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Milieu in Dental School and Practice |
Key words: interpreters, interpreting laws, limited English persons, communication, culturally competent care
Submitted for publication 02/22/07; accepted 09/20/07
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Abstract |
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Providing linguistically appropriate services for patients is a legal requirement, so health professions students, physicians, dentists, and other health care workers must be aware of this requirement and understand the laws behind it. Section 601 of Title VI of the Civil Rights Act of 1964 prohibits discrimination based on race, color, or national origin by any individual or institution that receives federal funding for its programs and activities. As an extension of existing Title VI legislation to enhance implementation of federally supported services for the public, Presidential Executive Order 13166 titled "Improving Access for Persons with Limited English Proficiency," 65 FR 50121, was issued in August 2000. This executive order directed all federal agencies that provide financial assistance to non-federal entities to publish guidance on how their recipients can provide meaningful access to limited English persons and thus comply with Title VI regulations forbidding funding recipients from "restrict[ing] an individual in any way in the enjoyment of any advantage or privilege enjoyed by others receiving any service, financial aid, or other benefit under the program" or from "utiliz[ing] criteria or methods of administration which have the effect of subjecting individuals to discrimination because of their race, color, or national origin, or have the effect of defeating or substantially impairing accomplishment of the objectives of the program as respects individuals of a particular race, color, or national origin."2 The legal tenets of this order have important implications for health care institutions.
The medical education literature and cultural competency literature have focused considerable attention on the use of professionally trained interpreters and linguistic competency in the medical setting.3–12 However, this author could not find any information about providing culturally appropriate linguistic/interpreting services in the dental setting in the United States, although a few reports have described strategies for providing cultural competency training to health professions students, including dental students.13–16 This investigator also identified a number of studies that address patient communication strategies and or methods of effective interpreting from the perspective of the interpreter.
One important study regarding dentist-patient communications and multilingualism was issued from the Australian Dental Association. In this study, Goldsmith et al.17 conducted a survey to understand the issues Australian dentists faced in dealing with limited English-speaking patients (LEP) and to identify ways to improve dentist-patient communication. Of the dentists who responded to the survey, most thought the best method of communication with LEP was using an informal interpreter (64 percent) and the next best method was using chair-side formal interpreters. However, this survey found that professional chair-side interpreters were rarely used and costs were identified as a barrier. Also, Australian dentists were concerned that professional interpreters lacked knowledge of specific dental terminology. Seventy-nine percent of respondents used forms of alternative communication such as diagrams, models, intraoral cameras, diagnostic imaging, and mirrors. Goldsmith et al. also identified the dental specialties of Endodontics and Periodontics as areas with the most difficulty communicating with patients with limited English skills because they required detailed explanations using dental terminology. Also, problems with informed consent were noted by 29 percent of the respondents. Based on the results of that study, the following recommendations were made to improve dental communication: 1) dentists should develop an awareness of situations in which language might be a potential barrier; 2) dentists should know how to access professional interpreting services; 3) alternative methods of communication should be provided with diagrams and drawings; 4) patients should receive written material in their own language; 5) dentists should take language courses to better communicate with their patient populations; 6) patients should be referred to dentists who speak the same language as the patient; and 7) additional time should be provided for patients who have limited English-speaking ability. Another recommendation from this study of Australian dentists was that dental institutions should provide both linguistic and cultural training for future oral health care providers.
There is a growing body of research demonstrating that health care interpreters improve the quality of clinical care and reduce health care disparities associated with language barriers. Findings based on a systematic review of the literature by Karliner et al.18 suggest that the use of trained professional health care interpreters can improve health care quality to the point that it approaches or equals that for practitioners and patients who speak the same language. For example, use of professionally trained interpreters is associated with higher-quality communication, more appropriate service utilization (e.g., appropriate use of preventive care), more positive clinical outcomes, and greater patient and provider satisfaction with care. However, Karliner et al. noted that these improvements were evident only for professionally trained health care interpreters. Use of ad hoc interpreters, including medical staff with limited ability to communicate or family members and friends who were not professionally trained, resulted in lower quality of care compared to that provided with professionally trained interpreters. Providing physicians with training on the use of professional interpreters was found to increase the level of satisfaction of both patients and physicians.
