the emergent role of qualified bilingual staff...

The Emergent Role of Qualified Bilingual Staff Interpreters

Marilyn Lynk, PhDProgram ManagerCenter on Health Disparities

National Conference on Quality Health Care for Culturally Diverse PopulationsOctober 20, 2010

Baltimore, Maryland

Background

•

Ad hoc interpretation is associated with:–

Reduced trust in physicians

–

Inaccurate communication

–

Misdiagnosis

–

Inadequate/inaccurate treatment

–

Reduced quality of care

•

Healthcare systems seek efficient ways to provide language services and quality care to address patient communication

needs

Background

•

Trained language interpreters or bilingual staff play a critical role in delivery of care to

limited English proficient (LEP) patients

•

Dual‐role bilingual staff facilitate cross‐ cultural communication between

healthcare providers and patients; however, increasingly navigating varying

levels of health literacy among patients, provider knowledge and biases,

and system barriers

Qualified Bilingual Staff Model & Program

•

Developed by Kaiser Permanente•

Goal:

To ensure and enhance the linguistic

and cultural competence of bilingual staff•

The QBS Model

aims to:

•

Identify•

Qualify

•

Enhance•

Mobilize

•

Monitor

Qualified Bilingual Staff Model

Adventist HealthCare Qualified Bilingual Staff Program

•

Provides three days (24 hours) of intensive training on interpretation concepts, roles,

and skills, including:•

Ethics

•

Legal/Regulatory Requirements

•

Medical Terminology

•

Cultural Competency and Diversity

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Interpretation Modes, Roles, & Protocols

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Role‐Plays and other Learning Activities

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Bilingual staff trained and qualified to serve in dual

roles as language interpreters

•

Language proficiency assessed in English and

language of service Level 1: Conversational

Level 2: Medical EncountersOfficial Qualified Bilingual Staff Badge

Adventist HealthCare Qualified Bilingual Staff Program

Qualified Bilingual Staff Program

•

Level One: –

Ability to converse in English and in the

Language of Service (LOS)

–

Ability to provide directions and simple instructions in English and LOS

–

Ability to provide language assistance in customer service related encounters where

understanding of medical terminology/concepts is not

required.

•

Level Two:–

Meets L1 QBS requirements (as described

previously)

–

Ability to provide language assistance in various clinical settings where understanding of

medical terminology/concepts is required


The Role of the QBS Interpreter in the Clinical Encounter

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Conduit: Convey meaning of message

•

Clarifier: Clarify concepts to limit confusion

•

Cultural Broker: Facilitate culture‐specific information

•

Advocate: actively supports change that benefits patient’s health and well‐being.

Advocacy Role Disclaimer

While the interpreter may occasionally be required to advocate a patient’s interests, such interventions are the exception and

the QBS must be careful not to “champion the patient’s cause”

as a general rule. In no

case should the QBS initiate an advocacy role without the patient’s informed

consent.

From QBS Participant Handbook, Kaiser Foundation Health

Plan, National Linguistic & Cultural Programs, National

Diversity

•

DATES: 2007‐2010

•

BACKGROUND:

–

Twelve three‐day (24 hour) trainings completed

–

10 Languages Trained: Spanish, Portuguese, Mandarin, Cantonese, Russian, French, Korean,

Farsi, Amharic, Arabic

–

Trained over 250 healthcare providers and staff at AHC and across Montgomery County; 130

tested and qualified to interpret at Level I (44%) and Level II (56%)


QBS Program Evaluation

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Purpose: to investigate the impact of the QBS program as it pertains to interpreters,

department managers, providers, and patients

QBS Program Evaluation

Phase 1

Phase 2

Phase 3

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Manager’s Survey

•

QBS Interpreter Survey

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QBS Interpreter Focus Groups

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Provider Survey

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Provider Education

•

Patient Survey

Interpreter Survey and Focus Groups

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Purpose: to assess the QBS interpreters’ confidence in interpreting post‐training and the impact of training on their morale,

satisfaction, perceived impact on the organization, and their department

Interpreter Survey and Focus Groups

•

Data was collected from interpreters at two Adventist HealthCare facilities via written survey

and focus groups

–

Survey: QBS interpreters listed on the facility roster (2007‐2009) were solicited to

participate in QBS focus groups and surveys

•Of 76 QBS interpreters on the roster, 26 participated in the survey (a response rate

of 34%) and 32 participated in one of four focus group sessions (a response rate

of 42%)

