The aim of this descriptive commentary is to improve communication in healthcare when an interpreter is used by providing practical advice to healthcare staff when they consider using interpreters. This descriptive commentary considered the issues of preparation and implementation of interpretation sessions to reveal the complexities and dilemmas of an effective healthcare encounter with interpreters. Using the design of a discursive paper, this article seeks to explore and position of what is published in the literature on the topic studied and on the basis of previous studies to provide practical advice on the use of interpreters. The descriptive commentary showed that the interpreter should be used not only as a communication aid but also as a practical and informative guide in the healthcare system. In preparing the interpretation session, it is important to consider the type (trained professional interpreter, family member or bilingual healthcare staff as interpreters) and mode (face to face and telephone) of interpreting. Furthermore, it is important to consider the interpreter's ethnic origin, religious background, gender, language or dialect, social group, clothes, appearance and attitude. During the healthcare encounter, the interpreter should follow the recommendations given in guidelines for interpreters. Healthcare staff should choose an appropriate room and be aware of their own behaviour, appearance and attitude during the healthcare encounter. Good planning is needed, with carefully considered choices concerning the right kind of interpreter, mode of interpretation and individual preferences for the interpretation in order to deliver high-quality and cost-effective healthcare. Depending on the nature of the healthcare encounter, healthcare staff need to plan interpreting carefully and in accordance with the individuals' desires and choose the type of interpreter and mode of interpreting that best suits the need in the actual healthcare situation in order to deliver high-quality healthcare.
In the context of globalisation, the world is becoming more multicultural. A multicultural society leads to a richness and diversity of languages. This implies a major challenge to provide individualised and holistic care based on each patient's needs. Clear communication between the parties in healthcare encounters is an essential part of delivering holistic and individualised healthcare. Problems arising from linguistic differences can negatively affect both patients and healthcare staff.[3, 4] The need to ensure accurate and effective communication between the parties in the healthcare encounter leads to an increasing use of interpreters. Working with an interpreter gives an opportunity for safe, high-quality and efficient healthcare and also better practice, service delivery and knowledge.[5-8] This study aims to improve communication in healthcare contexts when an interpreter is used by providing practical advice to healthcare staff when they consider using interpreters.
Communication is important as our language makes it possible to exchange thoughts and ideas with other people. Language is the carrier of our identity and is particularly important for making us feel confident and positive. Cultural values and attitudes are transmitted by language, including beliefs about, for example, what health is or what it means to be an immigrant in a certain country. These main beliefs, experiences or concepts are transferred between different generations with the aid of institutions in society such as schools, churches, hospitals, etc.
When a person is not able to communicate or lacks words or expressions for his or her needs and desires, there is an obvious risk of misdiagnosis, which can lead to inappropriate treatment. Health professionals are not always fully conscious of individual patient's communication problems and the consequences these might have. Thus, the language is not adapted to the level of language in the individual patient, or any accessible interpreter is used. Often information or explanations are given by families, which might mean that important information is never translated because of limitations in language ability, cultural barriers or social ties to next of kin. There is a risk that deficient ability to communicate health problems leads to inadequate or improper care.[13, 14] Examples of further consequences described are that the patients reported fewer symptoms, particularly mental ones, and that important aspects such as wound care, foot care, dietary advice and experience of pain were documented to a lower extent, constituting areas where the presence of an interpreter was uncommon.
To satisfy the requirements of the World Health Organisation (WHO) and codes of ethics for healthcare professionals stated by the World Medical Association – to promote good health on equal terms for the whole population and to prevent ill-health and disease – it is necessary to inform and instruct all patients and their relatives in an understandable language. Furthermore, healthcare should as far as possible be implemented in consultation and cooperation with the patient. An important aid in contact with persons speaking a different mother tongue from healthcare staff is the possibility to use an interpreter.
