Support Systems and Patient Care Delivery for Nonnative English-Speaking Patients: A Study of Secondary School Athletic Trainers

We used the consensual qualitative research approach to assess the experiences of secondary school ATs who have provided care for NNES patients or NNES patients and their support systems. The interview was semistructured with guiding questions. The study was approved by the Institutional Review Board of Indiana State University.

We used criterion sampling to identify ATs in the secondary school setting who noted having experience(s) providing care for an NNES patient or a patient with an NNES support system. First, we purchased from the National Athletic Trainers' Association a list containing a random sample of secondary school ATs who had indicated a willingness to participate in research. Next, the National Athletic Trainers' Association sent an email to potentially eligible participants in the secondary school setting. Finally, we used a demographic questionnaire to identify potential participants and exclude volunteers who did not meet the criteria. A total of 15 participants were interviewed. The participants were 34 ± 9 years old with 12 ± 9 years of experience, had various levels of education, and provided care for a widely ranging number of patients in a variety of regions and states across the United States (Table 1).

We created the semistructured interview protocol (Table 2) to investigate the research question related to the experiences of ATs in the secondary school setting who have provided care for NNES patients or NNES patients with their support systems. The interview protocol was then sent to, and reviewed by, 2 ATs with experience in treating NNES patients; we used their feedback to finalize the interview protocol. The protocol was piloted with a small group of ATs who met the inclusion criteria but were not included in the final data collection or analysis. The pilot interview allowed us to ensure that the question sequence flowed logically, establish the time to complete the interview, and practice for follow-up questions that might arise. No changes were made to the interview protocol after the pilot interviews were concluded, and a final set of 10 questions was used for data collection.

A recruitment email was sent to the secondary school ATs on the list. It contained a brief study description and an online link (Qualtrics) to the informed consent and demographics survey (Table 1). Specifically, the email indicated that we were seeking to speak with secondary school ATs who had previous experience with NNES patients and their support systems. The participants were able to review the online informed consent and provide their contact information for scheduling an interview. Once a volunteer indicated willingness to take part and completed the demographic survey, the primary investigator (B.M.S.) contacted him or her to schedule an interview. At the scheduled time, the participant joined the primary investigator on a video and audio platform (Zoom Video Communications) to conduct the interview. During this interview, the primary investigator read a prepared statement to (1) thank the participant, (2) provide the approximate length of the interview, (3) remind the participant of withdrawal procedures, (4) ask if he or she had any questions, (5) gain oral consent, (6) remind the participant of the purpose of the interview, and (7) define the terms of NNES and support system as they would be used throughout the interview. The primary investigator defined NNES as “someone who speaks in another language that is not English, also known as their native tongue. A[n] NNES can speak nearly fluent English, can have a limited ability to speak English, or cannot speak English at all.” Support system was defined as “any NNES individual that [sic] has access to the patient's medical information (either inherently or as directed by the patient) which could include, but is not limited to parents, guardians, grandparents, other family members, and coaches.”

Once oral consent was obtained, the primary investigator began the audio recording and conducted the interview, which lasted, on average, 25 minutes. Each interview was transcribed verbatim, and the transcript was deidentified and checked for accuracy by the primary investigator before being sent to the participant for member checking and clarification before data analysis. The process of member checking is a participant validation technique to ensure the accuracy of the recorded statements. All 15 participants had their interview transcripts returned to them and were asked to ensure that their responses were best captured and still represented their lived experiences. No content changes to the transcripts were requested by the participants during member checking.

A panel of 3 researchers (B.M.S., M.J.R., and L.E.E.) followed the consensual qualitative research tradition after a robust, multiphase process to analyze the data.¹²  In phase 1, the team reviewed the same 4 transcripts. Each member of the team developed a list of domains that reflected the data presented by the transcripts. The team then met to compare their lists and come to a consensus on the domains. At this meeting, the team also created the initial codebook by using the domains and core ideas that were listed and discussed. In phase 2, the initial codebook was applied independently by each member to 2 of the transcripts used in phase 1 and 2 new transcripts. After the codebook was applied to these transcripts to ensure its reflectiveness, the team met again to confirm or adjust the codebook.

