI interpreter when they laid down or moved around, so it was more
Table 6 Characteristics of interviewees. Healthcare Providers (n ¼ 8) ID
Gender
Age
Profession
BE EP GJ GO MN KS TY WD
Female Female Female Female Female Male Female Male
58 31 31 32 38 26 27 50
Physical Therapist Speech Language Pathologist Dentist Physical Therapist Nurse Practitioner Oral Surgeon Nurse Practitioner Physician
DHH Patients (n ¼ 8) ID
Gender
Age
Education
BU DE ED IK JA ML RM RP
Male Female Female Female Male Female Male Male
70 54 50 53 45 48 61 30
Graduate Degree Bachelor’s Degree Associate Degree Graduate Degree Some College, No Degree Bachelor’s Degree Associate Degree Graduate Degree
Please cite this article as: Yabe M, Healthcare providers’ and deaf patients’ interpreting preferences for critical care and non-critical care: Video remote interpreting, Disability and Health Journal, https://doi.org/10.1016/j.dhjo.2019.100870
M. Yabe / Disability and Health Journal xxx (xxxx) xxx
challenging to use VRI (Appendix, Table E). Comparison between healthcare providers and deaf/hard of hearing patients In sum, both groups had similar experiences with VRI technology issues. Both groups shared positive aspects of in-person interpreting, such as better patient-provider communication and relationships, but they also experienced concerns with the lack of in-person interpreters. Both groups suggested VRI training for providers and improving VRI equipment, including better connectivity, adjustable height, and larger screen sizes. Healthcare providers also suggested training patients and their families to understand their rights, while DHH patients suggested training hospital administrators and VRI companies to meet legal obligations. DHH patients also suggested medically training VRI interpreters. Additionally, DHH patients mentioned that in-person interpreters provided language assessment and could accommodate patients’ languages levels. On the other hand, DHH patients indicated that they would accept VRI for a specific reason, such as specific time demands or types of treatment care, while healthcare providers would accept VRI, as it was already available, or since it was better than nothing. Conflicts were expressed related to budget concerns between the two groups. While healthcare providers mentioned that in-person interpreting services were expensive, DHH patients stated that VRI was waste of money because VRI cannot provide effective communication. Discussion Video remote interpreting Previous studies connect with the Part II data collection. For instance, the increased use of VRI is due to its potentially lower cost based on how many minutes used instead of a flat two hour interpreter fee29, as well as VRI’s ability to connect with an interpreter at any hour even in more remote locations.27,28 Yet, both healthcare providers and DHH patients experienced with poor connectivity and visual and mobility limitations with the use of VRI.25,26 Furthermore, VRI is also not accessible for DHH patients who have cognitive disabilities, linguistic limitations, or visually impairments.3,27 DHH patients were unable to see when they are lying down and vomiting, or if they lie face downward on an examination table during x-ray appointments or biopsy tests. In-person interpreting Previous studies also connect the Part II data collection. Both groups mentioned that in-person interpreters provide enough patient-provider communication.26,30 Yet, healthcare providers mentioned that in-person interpreting services were expensive,4 and that they cannot get a refund for in-person interpreting services when patients miss appointments. The Part I study also found that healthcare providers are often not trained on how to use VRI.25,26 Healthcare providers also stated that budgetary constraints have limited the availability of in-person interpreters.31 Recommendations Overall, the findings of the study suggest that health care providers and systems should consider the advantages and disadvantages of using VRI and be mindful of how they may impact DHH patients’ care and satisfaction. The study also suggests that hospital administrators should not popularize VRI for 100% of their clinical
7
treatments and allocate funding for in-person interpreting for critical care treatments. The study suggests that hospital administrators and VRI companies need to follow legal obligations, and to establish a specific law regulating VRI companies. VRI companies need to work closely with hospital administrators to improve the quality of VRI equipment, as well as take initiatives to provide training for healthcare providers, DHH patients, and VRI interpreters. Limitations Limitations for the Part I study was the small sample size of healthcare providers who had worked with DHH patients, and a lack of accommodation in the ASL survey due to a limited timeframe for the study and grant constraints. Limitations for the Part II study were a lack of race/ethnic diversity, the age of interviewees, and the small sample size for interviewees. The demographics of the interviewees might not generalize for the demographics of the target populations. The online survey and interview guide were designed to illuminate communication barriers during clinical encounters between healthcare providers and DHH patients. This study was not designed to illuminate other cultural factors that might affect interactions between healthcare providers and DHH patients. Interestingly, those healthcare providers did not have much knowledge about Deaf culture, yet, they were aware of the importance of patient-provider communication. Conclusion Overall, the study’s findings suggest that further steps are needed to determine the appropriate use of VRI versus in-person interpreters while meeting the legal requirements of ensuring effective communication even in areas where access to interpreters is limited. Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.dhjo.2019.100870. References 1. National Association of the Deaf. Minimum standards for video remote interpreting services in medical settings. https://www.nad.org/about-us/positionstatements/minimum-standards-for-video-remote-interpreting-services-inmedical-settings/; 2018. Accessed 31st May 2019. 2. Alley E. Exploring remote interpreting International Journal of Interpreter Education. 2012;4(1):111e119. 3. Desrosiers P. Signed language interpreting in healthcare settings: who is qualified? Honors senior theses western Oregon university, United States. https://digitalcommons.wou.edu/cgi/viewcontent.cgi? article¼1123&context¼honors_theses; 2017. 4. Marsland MC, Lou C, Snowden L. Use of communication technologies to costeffectively increase the availability of interpretation services in healthcare settings. Telemedecine Journal of E-Health. 2010;16(6):739e745. https://doi.org/ 10.1089/tmj.2009.0186. 5. Barnett S, McKee MM, Smith SR, Pearson TA. Deaf sign language users, health inequities, and public health: Opportunity for social justice. Preventing Chronic Disease. 2011;8(2):A45. http://www.cdc.gov/pcd/issues/2011/mar/10_0065. htm. 6. U.S. Department of Justice. A guide to disability rights law. http://www.ada. gov/cguide.htm; 2009. Accessed 31st May 2019. 7. Reis JP, Breslin ML, Iezzoni LI, Kirschener KL. It Takes More than Ramps Rehabilitation. Institute of Chicago; 2004. 8. Jacobs EA, Shepard DS, Suaya JA, Stone E. Overcoming language barriers in healthcare: costs and benefits of interpreter services. Am J Public Health. 2004;94(5):866e869. https://doi.org/10.2105/ajph.94.5.866. 9. McKee MM, Barnett SL, Block RC, Pearson TA. Impact of communication on preventive services among deaf American language users. Am J Prev Med. 2011;41(1):75e79. https://doi.org/10.1016/j.amepre.2011.03.004.
