Working with Interpreters in Sexual Health
An Audit
29th November 2012
Author: Mr Donncha Mullin
5th year medical student
University of Glasgow
Email:
Phone: 07742249998
Supervisor: Dr Rona MacDonald, Sandyford Initiative Glasgow
Word Count: 1994
Audit carried out in March 2012
Introduction
Good communication is central to an effective consultation. Using interpreters is a vital component of any consultation where there is a language barrier between the client and the clinician. Clear communication is especially important in a sexual health setting due to the nature of the questions and physical examination.
Global migration trends are resulting in an ever-increasing need for interpreter use in healthcare and this increasing use has seen more reported problems related to their use. Glasgow, where this audit was carried out, has the added factor of being a reception centre for people seeking asylum in the UK, resulting in a further increase in people whose first language is not English and who are often particularly vulnerable (1).
Over the past year in this clinic there have been many anecdotal reports of issues arising from consultations using interpreters, resulting in eight Incidence Reporting Forms being filed. Notably, there is no local protocol for working with interpreters in sexual health.
An audit was performed to gather data about the rate of occurrence of issues, explore the reasons behind these issues and suggest improvements for practice. A major outcome of the audit was the development of a suggested protocol for working with interpreters in sexual health. This was influenced by an extensive literature review and an adaptation of a current Greater Glasgow and Clyde (GGC) protocol (Appendix 1). This audit and the suggested protocol was presented to the clinic staff and submitted for consideration.
Methods
The clinical notes of the most recent 43 clients seen with an interpreter in the clinic were reviewed. One client did not attend and there were no clinical notes recorded for another client so the final number included in the results and analysis was 41. After a comprehensive literature review, the information in box 1 was gathered for each client as it was considered important to the outcome of sensitive history taking when using an interpreter (2, 3).
Box 1: Data Gathered for Each of the 41 Clients
The clinical notes for each client consultation were read and a systematic and sequential approach was used to record any problems arising during the consultations and categorise them into themes.
Results
Client Demographics
The majority of clients were aged 25-45 years with the youngest aged 17 years and oldest aged 55 years. The primary language of the client was not recorded in 17 out of the 41 cases reviewed.
In over a quarter of cases the ethnicity of the client was not recorded.
Interpreter details
Interpreter gender was never recorded and the interpreter’s name was recorded just 14/41 times.
Consultation details
The details about the consultation in these four important areas were almost never recorded.
Key Findings
An interpreter-related issue was recorded in the notes of 7 out of 41 clients and these were arranged into the four themes as illustrated.
Discussion and Suggestions
Client Demographics
The ethnicity of the client was recorded less than 75% of the time. This may result in an inappropriate interpreter being assigned for a patient. This finding was brought to the attention of the reception staff, part of whose job it is to ensure that each service user completes the ethnicity section of the registration form.
Interpreter Details
As the gender of the interpreter was never recorded, it is impossible to tell whether client-interpreter gender matching occurred. When booking an interpreter, the receptionist could work through a check list to help match the client with their ideal interpreter e.g. preferred gender, language, dialect. This suggestion is incorporated into the protocol.
As the interpreter’s name was only recorded 14 times, it would be very difficult to ensure the same interpreter is used in future for repeat consultations with the same client. Also, if there are problems with an individual interpreter, it would be difficult to identify and track this by reviewing the notes. It would be important to know if issues were repeatedly arising from the use of any individual interpreter so that steps could be taken to remove any risk to patient care. For example, the interpreter could be referred for further training.
Consultation Details
A pre-consultation was only recorded to have taken place on one occasion. A pre-consultation discussion is an opportunity to ensure the interpreter and client speak the same language and dialect as well as giving the interpreter a clearer view of their role, thus helping to prevent issues arising later in the consultation. Although a client may speak a certain language, they may speak a very different dialect to the interpreter. This is especially the case for asylum seekers.
More detailed recording about the consultation details would improve clinical practice and allow easier and more useful audits to be carried out in the future.
Key Findings
A problem related to the interpreter was recorded in 7 (17%) of the 41 consultations reviewed. In total last year only eight Clinical Incident Forms were filed regarding issues with interpreters, which suggests the vast majority go unreported. Incidence reporting is a key part of the quality improvement strand of clinical governance and it is therefore included in the protocol (4).
On two occasions in the 41 reviewed notes, consultations were ended short when the interpreter left as their allotted time was up. On both occasions the clinician was taken by surprise as it was presumed the interpreter would stay until the consultation was over. A pre-consultation discussion would provide the opportunity to clarify how long the consultation was going to last and thus allow better consultation planning.
In one consultation a Mandarin interpreter was used for a client whose first language was Cantonese and in another a Slovakian interpreter was used for a Czech speaking client. The ensuing consultations ran into difficulties when it came to explaining the details of the tests and the conditions that were being tested for. This problem could be prevented by recording the exact details of each client’s preferred interpreter (gender, language, dialect) at reception when booking an interpreter. A pre-consultation discussion would also help spot this issue before problems arise.
During this audit it was noted that there are only 20 language options on the system for the receptionist to choose from with many common languages excluded e.g. Russian and Romanian. This helps explain why the primary language of the client was not recorded in 17 out of the 41 reviewed notes. It is impossible to match the client to an interpreter that speaks their language if an accurate record is not taken. This point was raised with the appropriate staff and it is an issue that is addressed by the suggested protocol.
A limitation of this audit is the small number of client notes reviewed. A larger audit might have highlighted more issues and unearthed more themes. Also, the methodology of the study limits the results to being solely retrospective. The findings would be strengthened if they were triangulated with the results of a prospective study.