In phase 3, the team split up the remaining transcripts and applied the codebook. Once each transcript was coded, an internal audit was completed, ensuring that each code was confirmed by 2 members of the team. If the 2 coders had differences, these were discussed, and a consensus was achieved. The primary investigator then performed a cross-analysis to confirm that the core ideas were placed accurately in categories. Four coded transcripts were sent to an external reviewer (Z.K.W.) to confirm the consensus codebook. After the external review and cross-analysis, we conducted a frequency count of the categories. Categories were assigned to 1 of 4 frequency classifications as follows: general meant the category was identified by all 15 participants; typical, by at least 8 participants but not all 15; variant, by 4 to 7 participants; and rare, by 3 or fewer participants.⁹  Of the 15 categories identified, 2 were characterized as general, 10 as typical, and 3 as variant. The final step of the analysis was selecting quotes to support the finding of each emergent category. Credibility and trustworthiness were established using member checking, triangulation of the data, an internal audit, and an external review.¹²  The internal audit yielded minor modifications to the terms used in the codebook; however, the external review confirmed the coded transcripts with no additional changes made to the codebook or coded transcripts.

We identified 4 emergent domains: (1) communication, (2) welcoming environment, (3) cultural agility, (4) resourcefulness (Figure 1, Table 3).

The participants described explicit experiences related to verbal and nonverbal forms of communication. Four categories emerged within the communication domain: nonverbal reliance, translated resources, interpreters, and fluency. When discussing nonverbal communication specifically, respondents used more alternative forms of communication to improve understanding. For instance, Dandy stated, “I use more visual cues and take things a little bit slower to try to communicate nonverbally as much as possible before doing things,” further demonstrating the use of nonverbal communication. The ATs indicated that they relied on interpreters to enhance communication between themselves and NNESs. They also discussed fluency as a barrier to effective communication. Bernie described his actions to become more fluent: “I think trying to learn a bit more Spanish and trying to communicate a bit more will help me, especially with trying to understand what they are saying as well.” Supporting quotes for the communication domain are provided in Table 4.

Participants noted ways they enhanced the environment of their athletic training facilities to make them more welcoming to NNESs, which included speaking in the patient's native language, serving as an advocate for the increasing patient comfort, and patient within the health care system. Approximately one-half of the participants (n = 7/15) commented on using the patient's native language when speaking, if possible, to make their facility more welcoming for NNESs. Bonnie said she used Spanish to help improve her patients' comfort: “I do speak Spanish. So, I will automatically switch into Spanish to make them feel more comfortable and then we go from there.” Some participants identified that providing a welcoming environment to NNESs allowed them to serve as advocates for NNESs within the health care system by demonstrating that health care does not have to be scary or confusing. Bernie emphatically addressed the role of an advocate:

Eighty percent (n = 12/15) of participants also spoke of increasing patient comfort by using various techniques for NNESs in their facility. For example, Phillis spoke to their efforts to help all patients feel comfortable in their clinic: “My goal in my athletic training office is just to make everybody comfortable and to understand what is going on with them and what we need to do to accomplish recovery and getting back to your sport.” Supporting quotes for the welcoming environment domain can be found in Table 5.

When discussing the importance of being able to effectively provide patient care for NNESs, the ATs included behaviors related to cultural agility. The cultural agility domain consisted of the categories of respect, acknowledging customs, and fear or shame or both. When referring to respect, participants perceived that demonstrating respect for the patient was beneficial in providing culturally agile care. Many respondents (10/15) recognized that acknowledging a patient's customs related to race, ethnicity, religion, culture, gender, or other factors enhanced their ability to supply culturally agile care. For instance, Lousile realized the importance of family dynamics in making health care decisions:

The ATs believed that patients were more likely to seek the care they needed when they felt that they and their customs were being recognized and respected. Most participants (13/15) also stated that some NNESs had feelings of fear or shame associated with their native language, ability to communicate, acceptance, or ability to progress through and understand the health care system. Phil observed, “I think it makes it harder for them to come forward with injuries or things that are bothering them because they know the process that it is going to entail.” Because NNES patients may experience fear and shame, they may benefit from encouragement to receive necessary care. This fear or shame that is felt by NNESs was identified by the ATs as a barrier to providing culturally agile care to NNESs in their populations or communities. Supporting quotes for the cultural agility domain are given in Table 6.