There is evidence that health care interpreters regularly face conflicts in defining their roles in supporting patient-provider communication. Standard codes of ethics for medical interpreters define the role as that of a "conduit" responsible for transmitting information in an objective, neutral manner. Research suggests that most interpreters stray from this limited role due to realities of the health care context and setting. Hsieh19 identified four sources of conflict: the patient’s cultural beliefs related to health care; providers’ and patients’ expectations about the interpreter’s role; situational dynamics, such as having multiple providers and/or family members communicating among themselves; and institutional constraints and policies that prevent interpreters from maintaining professional boundaries. Hsieh suggested that interpreters must develop strategies for managing such conflicts and reaching a compromise among professional requirements, situational demands, and personal comfort. Strategies identified included defining boundaries to determine when it is appropriate to take on an advocacy role versus a professional interpreter role, educating and informing patients and providers about the interpreter role, and using flexible communication strategies to meet provider expectations without violating patients’ expectations or cultural norms.
With increasing immigration in past decades, there is a greater need for cross-cultural research to identify and understand the health care needs of individuals from different cultures. A related need is to understand factors associated with the successful use of health care interpreters. This includes a need to better define interpreters’ roles and characteristics that improve the quality and fidelity of translation provided by interpreters. Wallin and Ahlström20 recommend that researchers who utilize interpreters implement standardized methods to track factors that may affect the quality and fidelity of interpretation, such as characteristics of the environment (e.g., seating arrangements), characteristics of the interpreter (e.g., ethnicity, gender), relationship of the interpreter to the research participant or patient, and style of interpretation (e.g., conduit role).
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Methodology |
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The primary method of data collection was a series of in-depth, face-to-face interviews with key informants using a semistructured, open-ended question interview guide. Probes were used as needed to encourage informants to expand on specific ideas and questions. The use of the semistructured open-ended question format provided some consistency in questioning the participants. Each interview lasted between sixty and ninety minutes. All interviews were audiotaped and later transcribed for data analysis.
Initial interviews were conducted in the offices of the interpreting agency, followed by additional interviews in the researcher’s office. Conducting the interviews first in the agency’s offices permitted the researcher to gain a broader perspective into how interpreting agencies work and what the environment is like, which provided context for assessing the comments of the interpreters who participated in this study.
A convenience sample of three key informants was purposefully selected to participate in this study. Key informants are "individuals who possess special knowledge, status, or communication skills, who are willing to share their knowledge and skills with the researcher, and who provide access to perspectives or observations denied the researcher through other means."22 The three informants were selected because of their years of interpreting experiences in the dental school and relationship with the investigator. In addition, two of the three speak the languages most often requested in the dental school, Spanish and Somalian. Two of the three informants have lectured in my course on communication skills. Two are female, and one is male. The interpreters were informed of the purposes of the study and the format of data collection before they provided their informed consent. Two of the three were also responsible for recruitment, training, and supervision of freelance interpreters, and one was also responsible for customer relations, handling all contracts and customer complaints related to placing interpreters in dental, medical, and other health care settings. The two other informants had worked as interpreters for four and seven years, respectively. Their basic responsibilities included providing interpreter services in medical and health care settings. Although the number of informants in this study may be considered small, the depth of their experiences and their current roles within their organization were viewed as sufficient to meet criteria for design of qualitative evaluation as described by Patton23 to provide reliable and rich information about all facets of interpreters’ roles in health care settings.
Interview transcripts were analyzed using an open coding approach with the goal of identifying and describing the phenomena found in the data. A second researcher reviewed the categories and related passages to verify their interpretation. Categories were combined as needed to identify overarching narrative themes.
