AS A RESULT of ongoing conflicts around the world, international immigration has increased substantially and societies are likely to become increasingly multicultural.1 Language barriers that impair communication impact patient care in primary healthcare settings.2 These may lead to deficiencies in the information exchanged between nurses and patients, and non-native language speaking patients may receive a lower standard of healthcare compared with the rest of the population.3,4 This article discusses a study on person-centered care and nurses' experiences as they utilized interpreters in primary healthcare settings in Sweden.
By Swedish law, healthcare professionals are responsible for ensuring that patients fully understand the information provided, despite challenges such as language barriers.5 This law aims to strengthen and clarify the patient's position and promote integrity, self-determination, and participation. As in the US, patients are invited and encouraged to be as involved as possible in their care.7
Healthcare professionals may run the risk of objectifying or reducing individuals to their diagnosis by using the term patient.6 By visualizing the person behind a disease, healthcare professionals can perform person-centered care.
Person-centered care emerges from the relationship between patients and healthcare professionals and relies on methods such as talking, active listening, and a mutual understanding.6 These relationships require strong communication skills, so using an interpreter to overcome language barriers may be beneficial.4 The role of healthcare interpreters is more complex than simply translating words, however, as the message must be delivered in exactly the way it was intended.4 Language barriers may be overcome by using interpreters, but factors such as cultural differences can interfere with precise communication.4
Instead of professional medical interpreters, the patient's relatives are sometimes used to translate in healthcare settings. Although the quality of these translations varies, the perception among healthcare professionals is that relatives offer the easiest solution.4,8,9 However, this presents significant challenges that can impair communication, such as an overall lack of knowledge and understanding of medical language among familial translators.9 Additionally, patients may withhold critical information they do not wish to share with their relative. In other cases, relatives may withhold information to protect the patient.3,9 As such, efficient and professional medical interpreters are recommended.
An efficient interpreter has extensive language skills and offers objective and verbatim translations while respecting professional discretion. Knowledge of medical language is also a desirable quality. Earlier studies offer similar descriptions regarding efficient interpreters.9,10
Design and sample
This descriptive interview study was approved by the Health Sciences Ethics Committee at the authors' facility and adhered to the Declaration of Helsinki. Participants must have served as nurses in a primary healthcare setting for a minimum of 2 years, with experience using interpreters in patient care. Factors such as gender, age, specialist training, or position were irrelevant and not part of the inclusion or exclusion criteria.
Following approval from their respective facilities, the nurses were recruited from health centers in the south of Sweden. They received a letter providing information on the study and defining person-centered care. Due to time constraints, only eight nurses were recruited who fulfilled the inclusion criteria and were able to participate.
Data were collected via semistructured interviews. An interview guide was developed, containing one main question: Tell me about your experiences using an interpreter. This was asked at the start of each interview. The interview guide covered themes such as professional confidentiality, relatives as interpreters, and the differences between having the interpreter present in the room versus over the phone, as well as person-centered care and cultural impact. The guide was tested in a pilot interview, which was not included in analyses, and revised to better mirror the area of interest with the additions of person-centered care and cultural impact.
The participants were all female, between ages 41 and 61, and had worked as nurses for between 18 and 28 years. Six of the eight nurses had specialities, four in public health and two in child healthcare. Each nurse chose her respective workplace as the location of the interview and provided written consent beforehand. The interviews were audio-recorded and lasted between 27 and 46 minutes, with an average length of 43 minutes. Each was conducted by both the first and second authors.
Interviews were transcribed verbatim while still fresh in the authors' minds. This allowed for information retention and helped the interviewers fill in any inaudible words or phrases. One of the authors entered the interview process with a foundation of understanding, as she had worked as an interpreter.
Qualitative content analysis was used according to Graneheim and Lundman.11 The authors read the text of each transcribed interview several times to gain an overview of the content. Meaning units were established based on phrases taken from the transcripts, chosen to mirror the aim of the study, and coded to reflect the content of the unit. Codes with similar content were abstracted, grouped into subcategories, and collected into three main categories.
Eleven subcategories were merged into three categories: interpreters' influence, challenges, and strategies. Interview excerpts illustrated the study findings.
Despite language barriers, interpreters influence nurses as they provide person-centered care. The participating nurses reported that these professionals are necessary to patient care, whether they are present in the room or via telephonic services. The nurses also noted that forgoing the use of interpreters increased the risk of important information being lost. Overall, their experiences with interpreters were satisfactory, but interpreter skill levels seemed to vary significantly.
The nurses relied on interpreters to perform their work thoroughly. For example, they described the importance of interpreters introducing themselves and translating as literally as possible without adding any opinions. The nurses felt that their ability to provide person-centered care was affected by their interpreter's professionalism. Those with deficient language skills or a lack of interest could limit person-centered care.
Several challenges were identified in analysis. The nurses described how sensitive topics were difficult to address when using an interpreter. They reported challenges in reading body language and understanding patients due to difficulty distinguishing important signals, expressions, and phrasing.
Two recurring themes were insecurity and frustration. Insecurity was rooted in the nurses' uncertainty regarding whether patients fully comprehended the information provided; frustrations emerged when nurses collaborated with less competent or unprofessional interpreters. Dependence on interpreters to provide care was an additional source of frustration.
According to the nurses, conversations through an interpreter require more time than those between parties speaking the same language. The findings also suggested that it typically takes several visits to determine the proper treatment or drug therapy using an interpreter. Additionally, the participating nurses felt limited in providing care while using interpreters due to lack of flow, depth, and sensibility in the conversation. The indirect information exchange affected communication negatively because conversations became brief and pragmatic.
