Providers’ Perspectives on Communication Barriers with Language-Discordant Patients in the Critical Care Setting: A Systematic Review
1
Keck School of Medicine, University of Southern California, 1975 Zonal Avenue, Los Angeles, CA 90033, USA
2
Department of Anesthesiology, Keck School of Medicine, University of Southern California, 1500 San Pablo St., Los Angeles, CA 90033, USA
*
Author to whom correspondence should be addressed.
†
These authors contributed equally to this work.
Anesth. Res. 2025, 2(1), 7; https://doi.org/10.3390/anesthres2010007 (registering DOI)
Submission received: 20 November 2024
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Revised: 30 December 2024
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Accepted: 7 February 2025
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Published: 2 March 2025
Abstract
:Background: Language discordance occurs when the patient and the healthcare provider are not proficient in the same language. Language discordance in the critical care setting is a significant global issue because of its implications in the quality of care and outcomes of patients who do not speak the primary language of the country in which they receive healthcare. Studies show that language-discordant, critically ill patients have increased use of restraints during mechanical ventilation, increased length of stay, and more frequent complications. Communication challenges are magnified in the intensive care unit because of the medical complexity and frequent need for challenging conversations regarding goals of care. To address language-based disparities in critical care, numerous qualitative studies in recent years have attempted to understand the barriers that providers face when caring for language-discordant patients. Our systematic review is the first to analyze this developing body of literature and identify barriers for which solutions must be sought to ensure equitable care. Methods: This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched PubMed, Embase, and Scopus from inception up to 20 February 2024. From among 2150 articles, nine articles were selected, which included eight qualitative studies and one cross-sectional study. Three studies were high quality, five were moderate quality, and one was low quality. Results: We found four major barriers to caring for language-discordant patients in the critical care setting. These included limitations in providers’ knowledge of best practices in professional medical interpreter use, challenges in navigating interpreters’ multiple roles, and limitations with different interpretive modalities and system constraints. These barriers caused clinicians distress due to clinicians’ desire to provide empathic care that respected patients’ autonomy and ensured patients’ safety and understanding. Conclusion: Interventions to increase providers’ knowledge of best practices, integrate interpreters into the critical care team, strategize the use of interpretation modalities, and address system-based barriers are needed to improve the care of language-discordant, critically ill patients worldwide.
1. Introduction
Language discordance occurs when the patient and the healthcare provider are not proficient in the same language [1]. In the United States (US), 21.7% of the population speaks languages other than English, and 8.2% speak English less than very well [2]. International migration has increased, contributing to language diversity globally [3]. There have been efforts to increase professional medical interpreter utilization through language legislation such as the Title 6 Civil Rights Act of 1964 in the US and the European Convention for the Protection of Human Rights [4].
Despite laws mandating professional medical interpreter use, healthcare inequities persist for this population. In the critical care setting, language-discordant patients have 12.4% more restraint use during mechanical ventilation compared with language-concordant patients [5]. Language-discordant patients also spend an additional 0.6 days in the intensive care unit (ICU) and an additional 2.7 days in the hospital [6]. Moreover, these patients are 23.8% less likely to utilize comfort measures before death and have comfort care orders placed 19.1 days later than their counterparts [6].
Disparities due to language differences are especially pronounced in the critical care setting because of increased medical complexity. Communication is also complicated by sedation requirements and high prevalence of delirium and agitation. However, effective communication in the ICU is required for frequent clinical assessments and patients’ participation in their care. To address language-based disparities in critical care, numerous qualitative studies in recent years have attempted to understand the barriers that critical care providers face when caring for language-discordant patients. Our systematic review is the first to analyze this developing body of literature to identify barriers for which equitable solutions must be sought.
2. Methods
This review was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) [7] and was registered prospectively with the Open Science Framework on 26 February 2024 [8]. No funding was received to assist with the review or preparation of this manuscript.
2.1. Eligibility Criteria
We included all studies that explored barriers experienced by clinicians when providing care for language-discordant patients in the critical care setting. Studies were excluded if they did not primarily focus on challenges with language discordance and were not specific to critical care settings, such as the pediatric, neonatal, adult surgical, or adult medical ICU. Studies were not excluded based on date of publication. All qualitative, quantitative, and mixed-method studies were considered. Non-English publications, unpublished studies, case reports, abstracts, and editorials were excluded.