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Results |
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Role of the Professional Interpreter
The informants described the major features of the role of professional interpreters in dental and health care settings, including key principles that guide their work, the range of services provided, and limitations to their role as interpreters.
Key Principles.
The informants referred to the use of "A National Code of Ethics for Interpreters in Health Care" as a guide for their work in health care settings.24 They indicated that the major principles guiding their work are based on this code. For example, fidelity to meaning was noted as a key principle guiding the interpreter role. As such, interpreters are bound by an obligation to provide a precise, word-for-word translation of every comment made by the patient and the provider during the health care appointment. Precise interpretation is required, even when comments are viewed as unrelated to dental health care services. For example:
"The interpreter interprets everything that is said, exactly as it is said, adds nothing, omits nothing, and changes nothing."
Another key principle is patient privacy. Informants noted that interpreters have an obligation similar to that of health care providers to uphold and protect patient privacy. For example:
"The interpreter should really let the patient know that they will protect their privacy and confidentiality and that the patient should feel free to say whatever they need to say or to answer questions however they need to because everything will be kept private."
Informants reported that the primary responsibility of an interpreter is to the health care provider, not the patient. In most instances, informants are paid by providers to ensure that providers meet their legal and ethical responsibility to provide their patients with the information necessary to obtain informed consent. For example:
"Like I said, you hear, ‘Patient, patient, patient, patient,’ but our responsibility in what we are doing, always hold the thought to, the provider’s ability to gain informed consent, to protect that person’s right to practice in the State of Ohio, and to take the legal liability for the interpreting process out of the facility. Those are the things that we are there to do."
Range of Services.
The primary service provided by interpreters in health care settings is translation of verbal communication between health care providers and patients. To a lesser extent, they also provide assistance with paperwork and legal documents related to the patients’ health care and insurance.
The informants reported that the interpreter’s role during a health care appointment is to facilitate direct communication between patient and provider. As such, interpreters try to make their presence in the office as unobtrusive as possible to encourage the provider and patient to speak to one another directly, rather than speaking to the interpreter. For example:
"Interpreters aren’t invisible translation tools, but it would be a really neat thing if we were and didn’t take up that extra space."
Due to their depth of experience with individuals from numerous cultural groups for which they translate, interpreters can also serve as an excellent resource regarding issues related to culture, religion, and gender. For example:
"In some cultures females usually interact with female individuals on a professional level and males usually with males; most often the interpreter would probably be aware."
Role Limitations.
Several limitations on the role of professional interpreters were noted. These limitations were viewed as critical to maintaining professional integrity and upholding ethical principles of the profession. First, the informants made it clear that interpreters are not to assume an advocacy role with patients. The informants indicated that assuming an advocacy role carries a number of potential risks to patient care, so it is not permitted in the ethics of their organization. For example:
"If someone tried to put you in a position to advocate, you need to make sure that you step outside of that and they understand what you are there to do. You need to maintain your professional integrity. If the health care provider leaves the room, so does the interpreter, because the boundaries blur very quickly."
"We are a for-profit company, not a social service agency."
A related limitation is the obligation to avoid any direct communication with patients. This includes avoiding being alone with patients when a health care provider is not present. For example:
"One major reason that as interpreters we try to avoid being alone [with the patient] is that sometimes a question of medical treatment or something about medical advice or something could come up no matter how benign it might seem."
Finally, informants noted that most interpreting services do not train their staffs to provide written interpretation, and most liability coverage for professional interpreting services only extends to interpretation of spoken language. Therefore, interpreters are not permitted to provide any instructions or notes in writing. In addition, they are not permitted to fill out paperwork for patients.
Challenges Encountered
The informants noted several important challenges that interpreters face in dental and other health care settings. Most problems are the result of patient and staff expectations that contradict professional and ethical responsibilities of health care providers and interpreters.
