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Working well with interpreters is key
The arrival of immigrants from around the world has brought a rich blend of cultures to American life. But that same blend of language and dialect can become a genuine obstacle to a key component of effective home health: communication between health care providers and the patients they serve.
In the 1990 U.S. census, nearly 32 million U.S. residents reported that they spoke a language other than English in the home; 6.6 million of them said they spoke English "not well" or "not at all." Many of this group are elderly residents — prime candidates for home health — who immigrated to the United States late in their lives and never learned English.
Adding to the mix are new waves of immigration, including Bosnians who have settled across the country in the past decade, and Albanians now en route from Kosovo. Each new group of immigrants presents a linguistic challenge to health care providers, one they’re required by federal law to make an effort to meet.
Know your rights
According to Julia Puebla Fortier, director of resources for Cross Cultural Health Care in Silver Spring, MD, provision of multilingual health care services is required by Title VI of the Civil Rights Act of 1964.
"What the civil rights language says is you can’t discriminate on basis of age, national origin, etc.," Fortier says. "[Providers] have a pretty clear-cut federal obligation, if their services are paid for with Medicaid or Medicare, to provide an interpreter."
A document created by the Office of Civil Rights on the subject spells out requirements regarding interpreters for limited-English-speaking patients. "In a nutshell, what they say is interpreters or bilingual staff must be provided to a patient, in the contest of these federal funds, free of charge, and [patients] are entitled to know that they can have those interpreters free of charge," Fortier explains.
In the home care setting, that requirement is often met by bilingual home health workers, particularly in communities that have long had speakers of a particular language. Most in the medical interpretation field agree that this option is ideal. But having multilingual speakers on staff doesn’t ensure that every patient has access to one as needed.
Another common fix, using relatives or neighbors to translate questions and information for patients, is fraught with medical and legal risks. Using an interpreter who does not understand medical terms can lead to misdiagnosis and improper treatment. Someone who isn’t schooled in ethics can breach confidentiality. When abuse is an issue, those at hand may not be the best interpreters.
"There are a lot of family issues," says Karin Ruschke, MA, director of Health Care Interpre t -ing Services, a nonprofit interpreting service in Chicago. "You have the maturity level of the person translating. They usually screen information. They won’t tell everything, particularly if they’re talking about bad news."
Ruschke’s agency, which has been in operation since 1996, contracts with local providers or makes interpreters available on demand for hospitals, home health, and other providers.
Her master’s degree is in translation. Her staff, many of whom were medical professionals in their home countries, are now are tested for English proficiency and knowledge of medical terminology and are trained in interpretive skills, including ethics.
Other such agencies are available across the country and may be accessed through community-based organizations such as a local service league. Fees for the service depend on the size of the agency and the volume of use.
Find a go-between
Another popular choice among health providers is Language Line Services (formerly AT&T Lang uage Line), which provides phone hookups to a medically trained interpreter who takes turns speaking with the provider and the patient.
The Visiting Nurse Association of Boston has several employees fluent in Spanish, Haitian Creole, and Portuguese, which are among the city’s most common non-English languages. But the agency uses Language Line as a backup when its multilingual staff is busy or when a patient presents a less common language.
Marie Keevern, RN, clinical educator for the VNA of Boston, says her agency has been helped several times by Language Line interpreters — and not just with turns of phrase. Keevern says she was visiting a young woman from Qatar who had breast cancer. The woman and her family spoke Arabic. When she started to ask a question about the woman’s body, the interpreter stopped her.
"She said, Wait a minute. She’s never going to be able to answer that question if a family member is there.’ There was a body image issue that I wouldn’t have thought of. She gave me suggestions how to get at the issue in a different way. I was eternally grateful to this woman."
Guidelines for working with translators
Whether the interpreter is on the telephone or standing in the room, nurses and aides can take steps to help make the process smoother and as close as possible to a visit with an English-speaking patient.
"One of the best compliments you can give a translator is that you forgot the translator was there," says Sana Jabara, MA, national sales manager for Language Line Services in Mont erey, CA. "The interpreter should attempt to be as transparent as possible." Jabara’s master’s degree is in translation and interpretation.
Communication is key. Health workers should try to speak with the interpreter before the visit begins, both to give and receive as much information as possible about the patient, his or her ethnic background, and any health or cultural issues that may come up.
