Research Commentary [17] April 2018

Apr 1, 2018

This review focuses on research in the health sector on the use of interpreters.

Language assistance services (LAS), such as interpreting and translation services are critical to bridge the communication gap and ensure people with limited English language proficiency can access public services and information to which they are entitled. Central Government agencies are working together under the leadership of the Ministry of Business, Innovation and Employment (MBIE) and the Department of Internal Affairs (DIA) on a multi-year work programme to:

  • improve the quality, consistency and coordination of language assistance services provided across the New Zealand public sector
  • provide equitable access to public services for those with limited English language proficiency
  • future-proof New Zealand’s public services to serve an increasingly culturally and linguistically diverse population.

The project aims to improve the quality, consistency and coordination of language assistance services provision across government. Information about the LAS project is available on this website.

Five articles are reviewed including interpreters in: general practice, mental health settings, emergency departments and in-patient wards; diabetes consultations; and in breaking down language barriers between nurses and patients. 

A lack of interpreter use is one of the primary barriers to accessing health and mental health services in New Zealand. The New Zealand health workforce has training in how to work with interpreters available as part of the suite of CALD cultural competency courses available online and face to face (see CALD 4: Working with Interpreters on www.ecald.com.

Commentary provided by Dr Annette Mortensen, eCALD® Services Project Manager: Research and Development 

The following articles are reviewed:

Article 1: How to use interpreters in general practice: the development of a New Zealand toolkit.

This study focuses on the use of interpreters in general practice. Depending on where practices are sited, the cost and availability of interpreters is a significant factor in whether or not trained interpreters will be used.  The article highlights the discrepancies in access to interpreters; and protocols around New Zealand.  In the Auckland region trained interpreters are free and available to general practices; outside of Auckland they are not. 

The authors have  developed a toolkit consisting of flowcharts, scenarios and information boxes to guide New Zealand practices through the structure, processes and outcomes of their practice to improve communication with Limited English Proficiency (LEP) and Non-English speaking patients. This paper describes this toolkit and the links to the evidence, and argues that every consultation with LEP patients requires clinical judgement as to the type of interpreting needed. Helpfully, the article addresses cost, where to source interpreters, staff training and patient information systems. Some of the actions are simple, such as adding fields to patient records. 

While this is a helpful process, its time consuming. In order to support every PHO to adopt best practice standards for the use of trained interpreters; all New Zealand health services need access to a free accredited phone (and face to face when required) interpreting services to  improve  patient and family engagement and follow up and critically patient safety. 

Authors: Gray, B. Hilder, J & Stubbs, M.

Citation: Gray, B. Hilder, J & Stubbs, M. (2012). How to use interpreters in general practice: the development of a New Zealand toolkit. Journal of Primary Health Care, 4 (7), 52-61.

Publication

Article 2: Rates and Predictors of Professional Interpreting Provision for Patients with Limited English Proficiency in the Emergency Department and Inpatient Ward.

The provision of professional interpreting services in the hospital setting decreases communication errors of clinical significance and improves clinical outcomes. This Australian study undertook a retrospective audit at an adult emergency department (ED) in a hospital in Brisbane. This is one of the few studies of published rates of interpreting provision in hospital settings in Australia.  The findings of the study have important implications for the provision of interpreting services in New Zealand hospitals for a number of reasons. The results show that the majority of non-English patients are not provided with professional interpreters in Australian hospitals despite hospital policies and the availability of interpreting services on-site and by phone. Of major concern are the lower rates of professional interpreting provision found in ED.  Consistent with the international literature, less than 1 in 5 non-English speaking patients were provided with professional interpreters in ED.   

Consistent with the literature, the findings of the study suggest that increasing professional interpreter engagement will require interventions at both the level of individual practitioners and the unique environments of the ED and wards. Establishing cultural norms, structural changes, and training for clinicians in working effectively with interpreters is needed. Cultural change means a shift away from “getting by” with the use of ad hoc interpreters such as family members or bilingual staff. Structural changes require environments that are conducive and practical for interpreter engagement. These include wireless speakerphone availability in both ED and wards. Training clinical staff in understanding the interpreter role, as well as the evidence-based benefits of improving engagement with patients, is critical for improved patient outcomes. 

Authors: Ryan, J., Abbato, S., Greer, R., Vayne-Bossert, P. & Good, P.

Citation: Ryan, J., Abbato, S., Greer, R., Vayne-Bossert, P. & Good, P. (2017). Rates and Predictors of Professional Interpreting Provision for Patients with Limited English Proficiency in the Emergency Department and Inpatient Ward. The Journal of Health Care Organization, Provision, and Financing, 54, 1–6. DOI: 10.1177/0046958017739981

Publication

Article 3: The interpreted diabetes consultation.

This article explores the relationship between the healthcare provider, patient and interpreter by examining research conducted by the authors and other groups. 