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10. Bartlett G, Blais R, Tamblyn R, Clermont R, MacGibbon B. Impact of patient communication problems on the risk of preventable adverse events in acute care settings. Canadian Medical Association. 2008;178(12):1555e1562. https:// doi.org/10.1503/cmaj.070690. 11. Kuenburg A, Fellinger P. J. Fellinger Health care access among deaf people. J Deaf Stud Deaf Educ. 2016;21(1):1e10. https://doi.org/10.1093/deafed/ env042. 12. Harmer LM. Health care delivery and deaf people: practice, problems, and recommendations for change. J Deaf Stud Deaf Educ. 1999;4(2):73e110. https:// doi.org/10.1093/deafed/4.2.73. 13. Meador HE, Zazove P. Health care interactions with deaf culture. J Am Board Fam Med. 2005;18(3):218e222. https://doi.org/10.3122/jabfm.18.3.218. 14. Kushalnagar P, Harris R, Pauldneviciene R, Hoglind T. Health information national trends survey in American sign language (HINTS-ASL): protocol for the cultural adaptation and linguistic validation of a national survey. J Med Internet Res. 2017;6(9):e172. https://doi.org/10.2196/resprot.8067. 15. Sheppard K. Deaf adults and health care: giving voice to their stories. Journal of the American Association of Nurse Practitioners. 2014;26(9):504e510. https:// doi.org/10.1002/2327-6924.12087. 16. Pendergrass K, Nemeth L, Newman S, Jenkins C, Jones E. Nurse practitioner perceptions of barriers and facilitators in providing health care for deaf American Sign Language users: a qualitative socio-ecological approach. J Am Acad Nurse Pract. 2017;29(6):316e323. https://doi.org/10.1002/2327-6924. 17. Johnson B, Christensen L. Educational Research: Quantitative, Qualitative, and Mixed Approaches. Washington DC: Sage; 2016. 18. Creswell JW, Clark VL. Designing and Conducting Mixed Methods Research. Washington DC: Sage; 2011. 19. International Business Machines Corporation. Statistical Package for the Social Sciences Software, 25.0 Version. 2018. 20. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual
21. 22.
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26. 27. 28. 29. 30.
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Health Res. 2005;15(9):1277e1288. https://doi.org/10.1177/ 1049732305276687. Dedoose. Dedoose qualitative and mixed method software. https://www. dedoose.com/; 2018. Dudovskiy J. Snowball sampling. http://research-methodology.net/samplingin-primary-data-collection/snowball-sampling/; 2016. Accessed on 31st May 2019. Lane D. Introduction to statistics. http://onlinestatbook.com/Online_Statistics_ Education.pdf; 2018. Accessed on 31st May 2019. Latham J. Qualitative sample size e how many participants is enough?. https:// www.drjohnlatham.com/many-participants-enough/; 2018. Accessed on 31st May 2019. Belz K. Family of Deaf Couple Sues Erlanger over Lack of Interpreters. Time Free Press; 2014. https://www.timesfreepress.com/news/local/story/2014/jul/23/ family-deaf-couple-sues-erlanger-over-lack-interpr/262471/. Accessed 31st May 2019. Kashar A. Doctor, can we please communicate? VIEWS. 2009;26:12e13. Garrett J, Maryland CT. VRI interpreting services cannot produce the same “quality” of interpreting in the hospital setting. VIEWS. 2012;29:29. Rosenblum HA. SHARE: Ask Howard Anything; 2015. https://www.youtube. com/watch?v¼Uy-9Iz-8xjw. Accessed on 31st May 2019. IU Group. Interpreters rates. https://interpretersunlimited.com/pricing/ interpretation/; 2019. Accessed on 31st May 2019. Bagchi AD, Dale S, Verbitsky-Savitz N, Andrecheck S. Using professionally trained interpreters to increase patient/provider satisfaction: does it work? Mathematica. 2010;6:1e4. https://www.issuelab.org/resources/11530/11530. pdf. Draper E. Lawsuit: Colorado deaf patient denied interpreter at Rose ER. The Denver Post. https://www.denverpost.com/2014/10/24/lawsuit-colorado-deafpatient-denied-interpreter-at-rose-er/; 2014. Accessed on 31st May 2019.