Within the resourcefulness domain, 5 categories emerged: a lack of formal training; on-the-job training; health information technology; initiation, effort, and time; and adaptability. Participants commented that they often had very little formal training, and many voiced that the training they did receive was through either informal live experiences or on-the-job training. For instance, Jolly reflected on her education: “I would say, to my recollection, I did not receive any formal education in dealing with NNES patients, and if so, it was limited.” Jolly later discussed how on-the-job training was used to better communicate with NNES patients: “There was no formal education. It was just being made aware of those resources that I could use and then trial and error using those actual resources.” Many participants described using health information technology resources to improve the care or communication they were able to provide to the NNESs. Health information technology involved the management and secure sharing of health information between providers and patients. Most of the identified health information technology resources helped the respondents by translating patient education materials. For instance, Bailey shared, “I do not think I have really done any formal professional development, but I have tried to use some language learning apps like Duolingo to learn some basics.” In reference to the initiation, effort, and time category, participants explained having to put in more of each to supply care, obtain resources, communicate, follow up on referrals and outside care, and make the patient comfortable. Some ATs (5/15) also remarked on having to be more adaptable when providing care or communicating with an NNES compared with a native English speaker. Supporting quotes for the resourcefulness domain are shown in Table 7.

We demonstrated that ATs noted several differences in their approach to care for an NNES compared with a native English speaker. The identified domains—communication, welcoming environment, cultural agility, and resourcefulness—have been addressed by earlier researchers^3,5,6,10  in studies of other health care professions. However, not all of the ideas within each domain have been discussed previously, so our results could inform recommendations for implementing and providing high-quality care and communication to NNESs.

Communication difficulties stemming from language barriers have been commonly recognized.^1,3–6,13  Our ATs stated that despite the language difference, they were able to communicate with patients using other techniques. All participants discussed either an interpreter or a translation service as being helpful in overcoming the language difference. This finding was consistent with the results of earlier investigators^1,3–6,13  who addressed the aid of interpreters in overcoming language barriers within the health care system. Respondents recognized that interpreters or reliable translation services increased their ability to effectively communicate with NNESs. Previous authors^{1–4,7,14–17}  evaluated the use of interpreters and their effectiveness based on their fluency, specific training, and role. Many of our ATs also commented on some of these components related to their interpreters and translation services.

In contrast to other health care professions studied, the participants in this study noted challenges with family members, coaches, or other students serving as interpreters, for fear of bias in the information shared, improper translation, or breach of personal health information. In other health care settings, family members are often called on to create cultural safety and trust, and patients benefit from the family members' knowledge of their medical background.^16,17  The differences between athletic training and other health care professions may have to do with the emergent nature of care, as the medical history may not be relevant to an acute injury. Respondents stated that they increased their reliance on nonverbal communication when providing care for and communicating with NNESs. The ATs reflected that although verbal communication may pose a specific barrier, they felt that using nonverbal communication would be beneficial to the overall care provided. However, it is important to note that nonverbal communication is different for some cultures in that actions such as eye contact, shaking hands, and physical gestures can be interpreted with positive or negative connotations. This increased reliance on nonverbal communication also aligns with previous research in health care.^1,6,13  Secondary school ATs should consider using more nonverbal communication when providing care for and communicating with NNESs and may also maximize health information technology to share information through electronic images and resources.

Translated resources were identified as being beneficial to many participants. They discussed putting up signage in and around their facility in other languages, using translated medical forms and documents, and relying on bilingual people as interpreters. The ATs described making, finding, and using translated resources to increase the care and comfort of the NNESs they interacted with, specifically within the health care system. Earlier researchers^4,5  demonstrated the benefits of translated resources in improving outcomes for NNESs. Athletic trainers should use translated resources to improve the communication with and care provided to NNESs.