Internationally, there are different rules in healthcare policies regarding interpretation. In Sweden, there is a law clearly stating that persons with another mother tongue than Swedish have the right to use an interpreter in all contacts with public authorities, but in the UK, it is unclear exactly what language rights individuals have,[19, 20] and there is no comparable law in Canada. In the United States, there are recommendations in terms of National Standards for Culturally and Linguistically Appropriate Services in Health Care based on an analytical review of key laws, regulations, contracts and standards stating that the healthcare organisation must offer and provide language services, including interpreter services, at no cost to each patient who needs assistance in all healthcare encounters. Australia provides national free telephone interpreter services to healthcare staff, but this remains underused.
Previous studies have shown that healthcare staff experience a lack of easily accessible interpreters,[25-29] difficulties in communicating while using an interpreter, not least because of lack of training in the practical use of an interpreter[12, 15] and also because of financial considerations. Family members or bilingual staff are often used instead of professional or trained interpreters, without any assessment of their skills.[29-33] Working with an interpreter can provide an opportunity to enrich the healthcare encounter with broader knowledge and perspectives. However, there are issues that require sensitivity and skill among healthcare professionals when they prepare for and use an interpreter in a healthcare encounter.
A discursive design was used; there was existing knowledge of past research that allowed the researcher to draw some conclusions. Using the design of a discursive paper, this article seeks to explore and position what is published in the literature on the topic studied and on the basis of previous studies to provide practical advice on the use of interpreters.
A broad review of the literature was undertaken in October 2011 to identify studies addressing use of interpreters. The databases CINAHL and PubMed were searched during the years from 1990 to October 2011. The search was in relation to two areas: interpreter and healthcare service, with the following key words: interpreter service and interpreting; healthcare service; migrant; and refugee. The terms were entered individually and in combination. The reference list of each article was also examined in order to find additional papers to add to the study. A total of 285 papers were retrieved that met key words criteria, but 248 were excluded with 37 being retained. It was decided to assess the quality of the included studies to give descriptive information on aspects of the quality of the included studies rather than as a basis for rejecting studies. The 37 papers were reviewed and extracted according to the Joanna Briggs Institute for Interpretive & Critical Research (JBI Quari) for qualitative studies and JBI Critical Appraisal Checklist for Experimental Studies for quantitative studies by both of the authors. The quality of 37 retrieved papers was judged as rational and they were heterogeneous in their clinical content and methods; consequently, no papers were excluded.
Preparations for using an interpreter
The first question to be posed when planning the use of an interpreter is: what kind of interpreter should be used?
Type of interpreter
Here, the choice can be between a qualified interpreter – a trained professional who may be specialised in either healthcare or legal matters – and an unqualified one – a family member used as an interpreter or bilingual staff not trained in interpretation. The trained interpreter is specially trained for his/her function that requires a specialised set of skills, ethical considerations and technical language and thus is considered professional. However, ‘professional’ can in some cases mean ‘paid’. The trained healthcare interpreter is trained in the kind of terminology that is used in healthcare. The training is a quality label and the cost of using a trained interpreter is thus higher than for an untrained one. Using trained interpreters has been recommended in the previous systematic literature reviews[6, 36] conducted in the United States, which was further supported by clinical investigations.[8, 14, 37]
The family member as an interpreter is an informal, non-professional interpreter, relative or friend with a knowledge of the language. The quality of an interpreter is determined by the person's language skill, which may vary. Previously implemented studies concerning relatives' assistance as interpreters have shown divergent results. Some studies have indicated that the person in need of an interpreter felt security and trust when using a family member.[11, 30, 38] In contrast, other investigations[39, 40] have shown that use of family members can also be perceived as poor and problematic because they might feel ashamed of some matters and thus not willing to convey a message, for example, concerning mental health problems. Furthermore, patients using family members as interpreters felt frustrated because of experiences of error and misdiagnosis and being unsure about following the doctors' advice for treatment at the end of their consultation.[39, 40] Family members as interpreters can be preferable in some contexts, but judgements of them as interpreters should be made on a case-by-case basis because they may have varying abilities to interpret for their near ones.[41, 42] Additionally, family members may be able to be more involved in patient support and decision making when they do not have the role of interpreters.[12, 22]
Bilingual healthcare staffs have been claimed as important because skill in both language and culture is found in one and the same person, but their use has also been questioned as it may be difficult to separate the two roles, that of interpreter and that of healthcare staff. However, the crucial thing is the aim of the interpretation and how it might influence the communication and how it affects their work. There are many practical[12, 40] and financial benefits[42, 43] of using bilingual staff as interpreters. However, there are also invisible costs involved in removing a staff member from one role to fulfil another. Bilingualism is insufficient to ensure adequate interpreting skills. Bilingual staff often lack training in interpreting, may have a limited knowledge of medical terminology and in some cases language skills may be inadequate.[22, 43, 44] Furthermore, they are not governed by interpreters' common code of ethics but may be governed by relevant professional standards and legislative requirements of their profession. Bilingual healthcare staff, when used correctly as interpreters, are a valuable benefit for good communication, but when used inappropriately they can experience workplace stress and may feel pressured to use their language skills.