Throughout the interviews, the participating nurses highlighted the importance of communicating clearly to ensure patient comprehension. To avoid misunderstandings, an explicit conversation structure was crucial to communicate concrete, direct information when using an interpreter. As aiding, facilitating, and assessing communication with an interpreter was vital to the nurses, they also preferred to plan visits in advance.
Repetition and having patients communicate clinical information back to the provider was recommended to identify potential misunderstandings, allow for follow-up questions, and prevent the loss of essential information. Similarly, speaking at a slow pace and allowing for interpretation by pausing and taking turns speaking was perceived as beneficial. Among other elements, limiting the number of people in the room to foster a calm and welcoming environment was recommended to enhance communication, as well as distributing any available reading materials in the patient's first language. Additionally, maintaining eye contact throughout the conversation allows nurses to offer their full attention to the patient despite the presence of an interpreter.
The nurses suggested that communication through an interpreter is an inevitability for healthcare professionals. In some exceptional circumstances such as short, spontaneous encounters, the use of relatives as interpreters was considered necessary. For prebooked appointments, however, the interviewed nurses emphasized the use of professional interpreters to ensure that all information was communicated accurately and efficiently.
None of the interviewees had experience with interpreters before becoming nurses, nor had they received any education in utilizing translation services. Instead, they had to learn for themselves over the years. As such, they emphasized education in helping inexperienced nurses utilize interpreters while providing person-centered care. This could spread awareness and insight on translation services. The participating nurses recommended introducing education about translation services into undergraduate curricula or workplace orientation.
This study highlighted the use of interpreters for satisfactory communication during nurse consultations. When interpreters were unprofessional or knowledge-deficient, sensitive topics were difficult to address. Additionally, the extended time and lack of flow, depth, and sensibility in conversation presented challenges. Nurses can incorporate strategies for person-centered care by planning visits, speaking at a slow pace, and maintaining eye contact.
In contrast to findings from interviews with general practitioners in Australia, this study's participating nurses emphasized the importance of using professional interpreters and were confident in their approach.12 It can be complex and challenging to communicate with patients from diverse cultural backgrounds.8,13 This study found that an efficient and competent interpreter can minimize these difficulties.
The participating nurses reported that having an interpreter in the room as a third party was sometimes difficult, especially when addressing sensitive topics. This was exacerbated if the interpreter was perceived to be incompetent. Similar frustrations occurred when nurses felt their empathy was not appropriately communicated to the patient. A Belgian study examined this challenge with video-recorded, interpreter-mediated, simulated consultations with medical students and found that the expressed empathy may be reduced, increased, or sometimes omitted by interpreters.14 In some instances, this may even turn into an ethical problem, as expressed empathy is an ability to put oneself in the patient's situation.15
According to the authors' study, nurses can enhance patient understanding with good planning and structured, straightforward communication. Such strategies could be valuable to improve adherence and patient outcomes in person-centered care.16 This is consistent with previous research and relevant to encounters in which nurses must provide person-centered care despite a language barrier.10 The interviewed nurses also found it relevant to ensure patient confidence in these conversations by informing them about the interpreter's professional discretion.
None of the nurses in this study had received any formal education on interpreters or translation services, but they felt they would have benefitted from training. Previous research suggests that nurses should become familiar with any knowledge relevant to a patient's language or culture to minimize barriers when using interpreters.4 Education increases nursing confidence with interpreters.3,4,8,9 It would also increase the likelihood of using professional interpreters, despite the convenience of relatives.3 Nurses are legally obligated to use professional interpreters for patient encounters in which language barriers exist, and it is their responsibility to ensure complete communication.9,17
Many eligible nurses were either too busy or felt they lacked enough experience with interpreters to participate. Each successful interview was read thoroughly and determined to address the aim of the study adequately. All participating nurses were sufficiently experienced. Accuracy was ensured by reevaluating the categories, subcategories, and original interview text during analysis and verified with excerpts.18 Additional analysis was performed separately by the authors and gathered to reach consensus.
In Sweden, as in the US, the use of interpreters is both a professional and legal obligation. Improved education could provide practical advice and information for nurses using an interpreter. This may also be beneficial in adjusting to different situations and understanding when interpreters are clinically necessary.
Welcome! I am excited to be joining Nursing2020 as the new Nursing Research department coordinator.
Given the ongoing changes in the US healthcare system, questions have been raised regarding the impact of the Affordable Care Act and the consolidation and reorganization of healthcare delivery. Timely information on healthcare organization, financing, and delivery is critical. A single study could represent a starting point for the implementation of evidence-based practices in any clinical setting. As such, nurses must collaborate with other disciplines to address the complexities of patient care.
Having started my nursing career years ago, I have had the opportunity to witness numerous changes in healthcare delivery. Over time, I have come to appreciate that many clinical questions can best be answered by studying the impact of care on patient outcomes. My interdisciplinary research has afforded me the chance to focus on obtaining a more complete understanding of the effects of nursing practices.
Currently, I am a professor of nursing at the University of Central Florida College of Nursing and the director of the PhD program, and I am looking forward to my new role as department coordinator. I will have the exciting opportunity to read your diverse research studies and create a column to translate your findings to other clinicians on the frontlines of nursing care.
Glad to join the team!
DONNA FELBER NEFF, PhD, RN, FNAP
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