2.2. Search Strategy
We selected databases and developed search terms in consultation with an experienced medical research librarian at the University of Southern California. We searched the literature in PubMed, Embase, and Scopus from inception up to 20 February 2024 using variations of the search phrase: (“limited English proficien*” or “primary language” or “second language” or “language preference”) and (“intensive care unit” or “ICU” or “critical care”). The detailed search strategy is shown in Table 1. No grey literature was searched.
2.3. Study Selection
All results were collated in Mendeley and duplications were removed. Two reviewers (B.M.L.-E. and M.I.K.) independently screened all citations by titles and abstracts against the defined inclusion and exclusion criteria, after which the full texts of selected citations were reviewed. Additional studies were selected after reviewing the reference lists of included studies. Throughout the screening and selection process, all discrepancies were addressed through discussion between the two reviewers, and a consensus was reached. The selection process is detailed in Figure 1.
2.4. Data Extraction
Two independent reviewers (H.S.S. and A.J.T.) extracted data. The accuracy of the extracted data was checked by two other reviewers (B.M.L.-E, H.S.S. or A.J.T.). The extracted data included author, year, location of publication, study setting, participants’ characteristics, study objective, design, analysis, data collection methods, and results. All discrepancies were addressed through discussion among the three reviewers.
2.5. Data Synthesis
Given the qualitative nature of the included studies, we categorized each study based on themes relevant to the review objective to enable comparison with other studies. Themes were derived and assigned through discussion and consensus among the reviewers.
2.6. Quality Assessment
The quality of the included studies was evaluated using two tools. First, the Critical Appraisal Skills Programme (CASP) checklist was used to systematically assess the credibility of findings, rigor of study design, and relevance of the included qualitative studies [9]. Second, the National Heart, Lung, and Blood Institute (NHLBI) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies was used to examine the credibility, bias, confounding factors, and rigor of study design of cohort and cross-sectional studies [10]. Both the CASP checklist and NHLBI tool provide frameworks consisting of specific questions to guide the quality assessment of qualitative studies or observational cohort and cross-sectional studies, respectively. Each of these tools determines a numerical score for the quality of an article. Quality was considered low for scores below 50%, moderate for scores between 50 and 75%, and high for scores above 75%.
3. Results
3.1. Literature Search
A total of 2150 articles were identified, 1892 abstracts were screened, and 21 articles were reviewed, of which 12 full-text articles were excluded due to the reasons listed in Figure 1. This review analyzed a total of nine articles that fulfilled inclusion and exclusion criteria.
3.2. Study Characteristics
Table 2 shows the studies’ characteristics. The studies involved a total of 1098 healthcare providers, including physicians, nurses, nurse assistants, and interpreters. All but one study was published within the last decade.
3.3. Study Setting
Six studies were conducted in the US at academic urban hospitals [11,12,13,15,18,19], and three were conducted in Sweden [14,16,17]. Three studies focused on providers in the neonatal ICU [15,16,17]. The remaining six studies were conducted in adult ICUs but did not specify whether the ICU was surgical or medical [11,12,13,14,18,19].
3.4. Study Participants
3.5. Study Design
Table 3 outlines the study objectives, designs, analytical methods, and results of the included studies. There were eight qualitative studies and one cross-sectional study. The cross-sectional study collected data through a Swedish national survey [16]. Of the qualitative studies, two collected data through focus groups [14,15]. The remaining six qualitative studies collected data through one-on-one interviews [11,12,13,17,18,19]. Patriksson et al. also included observations made in the field by one data collector [17]. In addition to a qualitative analysis that extracted themes from interviews, the studies quantitatively analyzed the use of interpreters and awareness of interpretation guidelines among healthcare providers. Pham et al. also analyzed physician–patient communication to identify interpretation alterations and determined their potential for clinical significance [18].
3.6. Quality of Included Studies
Table 4 shows the rating of each included study. We evaluated the qualitative articles using the CASP checklist. Three studies scored 8 or more out of 10 points and were considered high quality. Five studies scored between 5 and 7 out of 10 points and were considered moderate quality. The NHLBI Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies was used to evaluate the sole cross-sectional study in our review. Patriksson et al. received 5 out of 14 points and was considered a low-quality study [16].
3.7. Themes
In our analysis of the challenges that healthcare providers encountered while caring for language-discordant patients, five themes emerged. Barriers to providing care for language-discordant patients included limited provider knowledge and awareness of best practices for professional medical interpreter use, challenges in navigating interpreters’ multiple roles, limitations with different interpretive modalities, and systemic constraints. These barriers caused clinicians distress due to clinicians’ desire to provide optimal care for language-discordant patients. These themes were further divided into subthemes, which are shown in Figure 2. Corresponding articles are shown in Table 5. We describe the themes in detail below.
