When a qualified interpreter is used for non-english–speaking patients, the interpreter will:

It is helpful to learn a few words of the patent’s language, such as good morning and thank you. Taking the time to learn a few polite expressions shows an interest in the patient’s language. When you speak to the patient or an interpreter, use standard everyday English. Avoid slang expressions that may not be understood or may be misinterpreted by the patient or the person interpreting. Use simple words and phrases that are to the point and easily translated. However, using simple words does not mean the same thing as using simplistic words. Avoid talking to the patient or the interpreter as if they were children. Complete an entire sentence and then allow time for the interpreter to translate. When you stop in mid-sentence, the interpreter may not be able to understand the context of the entire sentence and may provide a confusing or inaccurate translation. Avoid giving long explanations. When the interpreter needs to interpret long speeches, he or she may try to make a synopsis of what you’re saying or forget part of the full thought you wish to communicate.

The cultural implications of topics as death, sexuality, childbirth, and women’s health are frequently poorly understood by health care professionals, and such topics should be probed with care and respect.

Be careful about making jokes or using humor to convey an English thought into another language. Remember that what is humorous in one language or culture may not be funny in another. What you may consider funny may, in fact, by considered offensive when it is translated. Know the language skills of the interpreter so that you have confidence that both you and the patient are having your ideas translated accurately. While the interpreter is translating what you have said to the patient, position yourself so that you are looking at the interpreter. Keep in mind that the patient is able to read your nonverbal messages. Look at the interpreter, smile occasionally or nod your head in agreement. If you look through the patient’s chart or gaze out the window while the interpretation is proceeding, you may send signals to the patient that you are not interested in the interaction. Table 17 shows methods of interpretation:

Table 17

Getting byrefers to using facial expressions and gestures, or using a few key words or phrases in the target language. For example, a nurse who „gets by“ in Spanish may be able to communicate about a patient’s leg pain by understanding the words pierna for leg and dolor for pain. In addition to using a few words in the target language, the nurse may obtain information about the patient’s pain by pointing to an area of the body, making grimaces as if in pain. „Getting by“ has both advantages and disadvantages. This method allows the nurse to communicate with the patient immediately without having to wait for an interpreter. „Getting by“ is effective when only basic information needs to be exchanged. It is often used in emergencies or when no one can be found who speaks the patient’s native language. However, the amount and complexity of information that can be obtained is limited, and there is a danger of miscommunication. For example, if the patient is complaining of chest pain, knowing just a few words of the target language will not allow you to assess important aspects about the quality and timing of the pain that may be vital in making a correct diagnosis. Nurses also may use the „getting by“ method because they feel that other methods are inconvenient. Sometimes we may also overestimate our basic skills in the target language.

An ad hoc interpreter is anyone available who speaks both languages, such as the patient’s friends or roommates. Using ad hoc interpreters has distinct advantages and disadvantages. In addition to being readily available, ad hoc interpreters often share the patient’s cultural background and can serve as sources of cultural information between the patient and the health care team. Disadvantages of using ad hoc interpreters include compromising the patient’s right to privacy and relying on someone without training as an interpreter. Due to lack of training or experience, ad hoc interpreters may leave out important words, add words, or substitute terms that make communication inaccurate.8 An example of this involves a young non-English speaking patient who comes to the emergency room with a long and detailed account of an acute episode of flank pain, nausea, and vomiting. The friend with her is used as an ad hoc interpreter. The interpreter tells the health care team that the patient has had back pain, but adds that she complains about back pain frequently. The interpreter also says that the patient has been vomiting, but states that in her opinion, it may be the flu because the patient’s husband was vomiting from what appeared to be the flu a few days ago. Thus, through omissions, additions, and opinions, an acute episode of kidney stones could be interpreted as a condition of less importance.

Volunteer interpreters can include the patient’s family and health agency employees who are bilingual. Health care professionals and administrators often think that using family and friends as interpreters is more cost-effective than using other methods of translation. However, strong anecdotal evidence suggests patient care and level of satisfaction are negatively affected by this method. Family and friends are not bound by any code of conduct. They may interpret, editorialize, or deliberately withhold information that they feel is embarrassing or that may upset the patient or health care provider. Family members are probably the least desirable source of translators because they may filter what the health care provider is trying to tell the patient. They may also „edit“ what the patient is trying to tell the health care provider. Using family members as translators also puts undue stress on both the patient and family member.10 Because of the high possibility of misinterpretation, don’t use a minor child as an ad hoc interpreter except in an emergency.

