You are admitting a 13-year-old girl, Viktoria, with a history of easy bleeding and bruising. A full blood count has been performed and shows pancytopenia with blasts cells seen on blood film. The parents have been waiting in ED for 7 hours and the nursing staff tell you they are very angry that she is being admitted as no one has explained why they have to stay. They have a 3-month-old baby whose mother is breastfeeding. The family are asylum seekers from Libya and mum speaks some English, but the dad speaks none.
When on rotation in haematology 2 years later, you meet the same family in the outpatient clinic for review. Unfortunately, Viktoria’s leukaemia has relapsed and the team looking after her have told them that a cure is not possible.
Our case highlights a language barrier between the patient and their health care professionals. This is a potentially challenging scenario. We will discuss how best to use an interpreter to improve communication in both directions.
To offset the risk of worsening health inequalities we must present information in a way that everyone understands. This includes those for whom English is not their main language.2 Interpreting services should be free at the point of delivery, and be of high quality, accessible, and responsive to the patient’s needs.
Research has demonstrated that the use of professional interpreters is associated with improved quality of health care for patients with limited English proficiency.3 Interpreters can only be effective, however, if the clinical team can use their skills appropriately. If healthcare staff are unable to work with interpreters patients may not receive the high standard of care we expect as they simply cannot understand the details of the consultation. This may lead to non-compliance with treatment or failure to attend for investigations or follow up.
Working with an Interpreter
The first step is to ensure the patients are aware of their right to an interpreter and to find out which language is needed. You can ask the patient (or person making the appointment) what is their preferred language. Ensure you have another method of finding this out though as they may not know how to refer to their native language in English. Language cards/posters or maps/flags to identify the country they are from can be used if they cannot understand the written form of their language. This information should be clearly documented in the notes. The patient, when possible, should be asked about their preferred gender, age, culture (including religion). They should give informed consent for interpreters to be present for consultations.6
Choosing an Interpreter
There are a number of different types of interpreters; professionally trained interpreters, bilingual staff, friends, family and health advocates. Professionally trained interpreters should be used whenever possible in a healthcare setting. Avoid using friends and family and never use children as interpreters. Professionally trained interpreters are neutral, independent and responsible for keeping all information confidential. They will only interpret what is said and will only intervene for clarification or repetition.6
Using family and friends to interpret is not recommended. Confidentiality is lost and the accuracy of interpretation cannot be guaranteed. Often these relatives may have little or no medical knowledge and could struggle with the terminology. They may not interpret everything that has been said or they may add in their own opinions or beliefs. The patient may not want to discuss sensitive information with a family member. When breaking bad news the family may want to protect the patient from the diagnosis or prognosis, and so a conflict of interests arises. If a patient wants their family member to interpret for them, even after they have been offered the option of a professionally trained interpreter, this must be documented in the clinical notes. In the case of child protection or vulnerable adult issues or if domestic abuse is suspected a friend or relative should never be used as an interpreter.6
Arranging an Interpreter
When booking an interpreter it is important to give as much information about the type of consultation so they can be adequately prepared. How long will you need them for? Who will they be talking to? Is it a routine review appointment for an asthmatic child or is it breaking the bad news that the child has a new diagnosis of leukaemia?
Planning Prior to Consultation
Once arrangements have been made you should consider the format of the consultation. Where is it going to take place? How are the seats This includes details such as seating arrangements, ensuring an appropriate location is available which will be free from interruptions, and also allowing sufficient time, acknowledging that the time taken will typically be double that of a regular appointment.7
Prior to the appointment, if possible, it is good practice to meet with the interpreter to explain again the purpose of the appointment and detail any important medical terminology that you plan to use. For example, in the case of a child with a suspected new diagnosis of leukaemia, you should explain what information the family have been given to date about the diagnosis, and if they will need a bone marrow aspiration you could briefly explain this procedure to the interpreter so they have the knowledge to explain to a parent to ensure consent obtained is fully informed.
During the consultation it is recommended that the healthcare professional introduces the interpreter to the patient and family and outlines their role as a ‘non-clinical member of the healthcare team, who is tasked with facilitating effective communication in the clinical consultation through accurate interpretation, is bound by confidentiality and maintains impartiality.’8
Everyone should be seated so that they can see each other and the clinician should speak directly to the patient. Information should be given in manageable amounts so the interpreter can remember what has been said and has time to interpret this effectively. If the patient or interpreter does not understand something it is the clinician’s responsibility to explain it in simpler terms.
Try not to talk directly to the interpreter, and if this becomes necessary for example to explain how a procedure will be performed then ask them to explain to the patient what you are talking about. As with any consultation always make sure the patient is given the opportunity to ask questions during and at the end of the consultation.
Following a consultation, it can be useful to de-brief with the interpreter to discuss any additional relevant information or any cultural references that may have affected communication. This can be useful for follow-up appointments as together you can plan any changes to the interaction that could be made for the patient’s benefit.
Some Dos and Don’ts
- Karliner LS, Jacobs EA, Chen AH, Mutha S. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res. 2007;42(2):727-754. doi:10.1111/j.1475-6773.2006.00629 h
- GMC: Duties of a Doctor
- NHS England. Accessible information. Specification v.1.1
- Health SCOTLAND. Now we’re talking, national resource centre for Ethnic Minority Health, Interpreting guidelines for staff of NHS Scotland.