3.8. Provider Knowledge and Practice
3.8.1. Limited Awareness of Guidelines Mandating Professional Interpreter Use
Patriksson et al. observed that many healthcare professionals in Sweden reported little or no awareness of guidelines on the use of professional medical interpreters [16]. Only 20.5% (13.2% of physicians, 18.5% of registered nurses, and 25.0% of nurse assistants) of all surveyed providers were aware of these guidelines, while 31.2% (22.6% of physicians, 38.9% of registered nurses, and 20.3% of nurse assistants) of respondents reported that no guidelines existed and 48.4% (64.2% of physicians, 42.6% of registered nurses, and 54.7% of nurse assistants) of respondents were not certain if these guidelines existed [16]. Nursing assistants had significantly less awareness of these guidelines compared with registered nurses (p < 0.0001) [16]. No significant differences in awareness were found between registered nurses and physicians [16].
3.8.2. Limited Awareness of Interpretive Resources
Espinoza Suarez et al.’s study noted a lack of awareness among healthcare providers of the 24/7 availability of professional interpreters [13]. No other study reported limited awareness of interpretive resources.
3.8.3. Limited Training on How to Communicate Using Professional Interpreters
Providers did not consistently receive training on the use of professional interpreters. In Patriksson et al., nursing assistants working in the neonatal ICU rated their ability to communicate through an interpreter as significantly lower than physicians and registered nurses [16]. For example, 4.2% of nursing assistants rated their ability to communicate with language-discordant parents through an interpreter as weak or extremely weak, compared with 1.9% of physicians (p = 0.0058) and 1.8% of registered nurses (p = 0.0026) [16]. Only 57.6% of nursing assistants rated their ability as strong or extremely strong, compared with 77.4% of physicians and 68.7% of registered nurses [16].
3.8.4. Inconsistent Use of Professional Interpreters
Limited awareness of guidelines for interpreter utilization and of interpretive resources led to inconsistent use of interpreters when communicating with language-discordant patients. For example, professional interpreters were more commonly used for planned conversations (84.1% of providers responded always/often) and during emergency situations (60.6% of providers responded always/often), whereas information about nursing care was more often communicated using ad hoc interpreters, such as family members or hospital employees who speak the patients’ preferred languages [16]. Nurses and nursing assistants demonstrated a higher rate of ad hoc interpreter use.
3.8.5. Less Frequent Communication with Language-Discordant Patients
In addition to inconsistent use of interpreters when communicating with language-discordant patients, Barwise et al. observed that healthcare providers had less frequent communication with this patient population about routine updates [11]. Potential factors contributing to the reduced frequency of meetings included additional time required for interaction, unconscious bias favoring more straightforward patients, or concerns about building rapport or the effectiveness of communication.
3.9. Controversies in Interpretation
3.9.1. Verbatim Interpretation Versus Cultural Brokerage
We identified a lack of consensus regarding the role of interpreters. In Suarez et al.’s study, some physicians described the interpreter’s role as providing only verbatim interpretation [19]. However, other providers viewed the interpreters’ role as cultural brokers [19]. Cultural brokerage involves explaining cultural differences to the patient or provider. For example, one interpreter explained that some patients’ families have never been asked to limit or withdraw life support in their home countries [11]. Withdrawing life support can be perceived as unacceptable due to faith-based and cultural beliefs [11]. Patriksson et al. similarly described the interpreter’s dual role in assisting healthcare providers and families with both language translation and cultural understanding [17].
3.9.2. Alterations in Interpretation
Providers recounted instances when an interpreter engaged the patient in a separate conversation before the patient’s answer was interpreted [15]. Pham et al. investigated alterations in interpretation that occurred during meetings with language-discordant families. Alterations encompassing additions, editorializations, and omissions were present in 55% of all interpreted speech passages in ICU family conferences with an in-person interpreter [18]. Over 75% of alterations had potentially clinically significant effects, where they either interfered with or enhanced the goals of the discussion [18]. Of these potentially significant alterations, 93% of alterations were deemed to likely have a negative effect on communication, including interfering with transfer of information, reducing emotional support, and reducing rapport [18]. The remaining 7% of alterations were determined to have a likely positive effect, including improved transfer of information and increased rapport [18].