"Ask, Is there anything here that culturally I should know?’" Ruschke advises. "For example, if providers are offered food and they turn down the food, or if taking off their shoes is part of this culture and they don’t do it, there’s this immediate barrier, just based on cultural issues. And you haven’t even gotten to the medical part yet."
Gender issues also can play a role. For example, a female patient from a modest culture may have problems discussing sensitive medical problems through a male interpreter.
She suggests the provider and the interpreter agree on a translating style before the visit starts. Translation is often consecutive, meaning the interpreter moves back and forth between the provider and patient for each question and answer. But for a long teaching session, it might be better to attempt a simultaneous translation, in which the interpreter translates the provider’s comments as the provider speaks.
Ruschke points out that the latter style can be confusing for a patient, who must block out the nurse’s words while concentrating on the interpreter.
For telephone translations, Jabara suggests the nurse or aide explain to the interpreter how the session will be conducted (via speakerphone or by passing the receiver back and forth) and who is in the room. It also is helpful to know as much as possible about the patient’s ethnicity because very different cultures often share the same language.
Are there any factors that may make translation difficult? Is the person hard of hearing? Is the patient a young child who may have trouble understanding what’s going on? If an interpreter of a specific gender is preferred, that can be arranged through the service at the time the call is placed.
It’s important that health care providers understand the role of the interpreter who is trying to make the exchange as close as possible to a discussion between a nurse and an English-speaking patient. "One of the ways a provider can facilitate that is by speaking directly to the patient instead of to the interpreter," Ruschke says.
She also suggests the provider speak directly to the patient: "I’m going to explain to you how to do this," rather than asking the interpreter, "Please tell the patient how to do this."
The interpreter is not supposed to give opinions or offer diagnoses but can give insight into cultural differences that might be relevant. Ruschke says interpreters should not comment on whether they think patients are being truthful or will be compliant. "Those are personal questions that an interpreter can’t answer and can’t know," she says.
When a patient’s answers are incoherent or disjointed, interpreters typically repeat them word for word, even if they don’t make sense.
If a nurse knows the patient suffers from dementia or some other disorder, Jabara says, the interpreter should be told upfront, if possible. "If you are able to provide me with that message, I’m not assuming that I misheard [the patient]. In that case, I, as the interpreter, will relay exactly what the person is telling you so you as the medical expert can make the determination or the assessment of their well-being. It would be no different than you dealing with an English speaker."
Speak slowly and clearly, especially on the telephone, Jabara says. Also, avoid jargon and acronyms, which can provide difficulty for even the most experienced medical interpreters. Encourage questions and frequently ask patients to confirm that they understand the instructions.
Ruschke says patients in some cultures aren’t used to taking an active role in their own health care and are not accustomed to asking questions of a provider.
"They will often not ask questions until the provider has left, and then if the interpreter is still there, they’ll ask the interpreter, and the interpreter is obviously not allowed to answer those questions," she says.
She advises providers to frequently ask patients and family members, "Do you understand?" and even ask them to repeat instructions back to make sure.
"Sometimes they’ll just say yes out of politeness, even if they didn’t understand, because they don’t want to take up your time," Ruschke says. "Compliance is a big issue with a limited-English-speaking population."
This translation and extra care can take more time, which should be built into the visit.
Ruschke says she’s seeing problems throughout the health care industry, as staff struggle to cope with ever-growing workloads.
"What that leads to is a decrease in communication, with maybe not enough time to ensure under standing," she says. "But that’s not so much an interpreter issue as a provider issue. The provider really needs to ensure that patients are receiving best quality care they can get."
• Julia Puebla Fortier, Director of Resources for Cross Cultural Health Care, 8915 Sudbury Road, Silver Spring, MD 20901. Phone: (301) 588-6051. E-mail: firstname.lastname@example.org
• Karin Ruschke, Director, Health Care Interpreting Services/Chicago Health Outreach, 1015 W. Lawrence Ave., Chicago, IL 60640. Phone: (773) 506-2876. E-mail: email@example.com
• Sana Jabara, National Sales Manager, Language Line Services, 1 Lower Ragsdale Drive, Building 2, Monterey, CA 93940. Phone: (800) 648-0156.