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Original Article
Healthcare providers’ and deaf patients’ interpreting preferences for critical care and non-critical care: Video remote interpreting Manako Yabe University of Illinois at Chicago, Department of Disability and Human Development, 1640 West Roosevelt Road, Chicago, IL, 60608, USA
a r t i c l e i n f o
a b s t r a c t
Article history: Received 4 January 2019 Received in revised form 2 November 2019 Accepted 13 November 2019
Background: While Video Remote Interpreting services provides prompt services for emergency care and is cheaper than in-person interpreting services, there have been several issues, such as poor connection and limited flexibility to maneuver. Objectives: This study proposes three research questions and four hypotheses to identify healthcare providers and deaf/hard of hearing (DHH) patients’ preferences for VRI and in-person interpreting on critical care and non-critical care. Methods: The study utilizes a mixed methods design incorporating both an online survey and qualitative interviews. A total of 103 participants responded to the online survey. This included 36 healthcare providers who worked with limited English proficiency (LEP) patients, 26 healthcare providers who worked with DHH patients, and 41 DHH patients. Qualitative interviews were also conducted with eight healthcare providers and eight DHH patients to explore the online survey findings. Results: In the Part I study, healthcare providers (n ¼ 62) included 16 males and45 females; most professions were dentists, nurse practitioners, and students. DHH patients (n ¼ 41) included 17 males and22 females; most education was graduate or professional degrees. There was no statistical difference in their preference uses for critical care (p ¼ 1.000), but there was a statistical difference for non-critical care (p ¼ .035). In the Part II study, both healthcare providers and DHH patients preferred in-person interpreting for critical care to obtain effective communication, translation accuracy, and better treatment. Conclusions: Recommendation to improve VRI equipment and training with healthcare providers, hospital administrators, VRI companies, VRI interpreters, and DHH patients to improve healthcare communication. © 2019 Elsevier Inc. All rights reserved.
Keywords: Video remote interpreting In-person interpreting Deaf/hard of hearing patient Healthcare providers Patient-provider communication
Introduction The popularization of using Video Remote Interpreting (VRI) has become a concern for the Deaf community.1 VRI uses a video camera on a computer or a tablet screen to connect healthcare providers and patients with remote interpreters to assist with interpretation needs.2 In recent years, VRI has emerged as a popular communication tool used by healthcare providers when working with Limited English Proficiency (LEP) and DHH patients.3 The widespread use of VRI has become increasingly popular because it is less expensive, and it makes it easy to contact an interpreter at almost any time. As a result, many hospitals no longer hire inperson interpreters.4 This study targeted healthcare providers who have experienced
E-mail address: [email protected].
using VRI with LEP patients and DHH patients, and DHH patients who have identified as American Sign Language (ASL) users and who have experienced using VRI. Most ASL users have been deaf since birth or early childhood.5 In the United States, an estimated 100,000 to one million people use ASL as their primary language.5 The Americans with Disabilities Act of 1990 and Section 504 of the Rehabilitation Act of 1973 have provided legal protections for DHH patients’ rights.6 Yet, healthcare providers often do not provide ASL interpreters.7 The reasons vary: Time constraints, little knowledge about the availability of professional interpreters, and high costs for interpreting services.8 Overview on healthcare communication barriers with deaf/hard of hearing patients Previous studies highlight the impact of communication barriers on the health outcomes and health experiences of DHH
https://doi.org/10.1016/j.dhjo.2019.100870 1936-6574/© 2019 Elsevier Inc. All rights reserved.
Please cite this article as: Yabe M, Healthcare providers’ and deaf patients’ interpreting preferences for critical care and non-critical care: Video remote interpreting, Disability and Health Journal, https://doi.org/10.1016/j.dhjo.2019.100870
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patients. For instance, DHH patients who are ASL users struggle to understand spoken English due to a lack of proficiency in written English. They may experience a lack of general knowledge about cancer, preventive health, and cardiovascular disease.9 Previous studies have found that language barriers have been shown to decrease the quality of care, and communication issues are associated with an increased risk of preventable adverse events.10,11 Communication strategies for deaf/hard of hearing patients Healthcare providers need to be trained to understand the advantages and disadvantages of interpreting services, as well as to be aware of their legal obligation to provide accommodations.12 Healthcare providers need to understand Deaf culture, such as differences between spoken English and ASL, and the fact that DHH patients have different types of communication styles.12 Healthcare providers need to consider various communication strategies, such as speaking to the DHH patients directly rather than directing communication at the interpreters.13 Due to the populations of VRI, healthcare providers also need to understand pros and cons of VRI versus in-person interpreting and provide appropriate interpreting services for clinical situations.1 Gaps in video remote interpreting research Few studies have discussed DHH patients’ healthcare communication through VRI. Kuenburg, Fellinger, and Fellinger11 examined the topic of healthcare access for the deaf population within the United Nation Convention on the Rights of People with Disabilities. The researchers reviewed literature published between 2000 and 2015 and found that the deaf people still experienced barriers to healthcare, yet, the literature had not addressed VRI issues. Kushalnagar, Harris, Paludneviciene, and Hoglind14 created an ASL version of the Health Information National Trends Survey and gathered information about health information seeking behaviors of DHH patients in the United States across technology-mediated platforms.14 The researchers found that some items from the survey required cultural adaptation for use with DHH patients who use technology,14 but they did not discuss DHH patients’ preferences regarding VRI for critical care and non-critical care. Sheppard15 collected Deaf adults’ stories about their lifelong experiences with health care. The researcher found that communication barriers between DHH patients and healthcare providers were attributed to healthcare providers’ lack of understanding of Deaf culture and inadequate communication.15 However, the study did not discuss communication issues from the use of VRI. Pendergrass, Nemeth, Newman, Jenkins, and Jones16 examined nurse practitioners’ perceptions of barriers and facilitators in providing healthcare for Deaf ASL users. The researchers found that nurse practitioners preferred to use ASL interpreters, but they often choose them as a last resource after the failure of attempting all other communication methods.16 However, this study did not discuss their experiences with VRI. Objectives of the study The above literature has discussed that healthcare providers and DHH patients experience communication barriers. However, VRI research is still scant. Therefore, this study proposes to identify healthcare providers’ and DHH patients’ interpreting preferences for VRI and in-person interpreting during critical care (e.g., surgery, urgent care) and non-critical care (e.g., follow up, non-urgent care). Based on study findings, recommendations are offered to identify appropriate interpreting solutions for specific clinical situations.