3.10. Issues with Interpretation Modalities
3.10.1. Technical Issues
Providers encountered technical issues when using professional interpretation via phone or video. Internet connectivity and audio quality were issues encountered in Michalec et al.’s study [15]. In Suarez et al.’s study, providers found these technical issues to negatively impact interpretation [19]. For these reasons, language-discordant patients in Michalec et al.’s study frequently requested to not use phone interpreters [15]. Patriksson et al. also found that these technical limitations made communication difficult and were associated with misunderstandings [16].
3.10.2. Difficulty Building Rapport
Some providers perceived remote interpretation to hinder the provider–patient relationship. For example, providers in Barwise et al.’s study stated that the “need for [a] third party” deterred the development of the patient–clinician relationship due to the focus being placed on relaying medical information accurately rather than building rapport [11]. Additionally, providers found that remote interpretation over video or phone lacked “cultural contextualization” and interpersonal warmth [19]. In Coleman et al.’s study, providers noted that patients’ families frequently felt “out of the loop” due to not being able to hear or speak through the phone [12]. In contrast to remote interpretation, providers in Suarez et al. observed that the value of an in-person interpreter comes from their role as a bridge between diverse cultures, building trust and providing guidance to the clinical team [19]. Coleman et al. similarly observed that having an in-person interpreter instilled a sense of comfort to the patient and fostered a more intimate environment that enabled meaningful exchanges [12].
3.10.3. Time Constraints
Time constraints frequently influenced the choice of interpretation modality. In Listerfelt et al.’s study, nurses reported that advanced booking and scheduling were required to secure an in-person professional interpreter, so scheduling an in-person interpreter was time-consuming and logistically challenging [14]. Michalec et al. similarly reported that in-person interpreters were not readily available during periods of high-demand. In this study, when in-person interpreters were not available, phone interpreters were utilized as the main method of interpretation. In Suarez et al.’s study, 24/7 availability of phone interpreters increased use of interpreters [19].
3.11. System Constraints
3.11.1. Resource Availability
In Michalec et al.’s study, in-person interpreters were not available after hours, on weekends, and during holidays [15]. During peak business hours, in-person interpreters were unavailable due to high interpretation demand. Listerfelt et al. reported that professional interpreters, both remote and in-person, were primarily reserved for physicians’ meetings, necessitating alternative interpretive methods for everyday encounters [14]. This sentiment was similarly reflected in Patriksson et al.’s study, where nurse assistants utilized professional interpreters less frequently than physicians or registered nurses [16]. Many providers perceived that limited interpreter availability impacted their ability to communicate effectively with language-discordant patients [11,19]. Limited interpretive resources also compelled providers to convey sensitive information with the assistance of family members, potentially compromising patients’ privacy and straining the patient–provider relationship [11,17].
3.11.2. Delayed Identification of Language-Discordant Status
In Michalec et al.’s study, providers frequently discovered patients’ non-English language preferences only after their initial encounters [15]. In Patriksson et al.’s study, patients’ language preferences were also not documented [17]. Providers felt that awareness of a patients’ language-discordant status prior to the initial meeting could facilitate more frequent and efficient utilization of professional medical interpreters.
3.11.3. Perception of Time Constraints
Providers in several studies observed that caring for language-discordant patients took significantly more time compared with language-concordant patients [12,14,15]. Nurses in Listerfelt et al.’s and Coleman et al.’s studies expressed that even routine assessments of patients were prolonged [12,14]. Providers needed to strategically organize their schedules when caring for language-discordant patients to allow for more time [12]. In Michalec et al.’s study, some providers suggested that institutions should consider language-discordant patients as higher-intensity cases and count towards a larger patient load because of the increased time required to gather and convey information [15].
3.12. Clinician Distress Stemming from Inability to Deliver Optimal Care for Language-Discordant Patients
Challenges in providing care to language-discordant patients caused distress for providers in several studies because of the providers’ desire to deliver optimal care.
3.12.1. Desire to Provide Emotional Support
3.12.2. Desire to Respect Patients’ Autonomy
Conversations between patients and providers, when facilitated by an interpreter, inadvertently increased the opportunity for family members to influence patients’ decisions [13]. Barwise et al. similarly observed that language-discordant patients more commonly had family involved in their decision-making [11]. Increased involvement of family members may limit the patients’ opportunity to make decisions independently.