One of the most difficult issues noted is the pressure felt by interpreters to act as advocates, rather than adhere to role limitations of their profession. For example:
"Interpreters are often more knowledgeable about health care options and how health care systems work [than the patient is], so there is a temptation to provide advice and make requests on behalf of the patient. This is not the interpreters’ role."
"It is not your responsibility to save the world. If you want to advocate and better people as a whole, you need to keep that separate."
Occasionally, conflicts and misunderstandings occur due to cultural differences. For instance, for patients from many cultures, the norms and expectations related to health care services are actually in conflict with legal and ethical responsibilities of providers in U.S. health care systems. For example:
"Our legal restrictions and requirements, especially with medical information, are extremely foreign to many of our clients. We have very, very strong legal responsibilities to make sure that patients are informed; that they know exactly what is going on, can make informed choices along with their doctors and dentists. In most Third World countries, that type of information is synthesized and passed along based on cultural norms."
The informants reported that some patients asked to use their own interpreters. These individuals are typically not professional interpreters, but rather family members or friends. The health care facility must then decide whether these individuals are qualified to serve as interpreters. If they are not professionals, there is no way to ensure that they are capable of providing an accurate interpretation. For example:
"It can happen that a patient has their own interpreter. The only question that really comes up then is, if the patient hires this individual, is it an accurate interpretation? Even in that situation, health care facilities might still have their own interpreter that does interpreting, but it is the health care facility’s interpreter and they are interpreting for them."
"Because of the liability thing going on, that licensure or potential licensure is at risk. Are you willing to put that on somebody you don’t know anything about, who doesn’t have insurance to cover and has no credentials? There are some major liability issues there."
In rare instances, patients refuse to have an interpreter. In those instances, health care providers have to decide whether they can legally and ethically provide service without an interpreter. For example:
"When the patient absolutely refuses to have an interpreter present, the health care staff must examine the situation and determine if communication is happening at the level that they would like it to. They might feel that they are not able to gain informed consent from the individual because they don’t believe that true communication is occurring or that the individual understands the message they are trying to get across."
Finally, the informants noted that conflicts sometimes arise because health care staff do not understand differences related to culture or do not understand the interpreter’s role. Lack of awareness of cultural differences can be misinterpreted as insensitivity. Misunderstandings also occur when staff members do not realize that the role of an interpreter is to provide interpretation only when the health care staff and patient are speaking to one another. For example:
"We had a staff member not too long ago ask one of our Somalian interpreters, ‘Why do you have to wear that?’ Well, of course, the interpreter was offended. 99.9% of the time, it is truly nothing but ignorant curiosity, but then that whole language thing gets messed up and it’s a debacle. Staff needs to know how to handle that stuff because it is going to happen."
"Sometimes staff has instructed interpreters to stay with the patient in case they need anything. This puts the interpreter in a role of advocate. . . . You are not a substitute for the health care provider. If the patient needs something, he/she needs to talk to the health care provider, not the interpreter."
The informants noted particular problems related to the dental setting. For example:
"The two main impediments in facilitating communication between patients and dental students are physical in nature. The first is the physical manipulation of the oral cavity during the interpreted session. Either manual manipulation or the presence of implements or other materials in the mouth can make understanding the patient’s utterances challenging. In addition, if the patient is suffering from some sort of oral condition, that may also hinder the interpreter’s ability to understand their utterances. The second impediment is the noise level of the operatories. It can be difficult with the sound level of both the voices and the equipment."
"The only ‘complication’ that is generally present in dentistry is the fact that the oral cavity is almost always affected in some manner, in turn affecting the patient’s ability to communicate clearly. Also, there is very limited physical space in the clinics, and the noise level can complicate communication."