Health literacy, or the ability of individuals to obtain, understand, and synthesize information to make health care decisions, is vital for patients to be able to make informed decisions.¹⁸  To help the patient make informed health and health care decisions, ATs need to effectively communicate with them to ensure true comprehension of the health information being shared. However, it is important to note that earlier investigators¹⁹  suggested that the use of family members as interpreters can place a heavier burden on a patient's health literacy and introduce complications regarding private health information. The burden on patients and their support system illuminates the need for ATs to seek alternate effective forms of communication, such as translation services and nonverbal communication.

In the welcoming environment domain, participants specified ways in which they made the environment more welcoming for NNESs. Respondents indicated that they tried to speak in the native language of the NNES if they had the ability to do so. The use of the NNES's native language was perceived by the ATs as increasing patient comfort and helping the NNES feel welcome and safe in their facilities. Nonetheless, this factor was not cited by all participants, which could have been because they were not all able to speak in the native language of their NNESs. Speaking in the patient's native tongue was found by previous authors^3,13,16  to help provide a caring and more welcoming environment for patients. Although it is not practical for ATs to speak in all languages of the populations they serve, it is worth noting that some participants who could use the native language of their NNESs thought it offered a more welcoming and accepting environment.

Respondents also commented on attempting to increase NNES comfort within their facility. The ATs increased NNES comfort in many ways and deemed patient comfort an important responsibility. Participants reflected that by making their facility comfortable for NNESs, they were able to build more trust and rapport. This comfort increased patient satisfaction and outcomes in several studies.^1,3,5,6,13  When ATs can form trusting relationships, they are often able to better serve and provide care for their patients.

By increasing trust and rapport, ATs may also be able to better serve as NNES advocates within the health care system. Secondary school ATs have the benefit of direct access to patients when they present with a symptom or concern. If ATs can establish good relationships with NNESs by providing a more welcoming environment, they can also serve as advocates for NNESs within the health care system if a referral is necessary. The AT can help the patient progress through the health care system by aiding in scheduling appointments, interpreting results, educating the other providers about language differences, or finding a provider who speaks the native language if one is available. Secondary school ATs, with their increased exposure and easy access, may be the first, and are often the only, health care providers that some NNESs know and trust. These ATs could serve as valuable advocates, both for NNESs within the health care system and to the health care system through their knowledge of how to create a welcoming environment for NNESs.

Similar to the welcoming environment domain, the cultural agility domain focuses on ensuring that NNESs feel accepted. However, instead of concentrating on only the language differences or the environment, this domain focuses on the entire culture of the NNESs. Participants discussed acknowledging and respecting customs, acting with respect, and sensing fear or shame or both when referring to cultural agility. Substantial debates have occurred both inside and outside health care about the concepts of cultural competence, cultural proficiency, cultural humility, and cultural agility. Cultural competence centers on knowledge acquisition about other cultures and is thought to have limits in that providers can learn the attitudes and skills of other cultures to supply culturally competent care. Cultural proficiency is thought to take this idea a step further by focusing on the application of this knowledge. Cultural humility refers to a mindset of lifelong reflective practice but has also been criticized as a potential replacement for cultural competence. Our participants' responses were limited to behaviors and actions and, therefore, we do not know if the ATs routinely engaged in proactive reflection that demonstrated the components of humility.

Respondents perceived how acknowledging customs and respecting the NNESs for who they are, including their customs, culture, and language, increased the comfort and feelings of acceptance in their facility. This feeling of acceptance has been shown to increase patient satisfaction and outcomes.^{1,3,5,6,13,17}  Providing culturally agile care to patients is always important and increases the quality of care. Acknowledging customs and respecting all people as individuals are beneficial in all circumstances, and this is no different in health care. Health care providers should deliver high-quality, moral, and ethical care to patients, and offering culturally agile care by acknowledging, respecting, and implementing customs and patients' cultures, values, and beliefs is part of that duty.