3.12.3. Desire to Ensure Patients’ Understanding and Safety
Ensuring patients’ understanding and safety was a common concern among healthcare providers. Providers observed that language-discordant patients often struggled to grasp the concepts discussed [11]. Physicians also had trouble assessing patients’ comprehension [11]. Nurses expressed apprehension regarding patients’ safety during discharge and ability to understand and adhere to treatment regimens [12].
3.12.4. Desire to Be Culturally Respectful
Some providers in Michalec et al. were fearful of offending their patients because of differing cultural beliefs [15]. This concern fostered feelings of inadequacy and impacted providers’ interaction with language-discordant patients. For example, Barwise et al. observed a dilemma between providers’ concern for patients’ comfort and their desire to show cultural respect, particularly when ending life-sustaining therapies are against cultural or religious beliefs [11].
4. Discussion
This systematic review identified four major barriers to caring for language-discordant patients in the critical care setting, including limitations in providers’ knowledge of best practices in professional medical interpreter use, challenges in navigating interpreters’ multiple roles, limitations with different interpretive modalities and systemic constraints. These barriers caused clinicians to experience distress due to clinicians’ desire to provide empathic care that respected patients’ autonomy and ensured patients’ safety and understanding. Interventions to increase provider knowledge of best practices, integrate interpreters into the critical care team, strategize use of interpretation modalities, and address system-based barriers are needed to improve the care of language-discordant critically ill patients worldwide. We identify studies below that provide potential solutions and areas where future research is needed.
4.1. Provider Knowledge and Practice
Education on language legislation and best practices in interpreter use may help overcome limitations in physicians’ knowledge and practice. Interpretation by professional or certified interpreters rather than by patients’ families or untrained “ad hoc” staff reduces interpretation errors and protects patients’ confidentiality [20,21,22]. Best practices for utilizing interpreters include using only certified interpreters, speaking slowly and in short sentences to minimize interpretation alterations and errors, repeating important concepts, and confirming understanding [18]. Additionally, medical jargon such as “palliative” and “hospice” as well as metaphors or analogies may not translate well across languages [23]. Studies have shown that physicians who received training on language legislation utilize professional medical interpreters at a higher rate than their counterparts [24,25]. Studies also demonstrate the effectiveness of training programs to improve medical students’ comfort, perceived efficacy, and adherence to best practices when using interpreters [26,27,28]. Residency programs have incorporated similar training for residents [29]. Recommendations to improve future training programs for healthcare providers include involving interpreters in simulated practice [30]. Educating providers on language legislation and best practices of interpreter use is therefore paramount to increasing effective professional interpreter utilization in the ICU.
4.2. Controversies in Interpretation
Professional interpreters are an integral part of the ICU team because they facilitate effective communication in a medically complex environment. Beyond their roles as linguistic conduits, professional interpreters also serve as patients’ advocates by alerting clinicians when patients’ understanding may be threatened [19]. When communication hinges on cultural understanding, interpreters serve as cultural brokers by helping providers understand patients’ cultural differences and assist patients in understanding the ICU environment [19].
The ICU team can harness the interpreter’s skill set by meeting with the interpreter prior to meeting with the patient or family to clarify expectations for the interpreter’s role, goals of the conversation, and any challenging terminology that will be used [11,18,27]. In-person interpreters employed by the institution who are familiar with ICU discussions such as end-of-life care fulfill these expanded roles more easily than remote interpreters [13]. Healthcare institutions can clarify the interpreter’s role to optimize collaboration and reduce potential conflicts within the medical team.
4.3. Issues with Interpretation Modalities
Differences in interpreter modality may be harnessed by institutions to their advantage. In-person interpreters are frequently the preferred modality of interpretation because their physical presence enables communication through nonverbal cues and is perceived to facilitate patient–provider trust [12,31]. When in-person interpreters are not available, video is usually preferred over phone interpretation for similar reasons [32,33]. The duration of training that interpreters receive rather than the type of interpretive modality determine the quality and accuracy of the interpretation [28,34]. However, remote modalities are limited by technical issues such as Internet connectivity and sound quality [32,33].
To address resource limitation and quality control issues, language services departments have implemented creative solutions. Marshall et al. detailed a career ladder at their institution that promoted interpreters based on metrics such as interpretation quality with an accompanying salary increase [35]. The institution also created guidelines to determine the most appropriate interpretation modality for different situations. For example, in-person interpreters were reserved for more complex discussions involving new diagnoses, goals of care, and end-of-life decisions [20]. Remote interpreters, which are more plentiful, can be used for less complex clinical conversations. They may also provide a sense of privacy for the patient because the interpreter is not physically present [36].
