https://orcid.org/0009-0009-0382-6944
Figures
Abstract
Objective
Failure to provide language services in health care settings negatively impacts patients with non-English language preferences (NELPs), yet underuse of language assistance remains rampant. Nurses in the Emergency Department (ED) handle critical communication in a fast-paced environment, posing a communication challenge. The aim of this study is to describe ED nursing perspectives on barriers and facilitators to accessing language services to construct interventions that increase the uptake of language services when interacting with ED patients with NELPs.
Methods
This is a qualitative study of ED nursing staff at two sites using the Behavior Change Wheel (BCW). Participants included registered nurses, nurse practitioners, and nursing assistants. The BCW was used to identify barriers and facilitators to accessing formal language services (professional interpreters, remote or in-person) which were mapped to intervention functions to construct proposed interventions.
Results
A total of 36 interviews were conducted with registered nurses (n = 29), nurse assistants (n = 3), and nurse practitioners (n = 4). Barriers and facilitators to calling an interpreter were identified in all three of the BCW categories of capability, opportunity and motivation. These were mapped to intervention functions on the BCW to construct tangible interventions including restructuring the environment to have designated parking spaces for video remote interpreter machines in private areas, standardized training on language access services, equipment and policies, and training senior nursing language access champions to model the behavior of calling interpreters and to discourage ad hoc interpretation.
Conclusion
We identified nursing perspectives on barriers and facilitators to language access and used the BCW to construct interventions. ED administrators can use these interventions as part of efforts to eliminate the underuse of language services and the potential negative impact outcomes for patients with a NELP.
Citation: Cordova D, Torres JR, Udagawa S, Qi X, Avra T, Taira BR (2025) Nursing perspectives on advancing language access in the emergency department: A qualitative study. PLoS One 20(11): e0336525. https://doi.org/10.1371/journal.pone.0336525
Editor: Stephen R. Milford, University of Basel Institute for Biomedical Ethics: Universitat Basel Institut fur Bio- und Medizinethik, SWITZERLAND
Received: November 12, 2024; Accepted: October 27, 2025; Published: November 20, 2025
Copyright: © 2025 Cordova et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its supporting information files as this is a qualitative study. Also, providing the full qualitative transcripts would increase the risk that the participant could be identified.
Funding: DC: UCLA David Geffen School of Medicine Global Health Pathway Short Term Training Program JT: National Clinician Scholars Program at UCLA https://nationalcsp.org/ Funders played no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Background
Patients with a non-English language preference (NELP) are common in clinical settings. Lack of access to interpreter services in healthcare contributes to persistent population level health disparities that negatively impact immigrant communities [1]. More than 25 million people in the United States speak English less than very well [2]. This is magnified in settings with diverse patient populations such as Los Angeles [3]. Providing language concordant care improves healthcare outcomes, and prevents errors from miscommunication [4–6]. Proper communication and understanding also helps reduce the use of overly aggressive diagnostics in situations where more limited testing may suffice [7]. Previous studies have demonstrated the clinical benefit of conducting care in a patient’s preferred language [8–11]. There is also a legal framework that entitles patients to language assistance [12]. Despite this, there remains an underuse of interpreters in clinical settings and patients with a NELP frequently leave medical encounters with limited understanding of what has transpired [8].
The Emergency Department (ED) is a dynamic environment where many critical conversations occur with patients with NELPs, however, historically, language access in the ED has been suboptimal [13,14]. Nurses are integral members of the ED team and are responsible for multiple areas of critical patient communications including triage, medication reconciliation and discharge instructions. Understanding how nursing staff utilizes language services in the ED is important considering their time sensitive and varied responsibilities. Despite being charged with such important communication, barriers and facilitators to working with interpreters have not been described from the perspective of ED nursing staff. Nursing perspectives are therefore key to optimizing the chances of success when designing ED-based interventions for improving rates of language access for patients with a NELP.
Objective
The aim of this study is to understand the perspectives of nursing staff regarding language access for NELP patients in the ED. We use qualitative interview data and apply the Behavior Change Wheel (BCW) framework to design viable interventions and implementation strategies to improve language access in the ED.
Methods
This is a qualitative study using an implementation science approach consisting of semi-structured interviews of Emergency Department (ED) nursing staff to understand their perspectives on language access for patients with a NELP in the ED.
