The number of individuals who speak English with limited proficiency (LEP) or who don't speak the language at all is growing in the United States as the population becomes more diverse. Language differenced can create barriers between practitioners and patients and affect the quality of patient care.
In the case of Mrs. Rodriguez, you will learn how professional interpreters facilitate important clinical communication, enhancing the patient-practitioner relationship and the quality of care. You will also learn the skills you need to work effectively with trained interpreters, and you will consider some issues that may arise.
Mrs. Rodriguez is a 66 year old woman who is failing to thrive after a second chemotherapy treatment for metastatic breast cancer. A CT scan shows that the tumor has grown. At this point, the options that her physician can offer Mrs. Rodriguez are to try a type of experimental chemotherapy, which is often accompanied by significant side effects, or to transition into hospice and comfort care.
Dr. Kim is responsible for Mrs. Rodriguez' follow-up care. Today, he needs to share the results of the most recent CT scan with her and discuss her options for care. He doesn't have much time to explain everything to her, as he has a large number of patients waiting to see him. Dr. Kim speaks a limited amount of Spanish.
As Dr. Kim enters the room, Mrs. Rodriguez looks up with a shy smile. The only family present at the moment is her 17 year old granddaughter. Born in Mexico, Mrs. Rodriguez does not speak English, and Dr. Kim needs to find a way to communicate with her. If you were the doctor, what would you do?
The consequences of misunderstanding can be serious and important in delicate discussions.
To facilitate such discussion, it is worth the time and effort to wait for a trained professional interpreter.
Dr. Kim decides to return when a trained interpreter is available. On his return he finds the interpreter, Cristina, whom he doesn't know, waiting for him outside the door. Before going in, Dr. Kim wants to establish a professional relationship with her and clarify his expectation.
Watch the video to observe Dr. Kim conducting a pre-session.
If you were Dr. Kim, which of the following would you choose as the most appropriate way to begin the discussion?
Now watch how Dr. Allen interacts with Mrs. Rodriguez.
Timing and level of speech are critical factors when working with an interpreter. Let's consider timing first.
As Dr. Kim starts the discussion, he knows he'll have to pause to let Cristina interpret. How often should he pause when working an interpreter?
Now that Dr. Kim has explained the current situation to Mrs. Rodriguez, he needs to help her decide how to move forward. Think about what style of speech would be the easiest to interpret accurately. If you were Dr. Kim, what level of speech would you use?
A medium register of speech - respectful and polite, neither highly formal nor extremely informal - is easiest to interpret accurately.
As the conversation continues, Dr. Kim begins to feel that the patient's responses don't match his questions. Watch what happens.
Dr. Kim begins to wonder if the interpreter is accurately interpreting what he is saying. What would you do in his place?
Watch how Dr. Kim confirms accuracy with Christina.
Watch the video to see what happens next.
As the discussion with Mrs. Rodriguez continues, Dr. Kim realizes that this conversation is taking a long time and that he is now late for his next clinic. He had planned to check with Mrs. Rodriguez's social worker after this meeting, but now he doesn't have time.
He considers asking Cristina to brief the social worker about the conversation. Cristina is a staff interpreter and will probably be interpreting for Mrs. Rodriguez and the social worker anyway.
Dr. Kim decides that he should not ask Cristina to brief the social worker.
The interpreter's role is to facilitate understanding in communication between you and the patient. However, interpreters are often asked to perform tasks that are outside interpreter's training, violate their professional boundaries, or interfere with the logistics of their work.
Any task that falls outside helping healthcare staff, patients, and their families understand one another across linguistic and cultural barriers is outside the scope of interpreter's work. The only exceptions are actions taken when a patient's health or dignity is at risk.
Keep requests within the interpreter's role of facilitating communication.
Mrs. Rodriguez's family accompanied her to her next appointment, and Mrs. Rodriguez made it clear that she wanted her children to make the decision about her healthcare.
The interpreter, the doctor, and the family met in a conference room, where Dr. Kim explained Mrs. Rodriguez' diagnosis, her treatment history, and the options for care. There followed a heartfelt and tearful discussion in a bewildering combination of Spanish and English, during which the interpreter provided a low-voice simultaneous interpretation of the Spanish discussion.