Family members or bilingual healthcare staff can be considered for use as interpreters after involving individuals and their families in the decision process of using them and after information is given about the availability of free interpreters[12, 22, 40, 45] (Table 1).
Table 1. Key points of practical advice to increase uptake of interpreters
- When planning the use of an interpreter, it is important to involve individuals and their families in the decision process about of the type of interpreter (a trained/professional interpreter, family member or bilingual healthcare staff as interpreter) and mode of interpreting (face to face or telephone) to choose the best suitable interpreter for the aim of the interpretation session.
- In the preparation phase, it is also important to consider the interpreter's competence, ethnic origin, religious background, gender, language or dialect, social group, appearance and attitude so that an appropriate interpreter can be ordered. When making the reservation for an interpreter, it is important to clarify the aim of the interpretation.
- During the interpretation session, the interpreter should act as a communication aid. Furthermore, the interpreter should be treated as a colleague whose neutrality and integrity should be supported. The interpreter should also act as a practical and informative guide for the patients within the healthcare system to be able to read and understand written information and find their way in the healthcare system.
- Healthcare staff should choose an appropriate room to be undisturbed when the interpretation session is held and be aware of their own behaviour, appearance and attitude during the interpretation session.
Modes of interpretation
Face-to-face interpretation is the most desirable mode of interpretation in healthcare.[12, 39, 40, 44, 45] The interpreter is present with the healthcare staff and the patient. The advantage of this approach is that it allows for observation and interpretation of verbal as well as non-verbal communication. However, there are many situations where an interpreter cannot be available in time because it can be difficult to provide access to trained interpreters within minutes, depending on where (geographically) or when (time of day) the interpreter is needed.[12, 40, 44, 45]
In telephone interpretation, the conversation is transmitted by a loudspeaker, so there is no eye-to-eye contact with the interpreter.[46, 47] The main difficulty with interpretation by telephone is that the body language is lost. This communication process – where the transmission of a message between the sender and receiver is made with the aid of technical equipment and without eye contact – implies a risk of distortion of the communication.[44, 47, 48] The benefits of telephone interpreters are accessibility for rare languages, demands for interpretation outside of normal working hours and confidentiality. Yet some patients may find this confidentiality disturbing if they fear that the invisible interpreter might be able to identify them, whereas they cannot identify the interpreter. Furthermore, disadvantages of telephone interpretation can be lack of continuity and personal relationship, individual intolerance of phone use and possible problems with background noise.[28, 45, 47] Telephone interpreter services should be used as a complementary tool when an interpreter is needed instantly or when the language is unusual.
In summary, healthcare staff need to plan for the use of interpreters in accordance with availability of interpreters and the individuals' desires and the need to organise a good healthcare encounter depending on the healthcare situation and the individual in order to deliver high-quality and cost-effective care.
The role of interpreter
The basic function of an interpreter is to provide a translation between two languages and maintain a disengaged presence. The interpreter's role in a healthcare encounter was described in previous studies from patients' and some family members' point of view not only as an aid in transmitting the message clearly but also considering the role as a practical and informative guide in the healthcare system. The findings were contrary to the recommendations in guidelines for interpreters.[49, 50] Individuals need help to find the right way to and within the healthcare system if they are unable to read signs. The questions are the following: Who will help these patients? Should the patients' and family members' wishes be considered and changes be made in the guidelines for interpreters, or should another function be developed in healthcare to meet these expressed needs? It is important to satisfy patients' and family members' wishes that those patients who need an interpreter will get help and support to handle the situation both before and after the healthcare encounter, not only during the healthcare encounter, to meet the requirements of the WHO to provide individualised and holistic care based on each patient's needs.