Methods Research questions This study proposes three research questions: 1. What are the perspectives of healthcare providers and DHH patients regarding the use of VRI and in-person interpreting? 2. Are there differences in healthcare provider and DHH patient preferences for VRI versus in-person interpreting based on critical care and non-critical care? 3. Are there differences in perspectives related to VRI and inperson interpreting between healthcare providers who primarily work with LEP patients and those who primarily work with DHH patients? In this study, a mixed methods approach using a sequential exploratory design was used, using a two-phase design where the quantitative data was collected first, followed by qualitative data collection. Both datasets were analyzed separately and compared.17 Collecting both quantitative and qualitative data allowed comparison of the preferences of healthcare providers and DHH patients, using two forms of data to understand the topic more comprehensively than would be possible with either type of data collected separately.18 Part I quantitative data were used to test hypotheses related to healthcare providers’ and DHH patients’ interpreting preferences for critical care and non-critical care. Hypotheses testing was conducted through SPSS 25 version software.19 Part II qualitative data explored in-depth findings from the Part I quantitative data collection. Qualitative content analysis in a direct approach was used,20 establishing the interview themes first and coding the data through Dedoose software.21 Questionnaires In Part I, the online survey questionnaires consisted of three parts regarding the participants’ interpreting preferences, their recommendations for improving VRI services, and their demographic backgrounds. Questions included in Part 1 and Part 2 were similar for two groups; however, questions in Part 3 were designed to fit each group’s demographic backgrounds. The survey for DHH patients included 15 questions and the survey for healthcare providers included 16 questions. In Part II of the study, semi-structured 1:1 interviews were done and explored the following questions: Q1. Please describe your experiences with video remote interpreting and in-person interpreting during healthcare appointments. Q2. If you see a patient (or a doctor) for critical treatment, which interpreting method would you prefer to use? Q3. If you see a patient (or a doctor) for non-critical treatment, which interpreting method would you prefer to use? Q4. How do you determine what interpreting method is appropriate for different appointments with your patient (or your healthcare provider)? Q5. What are your suggestions or ideas for improvement of video remote interpreting?
Inclusion criteria This study focused on: a) healthcare providers who had used VRI in clinical settings in the past 10 years, were 18 years or older, and
Please cite this article as: Yabe M, Healthcare providers’ and deaf patients’ interpreting preferences for critical care and non-critical care: Video remote interpreting, Disability and Health Journal, https://doi.org/10.1016/j.dhjo.2019.100870
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who spoke English; b) DHH patients who had used VRI in clinical settings in the past 10 years, were 18 years or older, and who used ASL. Healthcare providers were authorized to practice medicine or surgery in clinical settings, and included: Assistant practitioners, dentists, nurse practitioners, occupational therapists, physicians, physical therapists, pharmacists, speech-language pathologists, and students who practiced in clinical settings under supervision. Recruitment The researcher contacted healthcare professional associations and deaf agencies from the midwestern state asking permission to send a recruitment letter to their member list. Upon approval, participants were recruited via mass mail. The researcher posted flyers at a university’s hospital and health colleges, and deaf agencies. The researcher used snowball sampling22 through emails and national organizations’Facebook groups. Most of the survey data and the interview data were collected from Illinois. Procedures Interested participants who completed Part I were asked to enter their email addresses at the end of the online survey if they would also like to participate in Part II. They were provided a screening questionnaire via email to confirm their eligibility for qualitative interviews. Eligible participants were scheduled for a 20 to 30-min interview appointment in person, via videophone, Skype, or Google Docs. During interviews with healthcare providers in person and via Skype, the researcher used an ASL interpreter to facilitate communication. Audio-recording was used for transcription. The researcher completed the interview with one participant using Google Docs, which became a transcript of the interview. During the interviews with DHH patients, the researcher interviewed DHH patients via videophone in an interview location which provided a large screen for videophone and the space to set up a video-camera to record the interviews on the screen. The researcher used an ASL interpreter team, audio-recording, and video-recording for translating content from ASL into spoken English. Audio-recorded files were transcribed, and the researcher double-checked the accuracy of the transcription by reviewing video-recordings. All participants who completed both Part I and Part II were given $25 Target gift cards. Results Part I study One hundred and three respondents completed the online survey, including 36 healthcare providers who primarily worked with LEP patients, 26 healthcare providers who primarily worked with DHH patients, and 41 DHH patients. Incomplete and duplicate surveys were omitted from data analysis. Regarding demographic characteristics, healthcare providers (n ¼ 62) included 16 males and 45 females. The majority were between 20 and 39 years of age, and sixty-six percent of respondents were White. The majority of professions were dentists, nurse practitioners, and students. Eighty-four percent of respondents were from Illinois. DHH patients (n ¼ 41) included 17 males and 22 females. The majority were between 40 and 60 years of age, and sixty-eight percent of respondents were White. The majority of education levels were graduate or professional degrees. Seventy-three percent of respondents were from Illinois (See Table 1). This study proposed four hypotheses analyzed through chi-
