A crucial focus in health care today is ensuring clients receive inclusive and equitable care. Persons at high risk for adverse events are often those who have limited English proficiency (LEP; LEP.gov, n.d.; The Joint Commission, 2021). Such individuals, who cannot speak, read, write, or understand English well (http://LEP.gov), account for an estimated 21.7 percent of the population (US Census Bureau, 2022). Adhering to Title VI of the Civil Rights Act of 1964 (US Department of Health and Human Services, 2013), all federal agencies must examine and identify if services are needed for persons with LEP and provide guidance for meaningful use of these services.
The Joint Commission (2021) describes communication as key to providing safe and equitable care to clients with LEP and notes that certified language interpretation (CLI) via in-person interpretation, video, or telephone can decrease adverse health care events. Virtual remote interpretation (VRI), a method of CLI that can be used in the absence of in-person interpretation, provides audio and visual interpretation of spoken languages and American Sign Language (Locatis et al., 2010). Culturally responsive communication requires being aware of and knowledgeable about cultural differences and trying to accommodate to them (Minnican & O'Toole, 2020). In addition, the proper use of interpretation services, for example, looking the client in the eye; speaking directly to the client, and using short, simple sentences to avoid misunderstanding, is an important part of this communication (Juckett & Unger, 2014). Preparing nursing students to care for diverse populations should be a priority outcome of nursing programs. The purpose of our simulation was to evaluate students on culturally responsive communication when using VRI during a prenatal care simulation involving clients with LEP.
BACKGROUND
There are few studies involving VRI and even fewer involving the use of CLI in simulation. A study by Kenison et al. (2017) examined the perceptions of medical and nursing students regarding their training for clients with LEP. Negative themes were found related to role modeling by clinical supervisors or preceptors who did not value the use of interpretation services because of time constraints. Another study involving nurse practitioner students found no improvement in students' use of interpretation skills over a two-year period, indicating the need for improvements in training. It was thought that "bad habits" picked up in clinical practice while learning from other clinicians may have contributed to the results (Phillips et al., 2011).
With limited clinical sites available in nursing education, simulation is used to teach and evaluate prelicensure nursing students. The American Association of Colleges of Nursing (AACN) provides a framework for baccalaureate nursing education to cultivate the use of clinical or simulation experiences for LEP clients (AACN, 2008). Latimer et al. (2019) provided an overview of CLI and recommendations for implementation in simulation, stating that creating an LEP case in a simulated learning environment allows instructors to evaluate students' communication and better prepare them to work with diverse clients.
VRI SIMULATION ACTIVITY
To provide students with a real-life scenario, a standardized patient (SP) who spoke a language other than English was used to play the part of a pregnant client who required prenatal history and education. SPs were volunteer senior nursing students who were fluent in a language other than English. For reliability, the SPs were trained, provided a script, and instructed to stay in character by speaking only in their native language. The scenario involved an eight-week pregnant client with risk factors including a history of pregnancy loss, high seafood diet, employment with unsafe conditions, and no partner support. An internal technology grant paid for VRI services providing CLI via a tablet on wheels. Using Wi-Fi, a live, remote interpreter was available for audio/visual interpretation.
Before the simulation, students were placed in groups of four and were provided a 30-minute prebriefing by a content expert. Each group was given basic information about the client: language and ethnicity, practices typical for the client's ethnicity, and tips for culturally responsive communication using CLI. Demonstration of the VRI technology was also provided. Students within each grouping delegated roles for health history and nutrition education. Each simulation experience was 20 minutes. As student groups took turns in the simulation, other groups completed a virtual simulation in another room.
During the simulation, content experts evaluated students from a control room using multiple camera angles and audio. The evaluation focused on correctly obtaining a prenatal history, providing accurate client education, and the proper use of communication through an interpreter. SPs were also instructed to note eye contact and rapport. The simulation debriefing focused on students' perceptions of the client interaction, their performance, and techniques for improvement. The SPs provided feedback to students about how they felt as clients with LEP.
After the debriefing, interested students were invited to participate in a focus group. The focus groups lasted about 20 minutes and included five questions related to the experience. Students were asked about their experience with CLI, ease of use with VRI, presimulation resources, and if the simulation enhanced their ability to communicate with clients with LEP. They were also asked to provide additional feedback.
DEBRIEFING AND FOCUS GROUP FEEDBACK
Content expert evaluation of the students' performance found that they performed well obtaining client histories yet needed to ask more specific questions about cultural practices concerning pregnancy and nutrition. Evaluation of communication techniques revealed that most students kept sentences short for ease of interpretation. During one group, a student pulled up a chair to be at eye level with the client. The SP commented that this was a great technique that helped her feel more comfortable. Although most students maintained eye contact, a few students were drawn to the tablet and watched the interpreter. Some groups ran out of time; students were not aware of the time needed to utilize VRI for communication.
Of the 38 students who participated in the focus groups, about 55 percent reported previous experience using CLI. Regarding ease of use, students described VRI as user-friendly technology. Students identified the prebriefing resources, training on the device, and instruction about culturally responsive communication as helpful to ensure that practice during the simulation was purposeful. Students also reported that there was an abundance of information that needed to be communicated during the time allotted for the simulation. They mentioned that the VRI simulation greatly improved their confidence and highlighted the need for patience when using VRI interpretation.
Students also noted that it was difficult to focus on the client instead of the technology. A final point shared by students was that this simulation was "game changing" for future practice. Regarding the gender of interpreters, although there was a "curtain" that could be used for client privacy, students felt they should have asked the client if a female interpreter was preferred. Some students who participated in the simulation had English as a second language and had to repeat information multiple times to the interpreters and speak more clearly to ensure correct interpretation. Discussions during the debriefings and focus groups resulted in themes of appreciation for the experience and how more time is needed to achieve effective communication with LEP clients.
CONCLUSION
Although the VRI service provides more than 40 languages with live interpreters, some SPs in this project spoke languages that were not included in the service, therefore limiting the use of volunteer SPs. Another limitation to consider is the cost to implement this technology for nursing simulation. However, according to Latimer et al. (2019), LEP simulation can utilize faculty or volunteers with native languages to serve as an in-person interpreter. As the overall goal is to provide students the experience of caring for clients with LEP, any simulation training involving clients with LEP will ensure the next generation of nurses has the skills to decrease inequitable care in diverse client populations.
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