Theoretical framework
We used an implementation science approach and chose the BCW as the theoretical framework. When approaching a clinical problem with the goal of changing a provider behavior (such as calling an interpreter) an implementation science approach can support development of an intervention that has the highest likelihood of achieving an optimal result [15]. Implementation science is defined as “the scientific study of methods to promote the systematic uptake of research findings and other evidence practices into routine practice” [16,17]. The BCW framework, with the COM-B theory of behavior change at its core, was chosen a priori to assist in mapping qualitative findings to intervention functions and thus optimize the chances that suggested interventions would increase the rate of interpreter use. The BCW has three stages of development of a behavior change intervention: understanding the behavior, recognizing intervention options; and identifying the appropriate behavior change techniques [18]. The BCW uses the COM-B model of behavior where the target behavior (B) is assumed to be the result of the interactions between an individual’s capability (C), opportunity (O), and motivation (M) which can be subdivided into physical and psychological capability, physical and social opportunity, and automatic and reflective motivation. For a visual of the BCW and its COM-B components, we encourage the reader to visit the authors’ website [19]. The target behavior of interest was defined as a member of the nursing staff calling an interpreter during communication with a patient with a NELP.
Context
Interviews took place in the ED’s of Olive View-UCLA Medical Center (OVMC) and Ronald Regan UCLA Medical Center (RRMC). OVMC is an urban safety-net hospital with an academic affiliation and an annual census of approximately 60,000 patients. RRMC is an academic quaternary referral center with an annual census of 50,000 patients. At the time of the study, at OVMC there were phones that direct-dialed the remote phone-based interpreter in every patient room, video remote interpreter (VRI) machines, and one in-person Spanish language interpreter weekdays from 8am to 11 pm. There is a bilingual certification program for staff sponsored by the health system. At RRMC there were VRI machines and a phone line but no in-person interpreters or bilingual certification program for staff.
Participants and sampling
Purposive sampling was used to identify participants from each of the following categories: nurse practitioners (NPs), nurses (RNs), and nursing assistants (NAs). All nursing staff in both EDs were eligible and participants were recruited in-person in the ED and via email. Interviews continued until thematic saturation was reached after discussion and agreement of the research team defined as the absence of new codes or themes in participant responses [20]. This study was determined to be exempt by the Olive View-UCLA Education Research Institute Institutional Review Board (IRB) and a waiver of written informed consent was granted. The UCLA Office of the Human Research Protection Program also approved the project prior to the commencement of any research. Verbal consent was obtained from all participants prior to starting any interview.
Data collection procedures
Recruitment took place from May 1, 2021 to March 1, 2024. One-time interviews were offered as in person or by telephone with a planned duration of 30–45 minutes. In person interviews were conducted during staff break times and before or after shifts within the ED in a private space away from any active clinical areas. Telephone interviews were conducted at the participants’ convenience during non-work hours. Verbal consent was obtained and semi structured interviews were completed based on a predetermined interview guide that had been trialed for understandability. All enrolled participants completed the study. Interviews topics included general perceptions of language barriers, how staff utilize existing language services, and how language services could be optimized. We also collected demographics including position, languages spoken, and years of experience. All interviews were audio-recorded, transcribed and checked for accuracy by the study team. Participants did not have the opportunity to review transcripts of their conversations. No field notes were taken.
Qualitative analysis
Qualitative data were anonymized and transcribed verbatim using a professional online transcription service. Transcripts were reviewed to ensure accuracy. Analysis was conducted using ATLAS.ti (Berlin, Germany) a collaborative, cloud-based qualitative data analysis platform. A hybrid deductive/inductive thematic analysis approach was used with the BCW as an initial framework for coding but leaving space for salient inductive codes that fell outside the framework [21]. The qualitative researchers (DC, TA, SU, JT, BT) met regularly during the coding process to discuss the coding, refine, and consolidate identified themes, and resolve coding discrepancies. Member checking and deviant case analysis were used to enhance trustworthiness. Identified themes were then categorized as either a barrier or facilitator to the target behavior of a provider calling for an interpreter, and barriers and suggestions for optimization were mapped to intervention functions using the BCW. Intervention functions were used to suggest interventions with the most potential to impact behavior.