The next question to be posed, after having chosen a suitable kind of interpreter, is discussed below.
Where do I get into contact with an interpreter?
The recommendation is to contact an interpreter agency; often, such agencies are run by public authorities in the municipality or county council or by private enterprises.[12, 29, 32, 40, 49-51] In most healthcare institutions, there are lists of interpreter agencies, and often there is a possibility to contact immigration offices in the municipalities to get information about these agencies. When contacting the interpreter agency, it is possible to request the kind of interpreter that is suitable for the purpose of the interpretation. When making the reservation for an interpreter, it is important to clarify the aim of the interpretation, for example, whether it is a research investigation or a healthcare consultation focusing on delivering information or treatment. The cost of different types of competence varies; the most expensive interpreters are trained, but the training does guarantee good quality.[12, 32, 51, 52]
When ordering an interpreter, it is important to consider which language the interpretation should be held in. One question to be posed is of course what language or what dialect is spoken by the person one is going to interpret for.[12, 40, 45, 53] It needs to be observed that in big languages, for example, in Chinese, there are many different dialects that are difficult to understand. Thus, if possible, ask where the person originates from, and it will be easier to find the right interpreter.
The next important factor to consider is the ethnic origin of the person in need of an interpreter. Even among individuals speaking the same language but coming from different ethnic groups, there may be differences related to cultural aspects.[53, 54] In a previous study implemented in the middle of the 1990s in a department at the Medical Faculty of Lund University in Sweden, a conflict arose between the Bosnian refugees investigated, the Swedish project leader and the interpreter who was of Serbian origin. As a result of the conflict, the study was interrupted and later cancelled. The Swedish researcher said: ‘I would never have dreamed that the war in the former Yugoslavia could be continued in my office here in Sweden’. This is a striking example of how different ethnic groups, in conflict with each other in their home country, can bring their battles with them to the new country. The ideal is then to find an interpreter of the same ethnic origin as the person(s) in need of help with their communication.
Another aspect to consider is the gender of the interpreter. Men and women use language in different ways, which might affect the communication between them. Furthermore, gender is important for integrity of the person, and different questions might be of different importance to men and women. An interpreter of the same gender as the one in need of help with translation is recommended when investigating intimate areas, for example, a pregnant woman and her health, or questions regarding health of the man and aspects that might be related to his reproductive capability.[12, 45]
Being a member of an association for immigrants or a religious congregation might also influence communication in a situation using an interpreter. The role of religion and belief system as a part of an individual's well-being is being increasingly documented. One example was found in a previous study by Hjelm et al., in which a man originating from the Middle East expressed problems with impotence related to diabetes. The man was about 30 years of age and recently married, and his main problem was that he had not been able to become a father. When asked if he had not discussed the problem with the physician responsible for his treatment at the healthcare centre, he responded: ‘I haven't been able to talk to the doctor about it because I have had a female interpreter belonging to the same congregation as myself and I am so ashamed of my problems’. The ideal is to find an interpreter that is neutral and without any ties to the person concerned.[49, 58] For this reason, one needs to consider recruitment of an interpreter from another town or area.
Class, appearance or attitude may also affect communication. Social class or position often implies differences in educational level, which may influence the use of everyday language, ways of expressing oneself and verbal ability.[7, 53, 59] Highly educated persons often express themselves more easily and are used to arguing and discussing their opinion, and this is usually related to better knowledge than in those with low education.
