Techniques for educating with the aid of an interpreter

Interpreters can improve understanding

There are many basic practices that improve teaching encounters between health care practitioners and patients with limited English proficiency (LEP). These are applicable in all interactions within a medical center when the use of an interpreter is required.

In addition to the basics, patient education requires a little more preparation and work with the interpreter to make sure the session is effective, according to some experts.

What are some of the basics that must be mastered? Learning to speak directly to the patient rather than to the interpreter is one. According to Molly K. Smith, manager of Language Services at Clarian Health in Indianapolis, IN, people have a tendency to speak to the interpreter rather than the patient. They will say, "Ask the patient if he has pain" rather than "Do you have pain?"

"The goal of health care practitioners is to make the patient feel they are the focus of the communication and act as though the interpreter is not there," explains Smith.

The person teaching should be positioned so that he or she can see the patient. It is important to make eye contact so that non-verbal communication can be observed.

"If a provider is not looking at the patient he or she won't see the facial expressions that might indicate confusion," explains Smith.

Before the education session begins the health care practitioner should introduce the interpreter and make sure the patient is clear on the perspective roles of everyone in the room. It is important to remember that everything said in the room will be interpreted so nothing should be said that the patient shouldn't hear.

It is best for anyone using an interpreter to pause after finishing a complete thought. This gives the interpreter time to interpret what was said.

When using an interpreter for patient education the best way to capitalize on his or her medical interpreting skills is to plan ahead and be organized about the teaching session, says Susan Scritchfield, MA, MSW, LISW, coordinator of consumer health education at the James Cancer Hospital, which is part of the Ohio State University Medical Center.

"You have to plan ahead to allow time to get an interpreter on sight and to make sure the caregivers or family members the patient wants to be present for the teaching are also available," she explains.

The interpreter needs to know the nature of the teaching in advance so he or she can prepare, says Jose Sanchez, coordinator of Interpreting and Translating Services at Children's Healthcare of Atlanta. If teaching protocols are to be used interpreters should be given a copy in advance.

"Make sure the interpreter understands what the training is about so he or she is familiar with the terminology," says Sanchez.

When teaching patients with communication barriers use the teach back method, having the patient demonstrate the skill or repeat back what was taught, advises Mursal Khaliif, RN, director of Community Health & Language Services at the University of Minnesota Medical Center, Fairview in Minneapolis.

The use of the teach back method will give the practitioner confidence the patient fully understands. It will also help uncover misunderstandings so the information can be rephrased, explains Khaliif.

Relying on interpreter's observations

Sometimes it is the interpreter that observes that the medical terminology used is not clear to the patient and can ask the practitioner to use more family friendly terms, says Sanchez.

According to Smith the interpreter can serve as a "cultural broker" meaning if there are cultural practices or norms in either culture that might impede effective communication or lead to misunderstandings the interpreter will explain the differences.

For example some Hispanic parents might rub a tomato on a baby who has a fever leaving tomato seeds on the child's body. If staff in the emergency department are concerned that the baby has been abused the interpreter could tell the practitioner about the cultural practice and ask if they should find out if this is what the parents did, explains Smith.

Stephanie MacPhail, a Spanish interpreter and LEP Patient Advocate in the Hematology and Oncology Clinic at Children's Hospitals and Clinics of Minnesota in Minneapolis, says there are two schools of thoughts on interpreting. One is that interpreters only interpret what was said not actively participating in any education other than repeating what the other party said.

With the second model the interpreter is more of an integral part of the health care team and given an expanded role in terms of the input they can give the provider in a situation. This role is strictly for staff interpreters who have built a relationship with the health care practitioners, says MacPhail.

Interpreters can be instrumental in bringing the barriers out front but it is up to the provider to initiate the practices, she adds.

For example, in collaboration with the nurses at the clinic where she works, MacPhail came up with a system of calendars to help families with limited English proficiency manage confusing medication regimens during the course of their child's treatment.

The project was initiated because of a misunderstanding on dosage. A child's chemotherapy regimen was one half of a pill, yet instead of using numbers on the label the pharmacy had written the dosage in words. The family members, who could read a little English, saw the word 'one' but did not understand the 'half' therefore they had been giving their child a whole pill until the error was discovered.

Now families are given calendars to help with dosage and if the child is taking a pill there is a picture of the dosage whether a half pill or whole pill.

Liquid medicines are color coded and a sun and moon indicate whether or not the dosage is to be taken in the morning or at night. (For information on providing translated educational materials to LEP patients, see article below.)

Back up education with translated teaching materials

Each person has a learning style. Some people are visual learners, some learn best hands-on, and others will understand information better if they read about the subject. However instructional sheets help to reinforce education for all types of learning styles. Therefore it is important to give patients with limited English proficiency information sheets to take home that are written in their native language, says Laura Rocha Nakazawa, MA, program coordinator for Interpreter Services at Dana-Farber Cancer Institute in Boston, MA.

Following are a few web sites that provide educational materials in languages other than English that can be used when teaching patients with limited English proficiency.

www.healthinfotranslations.org — This joint project of Mount Carmel Health System, The Ohio State Medical Center and Ohio Health, features translations in Arabic, Chinese, French, Hindi, Japanese, Korean, Russian, Somali, Spanish, Ukrainian, and Vietnamese. They cover a variety of topics such as diagnostic tests, diseases and conditions, exercise and rehabilitation, as well as food and diet. All translations have an English version.

www.hmonghealth.org — The goal of the Hmong Health Education Network is to provide access to health, education, and social services to the Hmong community. Content includes anatomy drawings labeled in English and Hmong, English-Hmong anatomy, medical phrase book as well as educational materials.

"When I am in an encounter with a provider and patient I play a strict interpreting role, outside that role I do a lot of advocating and case coordinating working together with the nurses for purposes of education," explains MacPhail.

Sources

For more information on using interpreters during teaching sessions, contact:

  • Mursal Khaliif, RN, Director, Community Health & Languages Services, University of Minnesota Medical Center, Fairview, Minneapolis, MN. Phone: (612) 273-5850. E-mail: mkhalii1@fairview.org.
  • Stephanie MacPhail, LEP Patient Advocate, Hematology and Oncology Clinic, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN. Phone: (612) 813-7706. E-mail: Stephanie.Macphail@childrensmn.org.
  • Jose Sanchez, Coordinator, Interpreting and Translating Services, Children's Healthcare of Atlanta. Phone: (404) 785-2189. E-mail: Jose.Sanchez@choa.org.
  • Molly K. Smith, Manager, Language Services, Clarian Health, Indianapolis, IN. Phone: (317) 962-2725. E-mail: msmith19@clarian.org.
  • Susan Scritchfield, MA, MSW, LISW, Coordinator, Consumer Health Education, James Nursing Staff Development and Patient Education, Ohio State University Medical Center, Columbus, OH. Phone: (614) 293-3259. E-mail: Susan.Scritchfield@osumc.edu.