Researcher characteristics and reflexivity
The research team was made up of emergency physicians (JRT and BRT), medical students (DC, TA, XQ), and nursing staff (SU). During analysis, we reflected as a team on our positions and background and how they might impact the coding and interpretation of the data. Both EM physicians have formal training in research and qualitative methods and are bilingual certified providers (English/Spanish). SU is an ED nurse and a certified health care interpreter in Japanese. Medical students and nursing staff also had a 4-hour training session by primary investigators on qualitative methods and research approaches. DC and XQ conducted all interviews. Among the research team, 2 identify as female, 3 as male and 1 chose not to disclose their gender.
Reporting standards
All results are reported according to the COREQ standards for reporting of qualitative research [22].
Results
A total of 36 interviews were conducted with registered nurses (n = 29), nurse assistants (n = 3), and nurse practitioners (n = 4). Years of experience ranged from 0.5 to 36 years. Twenty-two of the participants spoke a language in addition to English. Barriers and facilitators were identified in all three of the BCW categories: capability, opportunity and motivation.
Capability
Capability is comprised of physical and psychological components. Physical capability describes the provider’s physical capacity to call or successfully interact with an interpreter [18]. Barriers to physical capability included the inability for both providers and patients to hear the remote interpreter because of ambient noise in the ED, especially with patients who are hard of hearing.
“Sometime over the phone it’s difficult to hear. They have a hard time, the translator has a hard time hearing the patient, especially if it’s like in our open areas. Have a lot of background noise.” Participant 9, RN, OVMC.
Participants also described the inherent difficulty of wearing personal protective equipment while using a phone. Other physical capability barriers included lack of patient privacy because of crowded physical spaces and lack of the time necessary to contact remote interpreter services in acute situations. The proposed interventions, based on the BCW intervention function of enablement, include increased availability of in-person interpreters and the designation of a quiet and private area where remote interpreter services can be used. (See Table 1) Facilitators related to physical capability included the presence of in-person interpreters and VRI devices where patients could see the interpreter’s facial expressions and lips. Participants appreciated the ability of the interpreter to see and be seen by the patient, participate in nonverbal communication, which fostered a more personal connection with the patient.
“If there’s a lot of people in the room, it’s hard to hear the interpreter on the phone…recently, a few months ago, we got the interpreters, physical bodies that go in with the doctors, and they do a good job.” Participant 14, RN, OVMC.
Psychological capability is the capacity to engage in the necessary thought processes, including comprehension, and reasoning to call or interact with an interpreter [18]. Participants were aware that language services were available, however many lacked training on the variety of ways to contact language services.
“I would say a majority of the people don’t even know they can use the phone… It’s not well known. So, when I tell them to use the phone, they’re like, oh, I didn’t know I could do that.” Participant 31, RN, RRMC.
The proposed intervention was additional training for nursing staff on how to access language services. An additional barrier within the category of psychological capability was the inability to read discharge instructions written by providers in Spanish. The proposed intervention functions included enablement and training. Nurses could be enabled to overcome this barrier by augmenting the available prewritten bilingual patient information sheets that can be chosen by providers in the Electronic Health Record (EHR). Additional training for both providers and nurses on the policy and procedure for discharging patients with NELP is important given that providers should not be entering discharge instructions in non-English languages without the presence of the English translation.
Awareness of legal consequences was mentioned in the context of obtaining informed consent and was considered a facilitator for accessing language services in the category of psychological capability
“But as soon as they start, you know, explaining procedures or like, hey, we need consent. That’s where I draw the line. And I’m like, hey, you have to get a translator for this because I’m not trying to open myself to any legality or any issues like that.” Participant 34, RN, RRMC.
Self-awareness of the limitations of one’s own non-English language skills was also a facilitator for contacting language services.
Opportunity
The category of opportunity is divided into physical and social opportunity. The physical opportunity to call for an interpreter is made of the physical circumstances afforded by the environment [18]. Physical opportunity related barriers included the absence of working phones and the inability to find the iPad to utilize interpreter services.
“We just lose track of them (iPads on wheels). There’s been times where we are paging overhead for the iPads because nobody can find them. And we only have three, which I don’t think is enough.” Participant 30, RN, RRMC.
The need to locate equipment contributed to the perception that using an interpreter would be slower or less efficient than an ad-hoc or in-person interpreter.
“The E.R. is just a very dynamic place where sometimes time is of the essence. And to get a translator on the phone, and, you know, that could take, 5 to 10 minutes trying to look for a phone or iPad or call somebody.” Participant 34, RN, RRMC.