4.4. System Constraints
System-level changes are needed to address interpretive resource availability. Currently, US federal law mandates that interpretive services be provided to language-discordant patients who require language assistance. However, many states do not reimburse for this service, putting the burden of financing the additional costs on both small and large institutions [36]. Amending current policy to require reimbursement for interpretive services may decrease the use of ad hoc interpreters and increase access to professional interpreters.
Quality improvement projects to facilitate the identification of a patient’s language status and secure a professional interpreter in advance of a clinical encounter can improve workflow and alleviate time constraints. In studies where providers were informed of patients’ language status and interpreters were requested before clinical encounters, providers had increased professional interpreter utilization [37,38]. Rajbhandari et al. instructed registration staff to verify and inquire about language preferences, and Gupta et al. had triage nurses solicit patients’ language preferences on admission [37,38]. Both studies documented patients’ language preferences in electronic health records, created consultation orders for in-person interpreters, and enabled pop-up reminders when opening a patient’s electronic health record [38].
5. Conclusions
This review explored the obstacles faced by medical professionals when caring for language-discordant patients in the ICU. Based on a moderate- to high-quality body of evidence, this systematic review identified barriers and challenges at the provider, interpreter, institutional, and systemic levels. To minimize healthcare disparities among critically ill language-discordant patients, creative solutions must be sought for these barriers.
6. Future Directions
Due to the variable cultural milieu, language laws, and healthcare systems around the world, the identification of barriers and challenges experienced by both providers and patients in different ICU settings remains necessary to identify optimal strategies for caring for language-discordant patients across regions. Future studies can assess how interventions to train providers on best practices for interpreter use, integrate interpreters into the ICU team, improve workflow, and increase interpreter availability impact the perceived and actual care of critically ill language-discordant patients. Quality improvement studies are needed to develop creative solutions at the individual, hospital, and system levels that could enhance the outcomes and experiences of critically ill language-discordant patients and their families. In addition, to better understand the specific barriers faced by non-English-speaking healthcare providers, subsequent investigations can expand the search to include non-English articles.
7. Strengths and Weaknesses
This systematic review utilized rigorous methods to search for and select articles, including clear inclusion and exclusion criteria. The search did not exclude studies based on publication location or year. However, the search was limited to English-only articles and did not include studies based on patients’ experiences.
Author Contributions
B.M.L.-E. conceptualized and designed the study. B.M.L.-E. assisted in data collection, analysis, and writing. M.I.K. assisted in the literature search and manuscript writing. H.S.S. assisted in data collection, analysis, and manuscript writing. A.J.T. assisted in data collection, analysis, and manuscript writing. All authors have read and agreed to the published version of the manuscript.
Funding
This research received no external funding.
Institutional Review Board Statement
The authors have no relevant financial or non-financial interests to disclose.
Data Availability Statement
No new data were created or analyzed in this study. Data sharing is not applicable to this article.
Conflicts of Interest
No conflicts of interest to declare.
Glossary of Terms
| CASP | Critical Appraisal Skills Programme |
| ICU | Intensive care unit |
| LEP | limited English-proficient |
| NHLBI | National Heart, Lung, and Blood Institute (NHLBI) |
| PRISMA | Preferred Reporting Items for Systematic reviews and Meta-Analyses |
| US | United States |
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Figure 1.
PRISMA flow diagram. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).
Figure 1.
PRISMA flow diagram. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).
Figure 2.
Providers’ perceived challenges and barriers when caring for language-discordant patients.
Figure 2.
Providers’ perceived challenges and barriers when caring for language-discordant patients.
Table 1.
Search strings.
| Strings | Database | Date Accessed |
|---|---|---|
| (“limited English proficien*” or “primary language” or “second language” or “language preference”) and (“intensive care unit” or “ICU” or “critical care”) | PubMed, Scopus | 20 February 2024 |
| (“limited English proficien*” or “primary language” or “second language” or “language preference”) AND (“intensive care unit” or “ICU” or “critical care”) | Embase | 21 February 2024 |
Table 2.