No decision was reached that day. In the end, the family opted to try the experimental chemotherapy. Unfortunately, the therapy was only minimally effective, and Mrs. Rodriguez died several months later in the hospital with her extended family around her.
You can use the following skills to improve your future interactions with interpreters and patients with limited English proficiency.
Use a skilled interpreter whenever possible.
A trained interpreter is a skilled professional. When understanding in communication is critical, and when you and the patient speak different languages, the interpreter is key to providing quality care.
Conduct pre-sessions.
Do a pre-session with the interpreter and let the interpreter do a pre-session with the patient.
Speak directly to the patient.
After the initial pre-session, address the patient directly, not the interpreter.
Pause after complete thoughts.
Pause after a full thought to let the interpreter interpret. If you see that the interpreter can handle longer segments of speech, you can pause less often.
Use plain English vocabulary.
Try to avoid very formal (high register) speech, slang, idioms, and where possible, highly technical terminology.
Let the patient know when you need to speak with the interpreter.
If you have to speak with the interpreter directly, let the patient know what you are going to say. Expect the same form the interpreter.
Consider the interpreter's cultural insights.
Take into account any cultural insights that the interpreter may offer. Remember to check those insights with the patient to ensure that they apply, as people who share a cultural background can vary greatly as individuals.
Limit requests to the interpreter's role of facilitating communication.
The interpreter's role is to facilitate understanding in communication between you and the patient. Any task that falls outside helping healthcare staff, patients, and their families understand one another across linguistic and cultural barriers is outside the scope of an interpreter's work. The only exceptions are actions taken when a patient's health or dignity is as risk.
Working through an interpreter may seem at first like a nuisance and an intrusion. However, as you practice the eight skills for working with an interpreter, you will recognize the benefits of having a trained interpreter present when you speak with patients who have limited proficiency in English.
Roat, C., Gheisar, B. Putsch, R., & SenGupta, I. Bridging the gap interpreter handbook (rev. ed.). Seattle WA: Cross Cultural Health Care Program, 1999.
This work was supported in part by grants from the Cambia Health Foundation and the National Institute of Nursing Research (NINR) at the National Institutes of Health (NIH). The content is solely the responsibility of the authors and does not necessarily represent the official views of the Cambia Health Foundation or the National Institute of Nursing Research.
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© 2015 University of Washington | School of Nursing | TIER Learning Technologies | Palliative Care Training Center
The basic purpose on an interpreter in healthcare is to facilitate understanding in communication between people speaking different languages. To fulfill this purpose, interpreters may take on a variety of roles, including:
Conduit: The default role of an interpreter is to convert the meaning of a message spoken in one language into the same meaning in another language, with no additions, deletions, or changes. It is not the words that are being interpreted, but the meaning.
Clarifier: At times, interpreters encounter barriers to understanding that require a change in role. If the register (level of formality) of the speech is very high, if there is no linguistic equivalent to what is said, if the interpreter didn't understand, or if the interpreter feels the patient does not understand, the interpreter may shift temporarily into the role of clarifier. In this role, the interpreter may lower the register of the speech, build word pictures, ask for clarification, or ask for permission to check the patient's understanding. When the specific communication barrier is passed, the interpreter returns to being a conduit.
Cultural Broker: When the barrier to understanding is cultural, rather than linguistic, the interpreter may become a culture broker, offering a brief and general insight into particular cultural beliefs and practices, so the provider can ask the patient about this specific case. The interpreter then returns to being a conduit as quickly as possible.
Advocate: Finally, in the rare case that the patient's health or dignity is being put at risk, the interpreter may act as an advocate. This is a delicate role that interpreters take on only under extreme circumstances and when other healthcare staff seem unaware of or unconcerned about a critical situation.
The Cross Cultural Health Care Program (1999). Bridging the Gap.
Collected by Cynthia E. Roat, MPH
Interpreters on the National Council on Interpreting in Health Care listserv reported in August 2008 that healthcare providers had asked them to do the following tasks. All of them are outside the scope of an interpreter's work, which is to facilitate understanding between people speaking different languages.