Proposed interventions, based on the intervention function of environmental restructuring, included designating a staff member to check the equipment every shift and a designated “parking space” for the VRI machines to eliminate the issues of nonfunctioning, uncharged or missing equipment. (See Table 2) In addition, reinforcement of training on the variety of methods to contact language services and how to escalate requests when problems are encountered would also be helpful. Facilitators included the availability of a phone at every bedside and the recent addition of in-person interpreters stationed in the ED at OVMC.
Social opportunity describes the “cultural milieu that dictates how a person perceives and thinks” [18]. Respondents described that it was socially acceptable for a provider to ask a colleague to interpret or use other ad-hoc interpreters such as family instead of using a certified interpreter.
“I’ve been in some situations where the doc then pokes his head out of the curtain or room and says, “Is there anybody that can help me (interpret) in person?” That’s that seems to be the fallback.” Participant 9, RN, OVMC.
Of note, this practice also poses unnecessary burden to some staff members. Multilingual nurses, especially those who speak Spanish, described an increased burden, as they were expected to both interpret for their colleagues and still perform the same amount of work.
“I want to help, but we’re task saturated. So when you get…‘hey, can you just discharge this patient because they only speak Spanish?’... Like, you want to help out your colleague, but you’re like, please don’t pull me for this stuff.” Participant 32, RN, RRMC.
The proposed intervention, based on the intervention function of modelling, was to identify senior members of the physician and nursing staff to model the appropriate use of language services and disseminate information about language services in real time when situations arise where staff are relying on untrained bilingual staff. Social opportunity also served as a facilitator to language access at OVMC where it was made clear that the administration expected staff to call for language services when necessary.
Motivation
Motivation is comprised of automatic and reflective processes. Automatic motivation refers to automatic processes involving emotions and impulses that arise from associative learning and/or innate dispositions [18]. This can include habitual processes and emotional responses in decision making. Automatic motivation was an identified barrier to calling an interpreter as some respondents had an established habit of using ad hoc interpreters.
“There’s always people around here. I mean, I know we’re not supposed to, but If I’m in triage I’ll even grab a housekeeper for a quick moment (to interpret).” Participant 18, RN, OVMC.
Participants described aiming to just “get by” when interacting with patients with NELPs using workarounds including the provider’s own non-fluent language skills, Google translate, or ad-hoc interpreters (e.g., family members, colleagues, housekeeping staff).
Further, participants reported that Spanish is treated differently than other languages. The frequency of contact with the Spanish language made providers feel they could communicate enough without calling an interpreter even when not proficient or certified, potentially leading to less language access for Spanish-speaking patients.
“They tried to do like a broken Spanish… there’s a gap already in communication, let alone like a broken Spanish. So I think that among my colleagues, they probably should use it (language services) more than what they do.” Participant 3, RN, OVMC
Reflective motivation refers to the processes that include evaluations and plans for how a provider uses language services [18]. Reflective motivation facilitated contacting interpreters when providers connected language services to ideas of patient’s rights and equitable provision of care.
“The care that an affluent English-speaking individual versus a Spanish guy gets for his chest pain is very different… we just have to do our part and get translation services.” Participant 34, RN, RRMC.
Other providers focused on the positive impact of proper communication on patient care, outweighing any potential time costs associated with calling an interpreter.
“The care I am giving should not be substandard. I use the language services, and I’m happy with that, and I don’t mind if I see one patient less.” Participant 16, NP, OVMC.
Participants who prioritized using language services countered perceptions of an efficiency cost by focusing on the benefit to patient outcomes and satisfaction. They also identified potential communication costs associated with forgoing interpretation. Further, recognizing language access as an issue of patient autonomy and recognizing potentially dangerous miscommunications and how they occurred also facilitated willingness to engage interpreters. (See Table 3) Encouraging reflective exercises during meetings and trainings are viable interventions to promote this type of reflection.
Discussion
Previous studies have shown that patient outcomes and satisfaction suffer when providers do not use professional interpreters when communicating with patients with a NELP [14,23–25]. Professional, as compared to ad hoc, interpreters have advanced skills that leads to more accurate interpretation [26]. Resource utilization arguments also support the use of professional interpreters [27], however, in most health care settings, underutilization or “getting by” remains the norm [28,29]. Emergency nursing is particularly challenging for communication with patients with a NELP because it is comprised of many short but important communications with undifferentiated patients. Through use of the BCW, qualitative interviewing of nursing staff elucidated concrete and actionable information about barriers and facilitators to accessing interpreters for ED patients with a NELP. The information obtained was mapped to the corresponding BCW intervention functions to design potential interventions with greatest likelihood of improving rates of interpreted conversations between nursing staff and patients with a NELP. The important next step in this research will be a formal implementation of the proposed interventions with measurement of process and patient outcomes.