Study setting and participants’ characteristics.
| Author (Year) [Ref. #] | Location | Setting | Participants’ Characteristics | Number of Participants (n) |
|---|---|---|---|---|
| Barwise (2019) [11] | Rochester, Minnesota, US | 3 adult ICUs in a large academic hospital | 16 physicians, 12 nurses, 12 interpreters | 40 |
| Coleman (2016) [12] | Las Vegas, Nevada, US | Adult acute care unit | 40 nurses | 40 |
| Espinoza Suarez (2021) [13] | Rochester, Minnesota, US | 3 adult ICUs in a large academic hospital | 16 physicians, 12 nurses, 12 interpreters | 40 |
| Listerfelt (2019) [14] | Sweden | 2 adult ICUs | 15 nurses | 15 |
| Michalec (2015) [15] | Newark, Delaware, US | Neonatal ICU in an academic community hospital | 36 providers, including postpartum nurses, labor and delivery/triage nurses, obstetric resident physicians, neonatal nurses, and attending physicians, nurse practitioners, and midwives | 36 |
| Patriksson (2019) [16] | Sweden | All neonatal units in Sweden | 858 providers including physicians, registered nurses, and nurse assistants | 858 |
| Patriksson (2019) [17] | Sweden | 3 neonatal ICUs | 10 parents and 10 providers including physicians, nurses, and nurse assistants | 10 |
| Pham (2008) [18] | Seattle, Washington, US | Adult ICUs in a large academic hospital and a community hospital | 9 physicians, 10 nurses, 26 non-nurse/physician clinicians, 70 families of patients | 45 |
| Suarez (2020) [19] | Rochester, Minnesota, US | 3 adult ICUs in a large academic hospital | 16 physicians, 12 nurses, 12 interpreters | 40 |
Intensive care unit (ICU), United States (US).
Table 3.
Study objectives, design, analysis, and results.
| Author (Year) [Ref. #] | Objective | Study Design | Analysis | Summary of Results |
|---|---|---|---|---|
| Barwise (2019) [11] | To assess the perceptions of healthcare team members about the factors that influence end-of-life discussions and decisions for patients and family members with LEP in the ICU | Qualitative study with 1:1 interviews | Transcripts were coded to develop themes. | Language-discordant patients had less frequent clinician communication, impaired relationship building and understanding, and different cultural values and decision-making processes. |
| Coleman (2016) [12] | To explore the lived experiences of acute-carebedside nurses caring for patients and their families with LEP | Qualitative study with 1:1 interviews | Transcripts were coded to develop themes. | Clinicians had a desire to communicate, connect, provide good care, and be culturally respectful. |
| Espinoza Suarez (2021) [13] | To understand the healthcare team’s perceptions of the negative consequences of suboptimal communication | Qualitative study with 1:1 interviews | Transcripts were coded to develop themes. | Suboptimal communication may lead to the suboptimal assessment and treatment of patients’ symptoms, unmet expectations of patients and their families, decreased patients’ autonomy, unmet end-of-life wishes, and clinician distress. |
| Listerfelt (2019) [14] | To explore nurses’ experiences in caring for culturally diverse ICU patients | Qualitative study with focus groups | Transcripts were coded to develop themes. | Nursing staff caring for culturally diverse patients described challenges due to linguistic and cultural barriers. |
| Michalec (2015) [15] | To understand providers’ perspectives on working with PMIs | Qualitative study with focus groups | Transcripts were coded to develop themes. | Barriers to the utilization of PMIs include institutional barriers such as time and resource constraints and provider-level barriers such as personal biases. |
| Patriksson (2019) [16] | To examine healthcare professionals’ use of PMI and awareness of local guidelines for interpreted communication in neonatal care | Cross-sectional study using data from a national survey | Mantel–Haenszel chi-square test Fisher’s nonparametric permutation test | Barriers to the utilization of PMIs included lack of awareness of language legislation, unavailability of PMIs, use of PMIs in selective situations, and use of untrained interpreters. Nurse assistants had less awareness of best practices for PMI use compared with other provider types. |
| Patriksson (2019) [17] | To describe communication between neonatal healthcare professionals and parents in the presence of language barriers | Qualitative study with 1:1 interviews; observations from a field study | Transcripts were coded to develop themes. Themes were also extracted from a field study. | Providers preferred to use PMIs when communicating with patients’ parents, while patients’ parents preferred friends for interpretation or multilingual providers. |
| Pham (2008) [18] | To characterize the types, prevalence, and potential effects of alterations in interpretation during family conferences involving end-of-life discussions in the ICU | Qualitative study with 1:1 interviews | Interpretation alterations were grouped as additions, omissions, substitutions, and editorializations, then assessed for impact on communication. | There was a 55% chance of alteration during interpreted exchanges between clinicians and patients’ families. Over 75% of alterations had a potentially clinically significant impact. Of these potentially significant alterations, 93% were likely to have a negative effect. |
| Suarez (2020) [19] | To understand healthcare team perceptions of the role of PMI and interpretation modalities during end-of-life and critical illness discussions with patients and families who have LEP in the ICU | Qualitative study with 1:1 interviews | Transcripts were coded to develop themes. | The roles of PMIs included verbatim interpretation, health literacy guardian, and cultural broker. Clinicians acknowledged advantages and disadvantages to each interpretation approach. |
Intensive care unit (ICU), limited English proficiency (LEP), professional medical interpreter (PMI).