The authors found that when interpreters filter out talk with the patient, it prevents patients’ issues being explored, which contrasts with English speakers’ consultations. Some studies found that some providers delegate general advice-giving to the interpreter.  When this occurs, practitioners will be unaware of inaccurate translations. Interpreters are not healthcare professionals, despite in this study often having basic training in diabetes management. 

One finding of the study is that when interpreters are given advisory “non-conduit” roles, it can lead to problems, as the practitioner may have no idea what is going on and what is being kept from them. As well, the research shows that providers may reduce the usefulness of the interpreted consultation by using oversimplified terminology when compared with English language consultations.  

Authors: Rivas, C., Kelly, M.,Seale & C.

Citation: Rivas, C., Kelly, M., Seale & C. (2014). The interpreted diabetes consultation. Journal of Diabetes Nursing, 18,  422–4. 

Publication

Article 4: Evidence-based approaches to breaking down language barriers.

This American studies shows much evidence for the impact of language barriers on patient outcomes and healthcare delivery. Patients with LEP have longer lengths of stay than English-speaking patients, even if they have a higher socioeconomic status. They also have a higher risk for 30-day readmission, by as much as 25%. Other outcomes sensitive to nursing practice include: an increased risk of central line- associated bloodstream infections; falls; surgical site infections; pressure injuries; and not understanding medication management (Betancourt et al., 2012). 

The study also shows that using interpreter services or bilingual healthcare professionals contributes to higher patient satisfaction ratings. 

In line with health care organisation’s policies and protocols the author urges nurses to use the health interpreters provided by the organisation. There is no need to repeat here warnings about the dangers of using family members. The author’s as well caution against the use of non-validated translation apps on smart phones. While there are many apps available, their accuracy can be poor. The quality of translation they provide is rarely evaluated systematically or using rigorous approaches. Most computer programs don’t yet have the sophistication needed to translate the language of healthcare. Critically interpreters are needed at admission, during patient teaching, and at discharge. Using interpreters at these times decreases the risks of medical errors and hospital readmissions.

Medication instructions should be in the preferred language of the patient. An oral review of medications using teach-back techniques will help promote adherence, reduce readmissions related to failure, to take new medications or understand changes to the old regimen, and help with care coordination with primary and community care providers.

Reference:  Betancourt, J.R., Renfrew, M.R., Green, A.R., Lopez, L. & Wasserman, M.  (2012). Improving patient safety systems for patients with limited English proficiency: a guide for hospitals. Rockville, MD: Agency for Healthcare Research and Quality, AHRQ Publication No. 12-0041.  https://www.ahrq.gov/sites/default/files/publications/files/lepguide.pdf.

Author: Squires, A.

Citation: Squires, A. (2017). Evidence-based approaches to breaking down language barriers. Nursing,47 (9), 34-40.  

Publication  

Article 5: The Interpreter Is Not an Invisible Being: A Thematic Analysis ofthe Impact of Interpreters in Mental Health Service Provision with Refugee Clients.

In this Australian study, particular attention is paid to the impact of interpreters on the therapeutic alliance and on educating mental health professionals concerning how best to accommodate interpreters by acknowledging their inherent value, treating them as an equal member of the therapeutic triad, and consulting them for specific cultural knowledge. Participants acknowledged the unique cultural insight that many interpreters offered as a factor that ultimately enhanced therapy and contributed to their cultural knowledge base. This information was seen as an important aspect in providing client specific information. 

The article confirms the benefits of using pre-and post-briefing sessions with interpreters in terms of better liaison between the mental health professional and the interpreter. In particular, case consultation prior to each session, whereby mental health workers can outline the specific therapy model and flag any potential issues of concern for the interpreter may be an important step in improving efficacy among interpreters working with refugee clients in mental health settings. Participants reported that at times interpreters could be vulnerable to experiencing distress during therapy sessions and emphasised the importance of monitoring the interpreter’s distress and protecting their safety as a critical obligation of mental health service providers. 

Australian mental health practitioners in the study reported that lack of access to training was an issue that prevented them from feeling competent when working with an interpreter when providing mental health support to clients with refugee backgrounds. In New Zealand, the Ministry of Health provides free on-line training in how to work with interpreters through eCALD® services for the  health workforce nationally (see CALD 4: Working with interpreters).

References:

Resera, E., Tribe, R. & Lane, P. (2015). Interpreting in mental health, roles and dynamics in practice.  International Journal of Culture and Mental Health, 8(2), 192-206. http://www.tandfonline.com/doi/abs/10.1080/17542863.2014.921207.

Authors: Gartley, T. & Due, C.

Citation: Gartley, T. & Due, C. (2017). The Interpreter Is Not an Invisible Being: A Thematic Analysis of the Impact of Interpreters in Mental Health Service Provision with Refugee Clients. Australian Psychologist, 52,31–40. 

Publication