3
square testing to examine differences in interpreting preferences among the three groups based on critical care and non-critical care. Statistical differences were double-checked by using Fisher’s Exact Test for accuracy.23 Hypothesis 1. The study examined whether there were differences in interpreting preferences for critical care between healthcare providers who primarily worked with DHH patients and DHH patients. A chi-square test found no difference in preferences, c2 (1, N ¼ 58) ¼ .011, p > .05 (Fisher’s Exact Test, p ¼ 1.000). Both groups preferred in-person interpreting for critical care. Hypothesis 2. The study examined whether there were differences in interpreting preferences for non-critical care between healthcare providers who primarily worked with DHH patients and DHH patients. Statistical testing found a significant difference. Healthcare providers and DHH patients had different preferences for non-critical care, c2 (1, N ¼ 53) ¼ 5.014, p < .05 (Fisher’s Exact Test, p ¼ .035). It appeared that healthcare providers had no preferences between VRI or in-person interpreting for non-critical care, while DHH patients tended to prefer in-person interpreting for non-critical care (See Table 2). Hypothesis 3. The study examined the differences between interpreting preferences of healthcare providers who primarily worked with LEP patients and healthcare providers who primarily worked with DHH patients for critical care and found no significant difference, c2 (1, N ¼ 54) ¼ .351, p > .05 (Fisher’s Exact Test, p ¼ 1.000). Both groups preferred in-person interpreting for critical care. Hypothesis 4. The study examined differences between interpreting preferences of healthcare providers who primarily worked with LEP patients and healthcare providers who primarily worked with DHH patients for non-critical care and found no significant difference, c2 (1, N ¼ 49) ¼ .007, p > .05 (Fisher’s Exact Test, p ¼ 1.000). Both groups did not have a strong preference for either VRI or in-person interpreting for non-critical care (See Table 3). Training experience. The study examined whether healthcare providers had training experiences in using VRI or for treating DHH patients. More than 50% of both healthcare providers who primarily worked with LEP patients and healthcare providers who primarily worked with DHH patients had no training in using VRI. Similarly, more than 40% of both groups had no training in treating DHH patients. The researcher tested to see whether there was a statistically significant difference between the two groups related to their training experiences using a chi-square test. The test revealed no difference for VRI training, c2 (3, N ¼ 62) ¼ 2.726, p > .05 (Fisher’s Exact Test, p ¼ .441), and for treating DHH patients, c2 (3, N ¼ 62) ¼ 0.569, p > .05 (Fisher’s Exact Test, p ¼ .857). (See Table 4). Recommendations. A chi-square test was used to assess whether there was a statistically significant difference related to recommendations for VRI training among the three groups. The test revealed that there were no statistically significant differences among the three groups, c2 (2, N ¼ 103) ¼ 3.455, p > .05 (Fisher’s Exact Test, p ¼ .221). (See Table 5). Part II study In Part II of the study, 21 of 26 healthcare providers and 33 of 41 DHH patients were interested in participating in the qualitative interviews. A sample size of 12e15 participants is a minimum for qualitative interview studies conducted in homogeneous groups.24 For this study, recruitment of 12 healthcare providers and 12 DHH patients would have been adequate to achieve data saturation.
Please cite this article as: Yabe M, Healthcare providers’ and deaf patients’ interpreting preferences for critical care and non-critical care: Video remote interpreting, Disability and Health Journal, https://doi.org/10.1016/j.dhjo.2019.100870
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Table 1 Characteristics of survey respondents. Healthcare Providers (n ¼ 62)
Total
Gender
Age
Race
Profession
DHH Patients (n ¼ 41) Gender
Age
Race
Education
N
%
Male Female Not Answered 20e29 30e39 40e49 50e59 Over 60 Not Answered White Black Hispanic Asian Other Assistant Practitioner Dentist, Dental Hygienist Nurse, Registered Nurse, Nurse Practitioner Occupational Therapist Physician Physical Therapist Pharmacist Speech-Language Pathologist Student Other
16 45 1 25 15 8 6 1 7 41 2 4 11 3 1 13 16 2 5 3 3 6 12 1
25.8 72.6 1.6 40.3 24.2 12.9 9.7 1.6 11.3 66.1 3.2 6.5 17.7 4.8 1.6 21.0 25.8 3.2 8.1 4.8 4.8 9.7 19.4 1.6
Male Female Other 20e29 30e39 40e49 50e59 Over 60 Not Answered White Black Hispanic Asian Other Less than High School High School Graduate Some College, No Degree Associate Degree Bachelor’s Degree Graduate or Professional Degree
17 22 2 5 6 9 8 9 4 28 5 4 3 1 1 6 4 9 8 13
41.5 53.7 4.9 12.2 14.6 22 19.5 22 9.8 68.3 12.2 9.8 7.3 2.4 2.4 14.6 9.8 22 19.5 31.7
After reviewing the participants’ demographic backgrounds, the researcher contacted 12 healthcare providers who were the midwestern state residents, including six males and six females. Four participants did not respond to the invitation. As a result, the researcher was able to recruit eight participants, including two males and six females.