Protocol for Working with Interpreters in Sexual Health
–a collaboration of audit findings, existing protocol and guidance in the literature (2, 3, 5)
There will be times when consultations involving interpreters are difficult no matter how well prepared the clinician is. However, the following protocol should help minimise interpreter-related problems arising out of consultations.
Before the Session
· Establish the need for an interpreter
· Ensure that language, dialect and gender match the needs of the service user
· Accessing an interpreter - start at option 1
o Option 1 - Trained interpreter for face to face interpreting sourced through Local Interpreting Service
o Option 2 - Interpreter through commercial agencies for face to face (Global Languages or Global Connections) or telephone interpreting
o Option 3 - Bilingual member of staff
o Option 4 – Friend or family member – use as last resort
· Duration - Allow approximately double the time normally required
· Pre-consultation discussion - Discuss alone with the interpreter:
o Background details including:
§ Client’s name, age, country of origin, language and dialect
§ Purpose and expected content of the session
§ Any specific terminology which may be used in the session
§ Ask interpreter for correct pronunciation of client’s name
o Working methods:
§ Explain your method of working and ask the interpreter to explain how he/she works best. Cover:
· Consecutive or simultaneous interpretation
· Short units of speech (2-3 sentences at a time)
· Ask the interpreter to speak in the first person e.g. say "I", "me", instead of "he says"
· Ask the interpreter to interpret everything that is said in the room
· All parties involved in the consultation can ask for clarification on any unclear points
· Seating arrangements – ensure easy eye contact between all parties
· Encourage the interpreter to intervene if there is a clear misunderstanding
During the Session
· Introduction - Introduce yourself to the client and allow the interpreter to introduce him or herself.
· Suitability - Look for client consent that the interpreter is suitable (consider gender, age, race/tribe - especially if client is an asylum seeker). Is the client prevented from disclosing details because of his/her relationship with the interpreter? Rebook with another interpreter.
· Confidentiality - Explain to the client that both you and the interpreter will maintain confidentiality
· When speaking -
o Speak directly to the client in the first person e.g. say "Can you tell me…" instead of "Ask him to tell me..."
o Look at the client rather than the interpreter
o Speak as simply as possible - no jargon, metaphors, colloquialisms
o Some words/concepts do not translate into other languages e.g. there is no Urdu word for "depression", so be prepared to explain what certain words mean.
o Avoid private discussions with the interpreter
· Interrupt - It is okay to interrupt and ask for an update on any lengthy conversations between interpreter and client
· Actively Listen - Ensure you utilise your own non-verbal skills to build a relationship with the patient and prevent the main relationship being between the client and the interpreter.
· Breaks - Be aware of when the client or interpreter may need a short break particularly if the client has been talking about distressing experiences.
· Leaving the room - If you need to leave the room, you should not leave the interpreter alone with the client.
After the Session
· Understanding - Check that the client has understood everything and invite questions
· Debrief - Ask interpreter to stay behind after the client has left to discuss:
o General feedback - did the session go smoothly? Were there any problems?
o Specific feedback and clarification – any factual observations from the interpreter, or feedback on the cultural context of gestures or modes of behaviour.
o Check how the interpreter is feeling after the session, particularly if it was an emotionally charged session.
· Forms - Complete and sign the Interpreters record slip.
· Reporting - Report any critical incidents or near-misses.
Tips
· If confidentiality remains an issue for the patient, a telephone interpretation interview may be more acceptable as it removes the fear of physical recognition
· Interpreter with specialist knowledge of Sexual Health will aid the process
· If the client is booked in for a subsequent visit, try to arrange for the same interpreter to attend also.
Conclusion
The audit findings and the suggested protocol were presented to the staff at the clinic at a weekly team meeting and submitted to the Clinical Director for consideration. They give an overview of the types of issues arising, where they issues arise from, and suggest ways to improve clinical practice. Problems related to the interpreter were recorded in a high proportion of the reviewed notes and many of these problems would be avoided by following the protocol suggested in this audit.
Teamwork and support from the organisation are central to the results of this audit being incorporated into routine clinical practice to improve client experience and outcomes. A review audit should be undertaken in 6-12 months using the same methods, to see if the suggested protocol has resulted in less issues arising when using interpreters.
Acknowledgements
I would like to thank Dr Rona MacDonald and Dr Andy Winter for their help on the auditing and writing process and those in the IT section for their help gathering and analysing data.
References
1. NHS Greater Glasgow and Clyde Equality Scheme. Communication support and language strategy and action plan. Glasgow; GGC, 2008.
2. NHS Greater Glasgow and Clyde. Working With Interpreters. Year unknown. Accessed 14/03/2012. Available from: http://www.staffnet.ggc.scot.nhs.uk/Partnerships/MHP/Specialist%20Services/COMPASS/Pages/COMPASS_TipsWorkingInterpreters_AM_130607.aspx
3. NHS Greater Glasgow Clyde. Working with Interpreters: Good Practice Guidelines - Appendix 1. Year unknown. Accessed 14/03/2012. Available from: http://www.staffnet.ggc.scot.nhs.uk/Info%20Centre/InterpretingServices/Documents/Interpreting%20Service%20procedure%20Guidance%20b.pdf
4. NHS Scotland. Educational Resources: Clinical Governance. 2007. Accessed 24/11/2012. Available from: http://www.clinicalgovernance.scot.nhs.uk/section1/introduction.asp
5. NHS Greater Glasgow and Clyde. Black/Minority Ethnic Communities Interpreting Services Policy and Procedure Year unknown. Accessed 14/03/2012. Available from: http://www.staffnet.ggc.scot.nhs.uk/Human%20Resources/Documents/workingwithinterpretersguide[1].pdf
Appendix 1: Summary of GGC Black/Minority Ethnic Communities Interpreting Services Policy and Procedure (9)
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