A Better Interpretation

Effective communication between the patient and the medical provider plays a vital role in the delivery of high quality medical care. But what if that patient is a non-English speaker?

Not only do healthcare facilities have a duty to provide language assistance services to limited-English proficient (LEP) patients to ensure quality medical care, but there are current equal language access requirements that recipients of federal funding must adhere to.

According to Title VI of the Civil Rights Act of 1964, “doctors and agencies getting federal money should make language services available to people who do not speak or understand English well enough to access services.”

Further, the Office of Minority Health’s National Standards on Culturally and Linguistically Appropriate Services (CLAS) mandate healthcare facilities receiving federal funding to comply with a set of four standards in regards to ‘Language Access Services.’

But just because federal requirements are in place to ensure LEP patients have access to language assistance services, it does not guarantee a successful language-mediated medical encounter.

There are a number of factors that contribute to a successful interpreted session in healthcare, such as the medical provider’s ability to understand, and respect, the interpreter’s roles as a conduit, clarifier and cultural broker.

Do You Need an Interpreter?

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The first (and most important) step of a successful interpretation session in healthcare is identifying when there is the need for an interpreter. In some cases, the need for an interpreter to facilitate communication will be obvious (i.e., when the patient lacks the most basic English speaking skills).

But that’s not always the case.

What if the patient’s comprehension of English is limited, meaning he understands certain words and phrases? What if the parents or guardians of a minor are in need of interpretation services but the patient is not? What if the patient is accompanied by an English-speaking relative who has volunteered to interpret?

Under these circumstances, should the medical provider still seek the assistance of a qualified and professionally trained interpreter? Absolutely! And if the LEP patient refuses interpreter services, this must be documented and the patient must sign a waiver, ideally in his or her native language.

Why is all of this necessary? Because of the dangerous – and highly avoidable – medical errors that may result from faulty communication between patient and provider. The inaccurate collection of even the most basic information by untrained or unqualified bilinguals can have devastating effects for all parties involved.

Unfortunately, many healthcare institutions still rely on bilingual personnel and/or English speaking relatives to facilitate communication with LEP patients. Doing so may have ethical and practical ramifications with greater liability for the institution.

Imagine yourself as the patient unable to communicate in English. Would you find it appropriate to have your minor child serve as your interpreter if you were raped? Could you make an informed decision about your course of treatment if a janitor with a limited command of English was asked to transmit the content of an informed consent form in your native language?

From an ad-hoc interpreter relaying an incorrect blood type to a provider to multimillion dollar settlements tied to bilingual misunderstandings, there are many documented examples of minor communication errors compromising patient’s quality of care and the reputation of the institutions involved.

Before the Interpreted Session

Once the need for an interpreter has been identified, there are several steps nurses or other medical providers should follow in order to adequately prepare for the interpreted session.

First, you should identify the language or dialect the patient is speaking. Many language-service companies provide healthcare facilities with various tools to assist in language identification, including “Please Point to Your Language” posters and desktop reference cards.

If these tools are not currently available at your facility, you may also ask the patient to write down his place of origin language or dialect. When requesting an interpreter for a Chinese patient, for example, determine if the patient speaks Mandarin, Cantonese, Fuzhao, Hakka, Taiwanese or other dialect. Some providers of telephonic-interpretation services have trained personnel to help you determine the best language match for your LEP patient. Once the ideal language has been identified, you should make a note on the patient’s file for future reference.

Next, determine if there is a gender-sensitive issue, e.g., a patient who for reasons of cultural modesty may prefer a medical interpreter of the same gender and make a note of that in your request for an interpreter. For face-to-face medical encounters, an interpreter of the same gender is typically the way to go; however, when using a telephonic interpreter a gender-specific request typically is a secondary consideration.

Finally, if you plan to refer to a questionnaire or form throughout the medical encounter, and you are using a telephonic interpreter, email a copy for the interpreter to your language service provider (LSP). This will ensure the interpreter is fully prepared and equipped to deliver the best interpretation possible.

At the Beginning

Once the interpreter is available, be it in-person or remotely, introduce yourself and explain the situation, e.g., “I am the RN and the LEP patient is complaining of stomach pains. We are at a detention facility and will be communicating by passing a single receiver back and forth.”

You should then let the interpreter know of your desired objectives. What are you hoping to achieve at the end of this language-mediated medical encounter? Finally, be sure to make any special requests known, such as if the patient is hard of hearing or slightly sedated, or if perhaps it is the parents of the patient whom need the interpretation service. The more information you provide the interpreter, the better.

The interpreter will likely begin by conducting a pre-session to explain to the patient and the provider how to best communicate through the interpreter, including speaking to one another directly as though an interpreter was not present, and that all information shared during the session is and will remain confidential. Even if you have heard the pre-session many times before in your nursing career, remember your patient may very well not have.

Managing the Session

To help you manage the interpretation session effectively, ensuring quality medical care is not compromised for LEP patients here are some tips from the interpreter’s perspective:

  • Look at and speak directly to the patient, not the interpreter.
  • Speak at an even pace and pause after short segments so the interpreter may render the interpretation.
  • Be aware some concepts have no exact linguistic equivalent and the interpreter may have to describe them in greater detail. Because of this, the interpretation may take longer than your original statement.
  • Avoid using metaphors, idioms, complicated sentence structures and sentence fragments, changing ideas in the middle of a sentence, interrupting the interpreter before the interpretation has been rendered or asking a question while another is being answered.
  • Try to avoid using high-level medical terminology, acronyms or jargon. If you must use them, be prepared to explain to the interpreter what they mean and what they involve.
  • Keep in mind that it is impossible for interpreters to memorize every word and they should be allowed to consult their dictionaries and glossaries, as needed.
  • If the LEP patient or interpreter is having trouble understanding a specific term or concept, try to explain it using examples.
  • Be sure to allow the interpreter to instruct the patient about the need to pause, speak up, repeat, explain or clarify.
  • Interpreters are trained to convey in English everything that is said in the foreign language. If necessary, remind the interpreter of this fact.

Cultural Brokers

Try to remember the interpreter is only the conduit of the message. He or she is not responsible for what you or your patient says or does not say, or whether the answers are vague or too detailed.

It is also important to remember all parties may ask for repetition, clarification or explanation at any time during the interpretation session. And don’t forget interpreters are trained to interpret¬†everything,¬†so if you wish to avoid having your comments to colleagues interpreted for the patient, make sure they’re made out of earshot.

Recognize your interpreter is a cultural broker. Encourage the interpreter to inquire, explain and alert you to culturally-sensitive topics. Respect their knowledge of cultural matters and consider their suggestions for more appropriate alternatives.

To ensure the patient clearly understands the treatment recommendations, the interpreter should ask the patient to repeat the information in his or her own words. As the healthcare provider, it is important to make sure the interpreter does not miss this crucial step in the medical interpretation process. If there is confusion on the patient’s end, the healthcare provider must clarify the message, through the interpreter, until it is understood.

This is a vital step to ensuring high quality patient care for non-English speakers. At this stage of the interpretation, you should also ask the patient if he or she has any further questions or needs any additional clarification.

Finally, be patient. To effectively communicate across language and cultural barriers takes time. The wellbeing of your LEP patient is worth it.

Armando Ezquerra Hasbun is the Director of Quality Assurance for Language Services Associates, a federally-certified court interpreter, speaker, certified trainer for the nationally-recognized “Bridging the Gap” medical interpreter training program, and an adjunct professor of interpretation at La Salle University, Philadelphia.

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