For DHH patients, the researcher reviewed participants’ demographic backgrounds and contacted 12 DHH patients who were the midwestern state residents, including six males and six females. Four participants withdrew from participation. As a result, the researcher was able to recruit eight participants, including four males and four females. (See Table 6).
Table 2 Healthcare providers’ and DHH patients’ interpreting preferences. Critical Care
Healthcare Providers DHH Patients N
In-Person
VRI
N
p
Fisher’s exact test
20 35 55
1 2 3
21a 37b 58
1.000
1.000
Non-Critical Care Healthcare Providers DHH Patients N
In-Person
VRI
N
p
Fisher’s exact test
11 26 37
10 6 16
21c 32d 53
0.035
0.035
Note. a, b, c, d healthcare providers who preferred telephone interpreting or had no preference and DHH patients who had no preference were omitted for data analysis.
Please cite this article as: Yabe M, Healthcare providers’ and deaf patients’ interpreting preferences for critical care and non-critical care: Video remote interpreting, Disability and Health Journal, https://doi.org/10.1016/j.dhjo.2019.100870
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Table 3 Healthcare providers’ interpreting preferences. Critical Care In-Person Healthcare Providers who worked with LEP Patients Healthcare Providers who worked with DHH Patients N
VRI
N a
p
Fisher’s exact test
30 20 50
3 1 4
33 21b 54
0.649
1.000
In-Person
VRI
N
p
Fisher’s exact test
1.000
1.000
Non-Critical Care Healthcare Providers who worked with LEP Patients Healthcare Providers who worked with DHH Patients N
15 11 26
c
13 10 23
28 21d 49
Note. a, b, c, d healthcare providers who preferred telephone interpreting or had no preference were omitted for data analysis.
The researcher established five themes: 1) experiences, 2) preferences, 3) opinions, 4) suggestions, and 5) other concerns for coding all interview transcripts. The researcher then divided the data into subthemes for each theme, including the following: the two groups’ positive and negative experiences with VRI and inperson interpreting; their interpreting preferences for critical care and non-critical care; their positive and negative opinions toward VRI and in-person interpreting; their suggestions for improving VRI services; and comparisons between LEP and DHH patients. Both groups mentioned positive and negative opinions based on their own experiences, the results of which were moved to opinions.
VRI, such as the VRI technology working and their providers’ comfort with using VRI. Seven patients (BU, DE, ED, IK, JA, RM, and RP) shared negative experiences with the use of VRI, such as poor connectivity, limited placement and positioning, lack of patientprovider relationship, and providing VRI without notification. Seven patients (DE, ED, IK, JA, ML, RM, and RP) expressed positive experiences with the use of in-person interpreting, including better patient-provider communication, promptness, and in-person interpreter’s professionalism. One patient (BU) had a negative experience with in-person interpreting due to limited availability (Appendix, Table A).
Experiences
Preferences
Six providers (EP, EK, GO, MN, TY, and WD) expressed positive experiences with use of VRI, such as the convenience of using VRI, comfort for patients, and providing a communication tool. Six providers (BE, EP, GJ, GO, KS, and TY) shared negative experiences with VRI, such as technology issues, lack of VRI training, lack of patient-provider relationship, and VRI interpreter’s unprofessionalism. Two providers (GO and KS) shared positive experiences with the use of in-person interpreting service, such as better patientprovider communication and better treatments. One provider (MN) shared a negative experience with in-person interpreting services due to limited availability. Three patients (BU, ED, and ML) had positive experiences with
Two providers (EP and TY) preferred using VRI for critical care because of its promptness. Three providers (GJ, KS, and WD) preferred using in-person interpreters for critical care because of the demands of surgery care. Two providers (GO and TY) preferred VRI for non-critical care for specific reasons, such as that VRI was already available in GO’s office and that in-person interpreter was not often available in TY’s office. Four providers (EP, KS, TY, and WD) preferred in-person interpreters for non-critical care because of better patient-provider relationships and communication. Four patients (BU, DE, ED, and RP) did not prefer VRI in general, but they would accept using VRI for a specific reason because of promptness. DE and ED would accept VRI for emergency care
Table 4 Healthcare providers’ training experience. For Using VRI
A Significant Amount A Moderate Amount A Little Amount None at All N
Healthcare Providers who worked with LEP Patients
Healthcare Providers who worked with DHH Patients
N
%
N
%
p
Fisher’s exact test
1 3 11 21 36
2.8 8.3 30.6 58.3 100.0
0 4 11 11 26
0.0 15.4 42.3 42.3 100.0
0.457
0.441
For Treating DHH Patients Healthcare Providers who worked with LEP Patients
A Significant Amount A Moderate Amount A Little Amount None at All N
N
%
Healthcare Providers who worked with DHH Patients N %
1 2 13 20 36
2.8 5.6 36.1 55.6 100.0
1 2 11 12 26
3.8 7.7 42.3 46.2 100.0
p
Fisher’s exact test
0.926
0.857
Please cite this article as: Yabe M, Healthcare providers’ and deaf patients’ interpreting preferences for critical care and non-critical care: Video remote interpreting, Disability and Health Journal, https://doi.org/10.1016/j.dhjo.2019.100870
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M. Yabe / Disability and Health Journal xxx (xxxx) xxx
Table 5 Healthcare providers’ and DHH patients’ recommendations for VRI training. Healthcare Providers who worked with LEP Patients
Need to be trained Not to be trained N