Also related to social group or position is the marking of status, not only by language but also by using symbols such as clothes or jewellery. In an interview study of low-educated men from the former Yugoslavia, a Serbo-Croatian-speaking female interpreter was used. The group interviews were implemented without any sense of language difficulties or language barriers. In a later interview session, another Serbo-Croatian-speaking female interpreter was used and language barriers were perceived by the interviewer as the discussions in the group did not flow as easily and spontaneously as in the previous session. Furthermore, dissatisfaction was expressed in the presence of the respondents. The third interview session was held with the first interpreter and no language or communication problems were perceived and the respondents' facial expressions showed only happy faces. Spontaneously, the men told the interpreter that they had found the previous interview session negative because the interpreter then present was perceived as ‘an upper-class lady, with all her diamonds and elegant clothes … and she spoke a language that was difficult to understand and had a condescending attitude to us labourers’. The respondents thus reflected on and reacted to the clothes and jewellery worn by the woman: black velvet jacket and trousers and several diamond rings on her fingers. In another investigation, caution could be observed in communication between one respondent and an interpreter with very extreme make-up and provocatively dressed in leopard-patterned tight clothes. The observation could be contrasted with the use of another interpreter without these properties during follow-up interviews with the same respondent and others, where the conversations flowed freely in a very unproblematic and spontaneous way. Afterwards, discussions were held with the interpreter agency concerning interpreters' appearance and the neutrality and objectivity that has been recommended in an interpretation session.
Previous studies of the perceptions of patients,[38-40] healthcare staff and some family members showed that they appreciated interpreters having a professional attitude. This attitude includes an ability to translate as a communication aid, being highly skilled in language, informing people about the role as a formal translator and the code of confidentiality, keeping themselves in the background so that the conversation can flow between the staff and the patient, turning up at the agreed time and being present during the entire consultation, showing respect and interest, and being pleasant and courteous to all involved. The interpreter's personal characteristics, such as non-provocative and/or neutral clothes, should also be considered when an interpreter is to be booked.
Implementation in the interpretation session
The main rule in the interpretation session is that The interpreter is responsible for and manages the question of language and thus is the link in communication, while the user is responsible for the matter at issue.[22, 49, 50, 58]
The interpreter is now your ‘talk machine’, a kind of aid, which implies that the one you are going to communicate with is the person considered. Some simple advices based on the literature[49, 50, 58, 61] that can be useful during the interpreting session are given in Table 2.
Table 2. Some simple advices that can be useful during the interpretation session
- Place yourself in a posture where you are seated at the same level as the person concerned and give a calm and relaxed impression where you do not mark a position in relation to the opposite party.
- Create a comfortable atmosphere where any of the participants feels able to ask questions. For example, show that you are actively listening and interested, by nodding your head, looking the person in the eyes and posing follow-up questions if necessary.
- Place yourself not only so that you can look directly into your discussion partner's eyes but also so that you are able to see the interpreter.
- Avoid as much as possible the use of specialist terminology, which often does not translate well. Everything that is said in the room must be interpreted.
- Adapt yourself to the level of language understanding of the person(s) concerned. Use simple, clear and straightforward language. If the person does not understand, you need to reformulate by simplifying. Use as few words as possible.
- Talk slowly and in moderate sequences. Let the interpreter steer the length of the answer. Remember to listen carefully and consider that you have two ears and one mouth!
- Avoid interrupting the other person.
- Always speak directly to the person(s) involved and not to the interpreter. Please observe that it is you as the user of an interpreter and the person concerned that are going to talk to each other.
- Avoid, as far as possible, turning privately to the interpreter, and do not let the interpreter and the person concerned end up in discussions with each other.
- Be sensitive to what is happening! It is not so easy to give all relevant information.
- Respect the working methods and professional ethics of the interpreter. Do not ask for the interpreter's personal opinions or advice concerning the content of the dialogue. However, it is possible to talk to the interpreter before and/or after the interpretation session in order to discuss the situation, any reactions during the conversation or questions that have arisen during the interpretation.
As the user of an interpreter, you are in command of the matter at issue and the interpreter is in command of the language being spoken. Accept that the interpreter sometimes has to check terms in the dictionary or ask for alternative expressions or elucidations of expressions that have not been understood.
If a relative or friend of the person concerned is participating in the conversation, work as usual with the interpreter irrespective of whether the person understands or speaks your language.