Recommendations to Improve Communication
The informants identified several strategies and approaches that could be used to improve communication between health care providers and their patients and to reduce misunderstandings and conflicts. Interpreters indicated that communication is facilitated when health care providers interact directly with their patients, rather than speaking to the interpreter. By interacting directly with patients, the health care provider can more easily develop a shared understanding with the patient and is more likely to notice body language suggesting that the patient does not understand what he or she is being told or needs additional information. For example:
"The provider can make sure that the patient understands. Different cultures may have different cues or clues, but it is maybe a universal blank stare or something like this where the provider will be able to tell that communication isn’t 100%."
Informants indicated that their work would be easier if health care staff were informed of the scope and limitations of the interpreter role in advance. However, they admitted that there is seldom time to provide any formal training. Training is typically not provided unless there are problems that rise to the level where health care administrators decide that staff training is needed. For example:
"Everyone would be happier if they were trained a little ahead of time."
In the absence of formal training, informants noted that it is helpful if a few minutes are set aside before the appointment for the interpreter to speak to both the health care provider and the patient about their role. A pre-session can be used to instruct the patient and provider to speak directly to one another rather than to the interpreter. A pre-session with the provider also provides an opportunity to discuss any potential cultural issues that could arise and to inform the interpreter of the nature of the appointment, so that he or she can be better prepared. For example:
"Pre-sessions with both the health care staff and the patient allow the interpreter to establish the rules of how the interpreted session will go."
"Staff tend to be extremely busy, overworked. . . . But if you can spare 2 or 3 minutes to just meet with that interpreter before you walk in there, they can help you avoid a lot of uncomfortable things."
Interpreters can prevent miscommunication and conflict by providing information to health care providers regarding norms and expectations related to culture and by being aware of ways in which patients’ cultural norms conflict with U.S. health care culture. For example:
"There will be instances where you have a female patient coming in for whatever the procedure is and you will not be allowed to talk to her. Her husband will answer every question for you. You need to make a decision whether he stays or goes. That’s up to the provider. You also need to understand what that may or may not mean to that patient when she walks out the door, but those are things that the interpreter can maybe prep you a little better for that you may not even think of."
All informants indicated that the selection of qualified interpreters is critical to ensuring that translation is accurate. Interpreters must not only be proficient in English and the patient’s native language; they must also be knowledgeable regarding U.S. health care culture and the legal and ethical responsibilities of their profession. The informants noted that, in the dental field, there are many appliances and devices of which interpreters must be aware. Interpreter training focuses less on dental medicine than other fields of medicine. The informants suggested that interpreters must be trained to understand health care terminology in dentistry and have a means of updating their understanding of new terminology on a regular basis.
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Discussion |
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These findings indicate that the use of professionally trained interpreters should receive additional attention in dental education and that training should focus on areas such as triadic interviewing skills, use of dental terminology, pre- and post-treatment meetings between the interpreter and the dental student or dentist, and ways to enhance communication among all parties involved.
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Conclusion |
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However, having a professionally trained interpreter working in a facility does not end the cultural learning processes needed in a multicultural society. Findings from the interviews in this study highlight the importance of knowing about the racial and ethnic groups serviced by our clinics in dental schools. The information gained from interpreting services and dental school records can inform dental educators about the norms, expectations, values, attitudes, and concerns of certain cultures and ethnic groups as they relate to oral health care.
This is the first study to examine the use of professional interpreters in the dental setting in the United States. This study, which explored the professional experiences of spoken language interpreters working in a dental school clinic, may be limited because the professionally trained interpreters who participated may not be representative of all professional interpreters since this sample was purposefully selected. However, the information obtained from the interpreters in this study is consistent with the National Standards of Practice for Interpreters in Health Care.25 Future studies might focus on students’ experiences working with professionally trained interpreters and patients’ perceptions of working with an interpreter and their overall satisfaction with the oral health care they have received.
This preliminary investigation underscores the need for further research in this area to determine strategies to enhance communication between dental care providers and the rapidly growing segment of the U.S. population comprised of individuals who have limited or no capacity to communicate in English.
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Footnotes |
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