DHH Patients
Healthcare Providers who worked with DHH Patients
N
%
N
%
N
%
32 4 36
88.9 11.1 100.0
19 7 26
73.1 26.9 100.0
36 5 41
87.8 12.2 100.0
unless an in-person interpreter could come less than two hours later. Six patients (BU, DE, IK, RM, and RP) preferred in-person interpreting for critical care because of the ability to clarify information and an effective translation process. Two patients (ED and IK) would not prefer VRI but would accept VRI for non-critical care for a specific reason, such as follow-up. Two patients (BU and DE) preferred in-person interpreting for non-critical care, such as if an appointment is scheduled in advance, and they would not accept VRI (Appendix, Table B). Opinion Five providers (BE, GO, MN, TY, and WD) shared positive opinions about VRI, such as it was already available, it was helpful for communication, it was better than nothing to have an interpreter, and it was economically viable. Three providers (BE, EP, and GJ) shared negative opinions about VRI, such as a lack of patientprovider relationship and limited access. Four providers (GJ, EP, MN, and WD) shared a positive opinion that in-person interpreting provided better patient-provider communication. Three providers (BE, GJ, and WD) shared negative opinions about in-person interpreting, such as limited availability and economic loss. Seven patients (BU, DE, ED, JA, ML, RM, and RP) shared negative opinions about VRI, such as limited placement and positioning, poor connectivity, limited visual access, inappropriate use, limited language assessment, lack of patient-provider relationship, lack of medically trained interpreter, and economic loss. Five patients (BU, DE, ML, RM, and RP) shared positive opinions about in-person interpreting, such as full accurate translation, flexibility to move, language assessment, and developing patient-provider relationship (Appendix, Table C).
p
Fisher’s exact test
0.221
0.221
Suggestions Six providers (BE, DO, GJ, GO, KS, and MN) provided suggestions for improving equipment use, such as more flexibility, larger screen size, adjustable height, and better connectivity. They also suggested educating healthcare providers in how to interact with DHH patients through VRI and educating DHH patients for their rights. Hiring more bilingual providers was another suggestion. Eight patients (BU, ED, DE, IK, JA, ML, RM, and RP) provided similar suggestions such as improving equipment use, hiring more bilingual providers, and educating both healthcare providers and DHH patients. The patients also suggested educating hospital administrators to identify which clinical situations would be appropriate to use VRI, VRI interpreters advocating for DHH patients, and VRI companies and hospital administrators meeting legal obligations (Appendix, Table D). Comparison with limited English proficiency patients and deaf/hard of hearing patients Six providers (BE, EP, GJ, KS, MN, and WD) made comparisons between LEP patients and DHH patients. As a similarity, the providers shared that VRI was beneficial for trilingual interpreting held among a provider, a DHH patient, and an LEP family member. Interpreting was beneficial for all populations, yet it required some time for communication access. The same providers also had budget concerns about paying for interpreting services. As for differences in interpreting requirements, LEP patients could hear when they laid down or moved around, so it was less challenging to use VRI. But DHH patients were unable to see the VRI interpreter when they laid down or moved around, so it was more
Table 6 Characteristics of interviewees. Healthcare Providers (n ¼ 8) ID
Gender
Age
Profession
BE EP GJ GO MN KS TY WD
Female Female Female Female Female Male Female Male
58 31 31 32 38 26 27 50
Physical Therapist Speech Language Pathologist Dentist Physical Therapist Nurse Practitioner Oral Surgeon Nurse Practitioner Physician
DHH Patients (n ¼ 8) ID
Gender
Age
Education
BU DE ED IK JA ML RM RP
Male Female Female Female Male Female Male Male
70 54 50 53 45 48 61 30
Graduate Degree Bachelor’s Degree Associate Degree Graduate Degree Some College, No Degree Bachelor’s Degree Associate Degree Graduate Degree
Please cite this article as: Yabe M, Healthcare providers’ and deaf patients’ interpreting preferences for critical care and non-critical care: Video remote interpreting, Disability and Health Journal, https://doi.org/10.1016/j.dhjo.2019.100870
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challenging to use VRI (Appendix, Table E). Comparison between healthcare providers and deaf/hard of hearing patients In sum, both groups had similar experiences with VRI technology issues. Both groups shared positive aspects of in-person interpreting, such as better patient-provider communication and relationships, but they also experienced concerns with the lack of in-person interpreters. Both groups suggested VRI training for providers and improving VRI equipment, including better connectivity, adjustable height, and larger screen sizes. Healthcare providers also suggested training patients and their families to understand their rights, while DHH patients suggested training hospital administrators and VRI companies to meet legal obligations. DHH patients also suggested medically training VRI interpreters. Additionally, DHH patients mentioned that in-person interpreters provided language assessment and could accommodate patients’ languages levels. On the other hand, DHH patients indicated that they would accept VRI for a specific reason, such as specific time demands or types of treatment care, while healthcare providers would accept VRI, as it was already available, or since it was better than nothing. Conflicts were expressed related to budget concerns between the two groups. While healthcare