Participants referred to NNESs' perceived feelings of fear, shame, or both within their facilities and health care. These feelings could be present for a multitude of reasons and have been identified by previous researchers as barriers for NNESs seeking health care.^1,3–6,13  Respondents discussed how feelings of fear, shame, or both could prevent NNESs from seeking medical attention in the early stages of an injury or illness, feeling accepted by the AT or environment, or offering complete information or trust to the provider. Earlier authors^3–6  demonstrated that these feelings were warranted, as major lapses in care have been attributed to language differences in health care. This fear or shame that NNES patients exhibit related to their native language is consistent with previous findings.^1,3–6  The potential for fear or shame felt by these patients needs to be discussed and addressed in the profession and health care in order to provide better, more equitable, and competent care to NNESs.

Provider resourcefulness in health care has been studied.^1,3,6  Many health care professionals have little to no formal education or training in communicating with or supplying care for NNESs.^1,3,5,6  This lack of formal training could negatively affect the care delivered to NNESs, as providers have not been educated on how best to give care, learn what challenges to expect, or know the resources available to them. Many of the participants noted that what little training they did have was motivated by their desire to provide better care to NNESs due to their experiences and not because of their formal education. Thus, ATs who have recognized a difference in the care provided for NNESs may seek more knowledge to supply better care and improve their patient outcomes. In relation to the lack of formal training and responsive motivation to clinical experiences, many respondents remarked that they engaged in some variation of on-the-job training to increase their knowledge and ability to provide equitable care to NNESs.

Other health care professionals have acknowledged the increased amount of initiation, effort, and time that is needed to communicate with and provide care to NNESs.^1,3,14  Previous investigators^3,6  began to explain the increased resource use in trying to improve clinician care for NNESs. When verbal understanding and communication are lacking, clinicians may feel forced to rely on other measures to help them feel comfortable in providing care. Some of these measures may include additional testing, more time for communication, interpreters, and follow-up calls. Participants also discussed how the increased amount of initiation, effort, and time not only helped the NNESs feel more confident about the care received but also helped the ATs feel more confident about the care they provided. It allowed them extra time to ask questions and ensure understanding as well as to demonstrate extra effort to convey that the care of the NNESs was important to the ATs.

All of the categories within the resourcefulness domain illuminate the differences in care provided to NNESs compared with native English speakers. To provide equitable care to NNESs, both the participants and earlier authors^3,6  found that increased resources were needed. These resources come in a variety of forms, such as bilingual health materials, interpretation services, and organizational interpretation policies. Increased resources highlight the need for improved education and experience in delivering health care for NNESs and to help enhance provider quality of care as well as NNESs' satisfaction.

Our participants volunteered to engage in the interview process. The population studied is possibly representative of those with an interest in care for NNESs and language fluency. Because they were asked in the recruitment email about secondary language fluency status, it may be that more ATs who were fluent in a second language volunteered to participate in the interview. We did not examine whether the ATs were bilingual or multilingual. It is also possible that those with more experience in providing care for and communicating with NNESs volunteered to participate. This could be attributed to the number of experiences they had or the importance they placed on their experiences.

Further research is needed regarding communication with and care of NNESs in athletic training and health care. To this point, no exploration has been conducted of secondary school ATs to determine the effects of language differences on patient care. This work could supply a foundation of knowledge about the perceptions of secondary school ATs on the effects of language differences. However, this study was descriptive and should be replicated across a larger population to be more representative of all secondary school ATs' experiences. Future investigators should confirm these perceptions across a larger population, characterize how to address these effects in an AT's care and education, and identify ways to increase equitable care for NNESs using athletic training services.

The ATs who participated in our study perceived themselves as being comfortable providing care to NNESs; however, many differences have been described in the care given to NNESs in comparison with native English speakers. The ATs reported having received little formal training in providing care to NNESs. This gap increased their resourcefulness and their use of different communication strategies to supply more equitable care. The participants also adapted their care to meet the cultural needs of NNESs. Creating a welcoming environment for NNES patients and their support systems was important in cultivating a patient-centered experience and delivering high-quality care.