Be prepared for the possibility that a wish for another interpreter might be expressed. Words and sentences cannot be translated clearly and in the same number of words as in your native language because languages are not constructed identically.
The interpreter should be treated as a colleague whose neutrality and integrity should be supported.[49, 61]
It is also important to choose an appropriate room to be undisturbed when the interpretation session is to be held.[12, 40, 45] Another important aspect of the interpretation situation is healthcare staff's own behaviour, appearance and attitude. If you want to focus on the person being studied and achieve maximum communication, then you can try to look as uninteresting as possible. It is also important to document the individual's language ability and communication preferences for an interpreter in both medical and nursing records and to update information continuously. This will help ensure that the healthcare encounter progresses well.
What kind of interpretation should be done?
There are differences in interpretation technique. Sequential interpretation or consecutive interpretation means that the interpreter speaks after the source-language speaker has finished speaking. The synoptic or summary interpretation technique is often used, which means that the interpreter summarises what has been said. When using this kind of interpretation technique, there is a great risk that important data and nuances in the language will get lost. Simultaneous interpretation is the third form of interpretation, which implies that as soon as the other person is expressing himself, the interpreter starts to interpret what is being said almost simultaneously, with just a few seconds' delay (as in conference interpreting). Whispering interpretation is a kind of modified form of simultaneous interpretation. The interpreter then whispers to the person(s) involved. The method is used, for example, when information should be given to a group where one or more persons do not understand the language.
Internationally, summarised interpretation, including the content and not only transmitting words but also general information about the patient's cultural background, is often used. In Sweden, it is sequential interpretation or consecutive interpretation, which means that interpretation is done word by word, which is most often used. According to the rules of Kammarkollegiet, satisfactory interpretation is achieved when the message and all its nuances are reproduced as correctly as possible. That means that terms and expressions as far as possible should be the same as in the original language and should be rendered in the same way. Curses, emotional expressions or body language should not be toned down. Consecutive interpretation is preferable from a quality point of view.
Face-to-face or telephone interpretation
It is important to involve individuals and their families in the decision process about the mode of interpretation, face to face or telephone.[40, 45] Face-to-face interpretation enables the user to observe non-verbal language, behaviour and personal characteristics, which can lead to better communication. On the other hand, telephone interpretation facilitates the direct communication as the interpreter becomes only a communication aid and the individual can be more anonymous, especially when discussing sensitive matters or undergoing physical examination. Furthermore, it is important to use well-functioning technical equipment in telephone interpretation.[12, 40, 45, 51, 66] Healthcare staff should be aware of when it is necessary to use face-to-face interpretation and when it is adequate to use telephone interpretation.
Finally, the following questions can be posed: What will the consequences be if an interpreter is not used, or if an interpreter with communication difficulties leading to poor language quality has been used?
In conclusion, the final recommendation for practice can be based on previous knowledge that has shown that communication without interpreter is an obvious risk of misdiagnosis possibly leading to inappropriate treatment.
The use of relatives as interpreters entails a risk that important information will not be interpreted because of limitations in language ability, cultural barriers and social ties to next of kin.[12, 67, 68] Previous research has also shown that the use of bilingual healthcare professionals can lead to misunderstandings in contacts with healthcare staff, while the use of a professional and trained interpreter instead has been shown to prevent unnecessary investigations of patients. The use of trained interpreters in the first hand was recommended in systematic literature reviews[6, 36] instead of using relatives as interpreters or bilingual healthcare staff, and this is thus supported. However, arranging for an interpreter can be problematic even when access to interpretation service is available to fulfil the existing policy in the healthcare sector. Problems shown have been related to the lack of interpreters with proficiency in a particular language, difficulties in the availability of interpreters and access to the interpreter agency.
Carefully conducted interpretation does not need to involve any kind of problems for either the quality of translation or the trustworthiness of newly acquired information, but it requires knowledge about the factors that influence communication during the interpretation session and good planning with carefully considered choices concerning the right kind of interpreter, the mode of interpretation and the patients' preferences for the interpretation.