Volunteer interpreters, usually drawn from a health care agency’s own workforce, can offer several advantages. The cost to use employee volunteers is low, and because the volunteer works in a health care setting, he or she is usually familiar with health-related terminology and procedures. Using volunteer interpreters instead of family or friends lets patients maintain their privacy and control the nature and amount of information shared with family members and friends. Using volunteer interpreters also has some disadvantages. Not all facilities provide training, and the educational, health care, and language backgrounds of bilingual staff who serve as volunteer interpreters vary widely. As a result, they may inadvertently commit errors or violate patient confidentiality. Another disadvantage is that the volunteer interpreter’s own work obligations may limit his or her availability.

Professional interpreters have excellent bilingual language skills and are bound by a code of conduct. Such individuals are usually contracted for directly or work with an interpreter agency. However, professional interpretation services are expensive, often costing between $50 and $100 an hour. They may also be unavailable on weekends or holidays or not be able to come in on short notice in an emergency. Some very large hospitals are able to employ professional interpreters or cultural mediators. A cultural mediator not only provides interpretive services, but also interprets cultural and social circumstances that may affect the patient’s care.

Using a telephone language line, an off-site interpreter communicates through a speakerphone or hand held phone. AT& T Language Line Services and Pacific Interpreters Inc. can provide access to interpreters in more than 140 languages, 24 hours a day, seven days a week. Language line interpreters receive training in medical interpreting and are tested for linguistic competency and knowledge of medical terminology. They also sign a code of ethics statement that protects the patient’s confidentiality. Agencies contracting with telephone language lines may pay a monthly fee plus a per-minute rate or just a per-minute rate. Such services are particularly useful in scarcely populated areas where there are few other options for interpretation other than the patient’s immediate family or close friends. A disadvantage of language line interpretation is that the interpreter must depend on oral language alone. The interpreters cannot see the patient’s body language or facial expressions and must depend solely on the content and tone of the conversation. In addition, this type of interpretation is difficult to do when teaching patients how to use equipment or perform a skill.

Written materials and educational programs

There are several issues to consider when translating written materials from English into other languages. Although the natural tendency is to translate materials directly from English into the target language, direct translation doesn’t always consider cultural influences and literacy limitations. The words used in an English version may not be appropriate for people of another culture. Keep in mind that many patients don’t read well in either English or their native language. It is helpful to ask an interpreter to talk with a sample of the intended population to determine if the instruction needs to be in that language or whether a simplified version in English, which includes lots of illustrations, could meet their needs just as well. If you are designing written materials, have several members from the culture work with you in the overall design and approach. Often, graphics, diet lists, and procedures do not translate with the same meaning in other languages. If you don’t have access to other members of the cultural group, look for community resources. A number of community services are becoming available to meet specific translation needs. For example, some churches and community agencies offer translation services.

In addition to ensuring the accuracy of language translation, it’s also important to design education programs that have cultural appeal to the target population. For example, the Los Angeles Cancer Education Project conducted a learner verification of a number of national and local publications from potential users from the Hispanic community to evaluate several of its upcoming national and local publications. The group found the materials unsuitable because they dealt with facts rather than with people and their concerns. Group members felt keenly enough to create a new publication based on one extended family’s experiences with cancer – Hablaremos Sobre Cancer de la Familia (Let’s Talk About Cancer Among the Family). This became the centerpiece for a comprehensive community effort to detect early cancer-family participation for cancer detection is more culturally appropriate than individual participation.

Ways to communicate when you don’t speak the patient’s language:

• Use pictures, synthetic body models, and demonstrations with actual equipment to get your message across.
• Use simulations to show what you are trying to communicate.
• Use audiotapes made in the language(s) of your patient population to present routine information such as admission procedures, room and unit orientation, or preoperative procedures.

It’s important that the patient has understood what you are communicating. After giving information verbally instead, test the patient’s comprehension by asking him or her to show, draw, or communicate with gestures what he or she is supposed to do. Ask the patient to repeat the feedback if there is hesitancy or body language shows uncertainty. Because some patients come from cultures that are very different from ours, it is important not to make assumptions that the patient knows what to do. Some of the most ordinary requests that we make in the health care system are not within the experiences of other cultures. For example, when a non-English patient who failed to fill a prescription was asked why he didn’t take it to be filled, he replied that the prescription was still in his car because he didn’t know what to do with it. He had never had a prescription before and had never been to a pharmacy.

Assess who should be included in patient teaching. The assumption in traditional American culture is that each person manages his or her own health care. However, in other cultures the critical decision making is influenced by others, e.g., the godmother, priest, or an outside group such as a council of elders; in those instances, the target audience broadens to include not only the patient but also the significant decision makers. Patients of other cultures also need to be taught to expect health professionals to ask questions about health history. Sometimes patients from other cultures may feel that if the nurse and physician have to ask so many questions, they aren’t very competent.

A model of care for cultural competence