We found that one of the key lessons to be learned from this study is the extent to which administrative decisions and interventions have the potential to positively impact daily practice. The underuse of interpreters is sometimes considered an engrained culture that is difficult to change, but participants in this study illuminated potential concrete administrative fixes that are promising to improve rates of interpreted conversations. Administrators should recognize the unique and fast paced environment of the ED and allocate more in person and video resources to the area because in-person interpreters, especially, have more flexibility to pivot with the team as acute situations evolve. Devoting more in-person resources that can handle complex patients (time critical, hypoxic patients with multiple team members in the room and high levels of ambient noise) may influence the calculus of time tradeoffs described by staff that led to ad hoc interpreter use. This preference for a visual connection also extended to the preferred methods of remote interpretation. Participants stated they felt the video-based interpreters (i.e. iPad) were better able to connect with patients, and patients felt they were speaking to a person as compared to phone interpretation. This is concordant with other studies showing a preference for this interpretation medium [30].
The second key point of the results are that consideration of the environment and workflows when constructing interventions have been critical. Having a dedicated parking space for the VRI machine, for instance, so that staff does not waste time searching for it, is a remarkably simple intervention but was mentioned by participants as an important need to influence nursing staff’s willingness to use the technology. Prior interventions that focused on enablement were mentioned as examples of useful interventions (having bedside phones in each room that autodial the interpreter line).
Finally, prior training and education was mentioned as influencing nursing staff decisions regarding language access. Those staff who had been exposed to education on hospital policy and the legal basis for the right to language access cited this training as influencing their thinking and empowering them to call interpreters, especially in the setting of informed consent. This is similar to previous studies that when organizational investment in language services is apparent providers prioritize language access [31]. Developing this element of workplace culture, too, may increase provider willingness to call an interpreter [32]. Finding staff who are “champions” of promoting and using these services would serve to model this behavior and has been effective [33]. Training staff champions to demonstrate and promote proper language access within clinical areas would serve to promote institutional knowledge, serve to promote social opportunity, and further advocate for the implementation of language services in common provider patient interactions in the ED.
A secondary benefit to the administrative investments described above is reduced burden for bilingual staff members. Bilingual nursing staff described a cost to their work performance when they were pulled as an ad-hoc interpreter for nonemergent conversations.
This has similarly been described by nurses in other settings and noted to be a sort of invisible additional workload that adds up [34]. Chang et al studies this phenomenon of bilingual staff being “pulled away” and found it was driven by the assumption that all bilinguals could interpret medical terminology and linked it to a workplace culture that did not address risk related to language barriers [35]. Utilizing the interventions proposed above will not only raise rates of interpreted conversations but also empower overburdened bilingual staff to remind colleagues to access language services.
Further study is needed to examine each of these interventions and their impact. Possible outcomes to examine may include documented interpreter usage rates, patient satisfaction ratings, and identifying concordance between patient’s perceived content of conversations and providers.
Limitations
The study was conducted at two urban EDs in Los Angeles and therefore may not represent all settings. Given the high proportion of patients with NELPs and bilingual providers in Los Angeles, staff in this setting may generally have had more exposure to the topic of communication with NELP patients than in other settings. This study did not collect the total number of staff invited to participate or the proportion of those who agreed which makes participation bias difficult to assess in this study. Because NPs and NAs are present at only one of the two sites, sampling of those roles was limited, but they were included as important stakeholders whose views may differ from the RNs.
Conclusions
The ED is a setting where fast and accurate communication is critical. We identified barriers to and facilitators of ED nursing utilization of language access related to each construct of the BCW. Analysis of nursing perspectives led to a variety of concrete and actionable interventions that ED and hospital administrators can implement to increase rates of interpreted ED nursing encounters. Addressing the underuse of interpreters through multifaceted interventions within the healthcare system has the potential to support lasting positive change for communication with patients with a NELP and their subsequent health outcomes.
Acknowledgments
Prior presentations: Results have been presented in part at the Society for Academic Emergency Medicine May 17, 2022 and the Emergency Nursing 2024 Conference September 4, 2024.
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