Shiva Bidar-Sielaff, M.A.Karin Ruschke, M.A.

Presented by: Jorge U. Ungo

American Translators Association 49th Annual Conference

A Health Care A Health Care Interpreter’s Best Interpreter’s Best Friend: The National Friend: The National Code of Ethics for Code of Ethics for Interpreters in Health Interpreters in Health CareCare

Creating the National Code of Creating the National Code of Ethics for Interpreters in Health Ethics for Interpreters in Health

Care Care

Overview of the NCIHC Review of the process used to develop the

Code of Ethics for Interpreters in Health Care Review the principles of Code of Ethics Case Studies

The National Council on Interpreting The National Council on Interpreting in Health Care (NCIHC)in Health Care (NCIHC)

1994 - informal working group 1998 - formally established Multidisciplinary membership:

medical interpreters interpreter service coordinators and trainers clinicians policymakers advocates researchers

Mission: to promote culturally competent professional health care interpreting as a means to support equal access to health services for individuals with limited English proficiency

Website: www.ncihc.org

Building a ProfessionBuilding a Profession

Create and build support for a single Code of Ethics that will guide the practice of interpreters working in health care venues

Develop a nationally accepted, unified set of Standards of Practice based on the Code of Ethics that will define competent practice in the field

Develop standards for health care interpreter training

Contribute to the development of a national certification for health care interpreters as part of the National Coalition on Healthcare Interpreter Certification

Challenges in Creating the Challenges in Creating the National Code of EthicsNational Code of Ethics

To design a code that built on and solidified existing work

To expand upon this existing work to ensure its relevance to all health care interpreters, irrespective of the languages or particular venue in which interpreters work

Designing the National Code of Designing the National Code of Ethics for Interpreters in Health Ethics for Interpreters in Health

Care: The ProcessCare: The Process

Step 1: Step 1: Reviewed Existing Codes of EthicsReviewed Existing Codes of Ethics

Identified and collected existing codes of ethics in health care and other related areas such as legal and sign language interpreting

Focused on ten codes that were considered most relevant to our work

Compared and identified the elements that were held in common and analyzed how each approached those issues that were most difficult and controversial in the field

Step 2: Created a Draft CodeStep 2: Created a Draft Code

Drafted a code that included the elements shared across these existing codes as well as a few that were controversial but relevant

Included a short commentary after each principle that further explained and illustrated that principle

Example of Draft PrincipleExample of Draft Principle

Principle #2. Accuracy and Completeness   The interpreter strives to render the message faithfully, conveying the content and spirit of the original message, while taking into consideration its cultural context. 

It is the interpreter’s responsibility to interpret everything the speaker says without changing the meaning. The interpreter should attempt to convey what is said and how it is said without additions, deletions or alterations, but with due consideration of the cultural context of both the sender and the receiver of the message.  Whenever possible, the interpreter should convey the meaning of gestures, body language, and tone of voice that add significantly to the content of the message.  Additionally, when the interpreter becomes aware of a mistake they have made, the interpreter must reveal and correct the error.  

First Draft Code of EthicsFirst Draft Code of Ethics

Confidentiality Accuracy and Completeness Impartiality Professional Boundaries Professional Development Cultural Competence Respect for all Parties Professional Integrity

Step 3: Step 3: Conducted National Focus Conducted National Focus

Groups to Review the Draft (Fall 2002)Groups to Review the Draft (Fall 2002)

17 focus groups across the country Broad representation of language groups and

modes of service delivery (e.g. face to face and telephone interpreting)

Groups confirmed the need for a unified national code of ethics and affirmed its development as a positive step for the profession

Feedback also concluded that the draft code was fundamentally complete and appropriate although some principles were seen as more or less controversial

Step 4: 2Step 4: 2ndnd Draft Code of Ethics Draft Code of EthicsIncluded focus group commentaries and incorporated recommended changes:

Confidentiality Accuracy and Completeness Impartiality Professional Boundaries Professional Development Cultural Competence Cultural Intervention Respect for all Parties Professional Integrity Advocacy

Step 5: National SurveyStep 5: National Survey

  2nd draft introduced to a larger cross-section

of working interpreters through a survey survey disseminated through the NCIHC

website and state associations of health care interpreters

approximately 2,500 surveys were distributed, with a return rate of 20%

Sample Survey QuestionsSample Survey Questions

Principle #9. AdvocacyAdvocacy is an action that is taken on behalf of an individual that goes beyond facilitating communication with the intention of supporting good health outcomes. In some special circumstances, the interpreter may advocate for the interests of any individual patient, provider, or community.

Advocacy must be undertaken carefully, if at all, only if other mechanisms for addressing a problem do not work.

Sample Survey QuestionsSample Survey QuestionsPrinciple #9. Advocacy1. This final principle is being considered for inclusion in the Code of Ethics. Do you think the code should include a principle regarding advocacy?

___ Yes ___ No2. Do you agree with this principle? ____ Yes ____ No Please explain.3. When do you think it is appropriate for a health care interpreter to act as an advocate for the patient? (Check one or more)

a. When the interpreter has tried all other avenues to resolve the problem. b. When the health, well-being or dignity of the patient is at risk.c. Never.