providers mentioned that in-person interpreting services were expensive, DHH patients stated that VRI was waste of money because VRI cannot provide effective communication. Discussion Video remote interpreting Previous studies connect with the Part II data collection. For instance, the increased use of VRI is due to its potentially lower cost based on how many minutes used instead of a flat two hour interpreter fee29, as well as VRI’s ability to connect with an interpreter at any hour even in more remote locations.27,28 Yet, both healthcare providers and DHH patients experienced with poor connectivity and visual and mobility limitations with the use of VRI.25,26 Furthermore, VRI is also not accessible for DHH patients who have cognitive disabilities, linguistic limitations, or visually impairments.3,27 DHH patients were unable to see when they are lying down and vomiting, or if they lie face downward on an examination table during x-ray appointments or biopsy tests. In-person interpreting Previous studies also connect the Part II data collection. Both groups mentioned that in-person interpreters provide enough patient-provider communication.26,30 Yet, healthcare providers mentioned that in-person interpreting services were expensive,4 and that they cannot get a refund for in-person interpreting services when patients miss appointments. The Part I study also found that healthcare providers are often not trained on how to use VRI.25,26 Healthcare providers also stated that budgetary constraints have limited the availability of in-person interpreters.31 Recommendations Overall, the findings of the study suggest that health care providers and systems should consider the advantages and disadvantages of using VRI and be mindful of how they may impact DHH patients’ care and satisfaction. The study also suggests that hospital administrators should not popularize VRI for 100% of their clinical
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treatments and allocate funding for in-person interpreting for critical care treatments. The study suggests that hospital administrators and VRI companies need to follow legal obligations, and to establish a specific law regulating VRI companies. VRI companies need to work closely with hospital administrators to improve the quality of VRI equipment, as well as take initiatives to provide training for healthcare providers, DHH patients, and VRI interpreters. Limitations Limitations for the Part I study was the small sample size of healthcare providers who had worked with DHH patients, and a lack of accommodation in the ASL survey due to a limited timeframe for the study and grant constraints. Limitations for the Part II study were a lack of race/ethnic diversity, the age of interviewees, and the small sample size for interviewees. The demographics of the interviewees might not generalize for the demographics of the target populations. The online survey and interview guide were designed to illuminate communication barriers during clinical encounters between healthcare providers and DHH patients. This study was not designed to illuminate other cultural factors that might affect interactions between healthcare providers and DHH patients. Interestingly, those healthcare providers did not have much knowledge about Deaf culture, yet, they were aware of the importance of patient-provider communication. Conclusion Overall, the study’s findings suggest that further steps are needed to determine the appropriate use of VRI versus in-person interpreters while meeting the legal requirements of ensuring effective communication even in areas where access to interpreters is limited. Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.dhjo.2019.100870. References 1. National Association of the Deaf. Minimum standards for video remote interpreting services in medical settings. https://www.nad.org/about-us/positionstatements/minimum-standards-for-video-remote-interpreting-services-inmedical-settings/; 2018. Accessed 31st May 2019. 2. Alley E. Exploring remote interpreting International Journal of Interpreter Education. 2012;4(1):111e119. 3. Desrosiers P. Signed language interpreting in healthcare settings: who is qualified? Honors senior theses western Oregon university, United States. https://digitalcommons.wou.edu/cgi/viewcontent.cgi? article¼1123&context¼honors_theses; 2017. 4. Marsland MC, Lou C, Snowden L. Use of communication technologies to costeffectively increase the availability of interpretation services in healthcare settings. Telemedecine Journal of E-Health. 2010;16(6):739e745. https://doi.org/ 10.1089/tmj.2009.0186. 5. Barnett S, McKee MM, Smith SR, Pearson TA. Deaf sign language users, health inequities, and public health: Opportunity for social justice. Preventing Chronic Disease. 2011;8(2):A45. http://www.cdc.gov/pcd/issues/2011/mar/10_0065. htm. 6. U.S. Department of Justice. A guide to disability rights law. http://www.ada. gov/cguide.htm; 2009. Accessed 31st May 2019. 7. Reis JP, Breslin ML, Iezzoni LI, Kirschener KL. It Takes More than Ramps Rehabilitation. Institute of Chicago; 2004. 8. Jacobs EA, Shepard DS, Suaya JA, Stone E. Overcoming language barriers in healthcare: costs and benefits of interpreter services. Am J Public Health. 2004;94(5):866e869. https://doi.org/10.2105/ajph.94.5.866. 9. McKee MM, Barnett SL, Block RC, Pearson TA. Impact of communication on preventive services among deaf American language users. Am J Prev Med. 2011;41(1):75e79. https://doi.org/10.1016/j.amepre.2011.03.004.
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Please cite this article as: Yabe M, Healthcare providers’ and deaf patients’ interpreting preferences for critical care and non-critical care: Video remote interpreting, Disability and Health Journal, https://doi.org/10.1016/j.dhjo.2019.100870