Table 4.
Quality of studies.
| Author (Year) [Ref. #] | Scale Used | Rating | Quality | Strengths | Weaknesses |
|---|---|---|---|---|---|
| Barwise (2019) [11] | CASP Qualitative | 7/10 | Moderate |
|
|
| Coleman (2016) [12] | CASP Qualitative | 7/10 | Moderate |
|
|
| Espinoza Suarez (2021) [13] | CASP Qualitative | 7/10 | Moderate |
|
|
| Listerfelt (2019) [14] | CASP Qualitative | 8/10 | High |
|
|
| Michalec (2015) [15] | CASP Qualitative | 7/10 | Moderate |
|
|
| Patriksson (2019) [16] | NHLBI Quality Assessment | 5/14 | Low |
|
|
| Patriksson (2019) [17] | CASP Qualitative | 6/10 | Moderate |
|
|
| Pham (2008) [18] | CASP Qualitative | 9/10 | High |
|
|
| Suarez (2020) [19] | CASP Qualitative | 9/10 | High |
|
|
Critical Appraisal Skills Programme (CASP); National Heart, Lung, and Blood Institute (NHLBI).
Table 5.
Themes of included articles.
| Themes | Articles Referenced |
|---|---|
| Provider Knowledge and Practice | |
| Limited awareness of guidelines mandating professional interpreter use | [16] |
| Limited awareness of interpretive resources | [13] |
| Limited training on how to communicate using professional interpreters | [16] |
| Inconsistent use of professional interpreters | [16] |
| Less frequent communication with language-discordant patients | [11] |
| Controversies in Interpretation | |
| Verbatim interpretation versus cultural brokerage | [11,17,19] |
| Alterations in interpretation | [18] |
| Issues with Interpretation Modalities | |
| Technical issues | [15,16,19] |
| Difficulty building rapport | [11,12,19] |
| Time constraints | [14,19] |
| System Constraints | |
| Resource availability | [11,14,15,16,17,19] |
| Delayed identification of language-discordant status | [15,17] |
| Perception of time constraints | [12,14,15] |
| Clinician Distress Stemming from Inability to Deliver Optimal Care for Language-Discordant Patients | |
| Desire to provide emotional support | [12] |
| Desire to respect patients’ autonomy | [11,13] |
| Desire to ensure patients’ understanding and safety | [11,12] |
| Desire to be culturally respectful | [11,15] |
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MDPI and ACS Style
Seo, H.S.; Tsao, A.J.; Kim, M.I.; Luan-Erfe, B.M. Providers’ Perspectives on Communication Barriers with Language-Discordant Patients in the Critical Care Setting: A Systematic Review. Anesth. Res. 2025, 2, 7. https://doi.org/10.3390/anesthres2010007
AMA Style
Seo HS, Tsao AJ, Kim MI, Luan-Erfe BM. Providers’ Perspectives on Communication Barriers with Language-Discordant Patients in the Critical Care Setting: A Systematic Review. Anesthesia Research. 2025; 2(1):7. https://doi.org/10.3390/anesthres2010007
Chicago/Turabian StyleSeo, Hyun Seong, Amanda J. Tsao, Michael I. Kim, and Betty M. Luan-Erfe. 2025. "Providers’ Perspectives on Communication Barriers with Language-Discordant Patients in the Critical Care Setting: A Systematic Review" Anesthesia Research 2, no. 1: 7. https://doi.org/10.3390/anesthres2010007
APA StyleSeo, H. S., Tsao, A. J., Kim, M. I., & Luan-Erfe, B. M. (2025). Providers’ Perspectives on Communication Barriers with Language-Discordant Patients in the Critical Care Setting: A Systematic Review. Anesthesia Research, 2(1), 7. https://doi.org/10.3390/anesthres2010007