A nurse in the pre-operative area of a hospital tells a patient that her left leg is being amputated. The patient becomes increasingly agitated, insisting that her right leg was to be amputated. The interpreter interprets what the patient is saying, and the nurse in charge ignores the patient’s protests. The interpreter is aware from a previous appointment that the patient is correct and the doctor had been planning on amputating the right leg. The patient continues to protest, even as the anesthesia is being prepared. The interpreter continues to interpret for the patient, attempting to convey his frustration and fear, but when the situation is not resolved, the interpreter leaves the room and calls the nurse’s supervisor. Do you agree with this application of the advocacy principle?

____ Yes ____ No

Survey ResultsSurvey Results

Strong agreement on the principles as stated in the draft.

Most controversial principle was “Advocacy”

Commentaries generated most controversyCommentaries generated unresolved

questions about implementation

Step 6: The National Code of Ethics for Step 6: The National Code of Ethics for Interpreters in Health CareInterpreters in Health Care

Code of ethics highlights the consensus there was on the principles themselves - published without commentary

Final draft was also reviewed by a select number of health care providers and medical ethicists

Companion document is created that offers a more thorough discussion of the issues raised

places the code in the context of ethical behavior in general provides an elaboration and discussion of each principle and the

interrelationships among them, acknowledging that controversies still exist while offering the working interpreter a way to think about these controversies

National Code of Ethics for National Code of Ethics for Interpreters in Health CareInterpreters in Health Care

“The role of interpreter is a‘tightrope’ balancing act: A code of ethics is a good guide for the ‘bar’ carried on such a walk on the tightrope. It offers balance, some security and especially is a comfortable way to face the unknown risks faced on the interpreter’s path.”

Anonymous Respondent to Code of Ethics Survey

Core ValuesCore Values

Support health and well-being of patient and do no harm

Remain faithful to original messageTake into consideration culture and cultural

differences to ensure understanding

The interpreter treats as confidential, within the The interpreter treats as confidential, within the treating team, all information learned in the treating team, all information learned in the performance of their professional duties, while performance of their professional duties, while observing relevant requirements regarding observing relevant requirements regarding disclosure.disclosure.

Shared with other health care professionals Sharing information with the treating team does not

violate confidentiality Avoid situations that expose you to confidential

information Explain your role Avoid being alone with the patient

If information is shared in confidence, encourage patient to disclose information to provider decide, based on core values and legal obligations,

whether or not to share

The interpreter strives to render the message The interpreter strives to render the message accurately, conveying the content and spirit accurately, conveying the content and spirit of the original message, taking into of the original message, taking into consideration its cultural context.consideration its cultural context.

Essence of interpreter role Remain unbiased Do not omit, add or distort message

Offensive language, derogatory remarks Possible exception: if not intentional, warn

speaker Interpret meaning, not words Correct all mistakes

The interpreter strives to maintain The interpreter strives to maintain impartiality and refrains from counseling, impartiality and refrains from counseling, advising or projecting personal biases or advising or projecting personal biases or beliefs.beliefs.

Provider-patient relationship is key Refrain from judging No personal biases and beliefs Last resort:

Withdraw from assignment Disclose limitations

Impartial Uncaring

The interpreter maintains the boundaries of The interpreter maintains the boundaries of the professional role, refrainingthe professional role, refraining from from personal involvement.personal involvement.

DO NOT mix roles Know your limitations

Accept assignments you can manage Withdraw from assignment Disclose limitations

Maintain professional relationship Do not provide personal information Avoid personal involvement

The interpreter continuously strives to The interpreter continuously strives to develop awareness of his/her own and other develop awareness of his/her own and other (including biomedical cultures) encountered (including biomedical cultures) encountered in the performance of their professional in the performance of their professional duties.duties.

Culture is a central factor in health care and necessary to interpret meaning

Be aware of your own culture Possess enough understanding of patient and

biomedical culture to facilitate communication across cultures

Cultural competence should be a value shared by the whole medical team

The interpreter treats all parties with The interpreter treats all parties with respect.respect.

Treat everyone with courtesy and dignity Respect autonomy and expertise of all parties

When the patient’s health, well-being, or dignity are When the patient’s health, well-being, or dignity are at risk, the interpreter may be justified in acting as at risk, the interpreter may be justified in acting as an advocate. Advocacy is understood as an action an advocate. Advocacy is understood as an action taken on behalf of an individual that goes beyond taken on behalf of an individual that goes beyond facilitating communication, with the intention of facilitating communication, with the intention of supporting good health outcomes. Advocacy must supporting good health outcomes. Advocacy must only be undertaken after careful and thoughtful only be undertaken after careful and thoughtful analysis of the situation and if other less intrusive analysis of the situation and if other less intrusive actions have not resolved the problem.actions have not resolved the problem.

Most controversial principlesAdvocacy taking sides, judging, personal opinionsOnly after careful and thoughtful analysisSeek supervisor advice whenever possibleOnly when clear and/or consistent observation that

something is not right and action needs to be taken to protect patient’s health and well-being

The interpreter strives to continually The interpreter strives to continually further his/her knowledge and skills.further his/her knowledge and skills.

Continue to sharpen your skills Language is dynamic Keep abreast of developments in your

profession Attend trainings/workshops/conferences

The interpreter must at all times act in a The interpreter must at all times act in a professional and ethical manner.professional and ethical manner.

Monitor own performance and behavior Do not use knowledge to your personal

advantage Do not exploit the vulnerability of the patient Ethical business practices

Compensation Punctuality Keeping appointments

Case StudiesCase Studies

Which ethical principles apply to each case study?

What would you do?

The National Council on Interpreting The National Council on Interpreting in Health Care (NCIHC)in Health Care (NCIHC)

www.ncihc.orgwww.ncihc.org