Interpreter Survey: Items

Item 1:

I am confident in relaying messages between patients and health professionals accurately

Item 2:

After being trained as a QBS interpreter, I feel more valued as an employee in my department

Item 3:

My experience as a QBS interpreter has been rewarding

Item 4:

As a QBS interpreter, I feel there is an appropriate balance between my regular work responsibilities and my QBS responsibilities

Item 5:

I feel that my QBS training has positively affected my coworkers

Interpreter Survey: Results

2.8

2.9

3

3.1

3.2

3.3

3.4

3.5

3.6

3.7

3.8

1 2 3 4 5

Figure 3. Average Score on Focus Group Questionnaire Items 1‐5

Interpreter Survey: Results

Overall, QBS staff members express satisfaction with their experiences interpreting for patients:

•Feel valued by patients and co‐workers•Find the skills attained through training useful

QBS interpreters complain that there is a:•Lack of visibility of the program•Lack of knowledge of protocol for interpreting

services among providers•Need for continuing education for interpreters •Need for cultural sensitivity training for providers

Interpreter Focus Group

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Interpreters were gathered in one of four focus groups:

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Focus groups were 1 hour long–

Snacks were provided

–

Complete focus group sessions were recorded and transcribed for analysis without identification of

the speakers–

Transcripts were read and coded for key themes

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Focus groups were facilitated by experienced moderators

Interpreter Focus Group: Questions

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Interpreters were asked two main questions to prompt dialogue about their experience:

–

Has QBS training equipped you to better perform your interpreting role? Explain.

–

What was the most challenging aspect of being a QBS interpreter?

Interpreter Focus Group: Themes

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Has QBS training equipped you to better perform your interpreting role?

–

Increased personal morale

–

Greater perceived appreciation within the department

–

Increased professionalism

Quotes from Focus Group

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Interpreters noted an overall increase in morale related to their certified skills:

“I feel twice as useful [and] more valuable to the hospital, now that they know not only can I do my

job, but I can do this interpreting … it adds to who I am as a person to the organization.”


•

Interpreters noted greater perceived appreciation within their department:

“It makes you feel like you’re helping. Before you were doing it, but after the class you do it [more professionally] and [co‐workers] appreciate you more….[co‐workers] always appreciate it, they

always say ‘thank you’…”

“My supervisor appreciates that [patients] were served by me in some way. It makes the

department look good, too.”


•

Interpreters noted greater levels of professionalism:

“…now you present yourself formally…I’m here to help you…make it very formal and you let them know you there not as their friend but you know to

facilitate that communication.”

“I’m grateful we have some type of certification, we are backed up by the system.”

Interpreter Focus Group: Themes

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What was the most challenging aspect of being a QBS interpreter?

–

Remaining transparent in the encounter

–

Overcoming provider insensitivities


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Regarding remaining transparent, interpreters noted times when patients viewed them more personally than professionally:

“…a lot of time they think you are there because you’re friendly or that you will be their advocate;

and that’s really not necessarily the truth. You’re not really there to be their advocate; you’re there to provide a service, an interpreting service, to

them not as their advocate.”


•

Contrary to training, interpreters were often perceived as advocates by patients:

“…patients a lot of times they want you to be their advocate...you’re not really there to make

recommendation or tell them what has been your experience…that’s not to say you don’t want to be friendly, but its very hard to remain objective…to

the point they don’t get carried away [with] telling you things that do not pertain to what their really

here for…”


•

Interpreters note provider insensitivity towards LEP patients:

“I also wish that other people who don’t speak a language other than English would

have a little bit

more patience with foreign patients. If they go to another country, they would be in the same

position.”


“I think that’s rude. Yeah, they don’t speak English, but they need your help right now. They [are]

already worried that they don’t speak English and …then the nurses and some of the providers make it hard for the person to come back to this

hospital.”

“I think [providers should attend] some kind of class or training to help them understand other

cultures…or how to…

become more sensitive to other cultures.”


•

Interpreters note serving as health educators and filling in pertinent health information:

“[S]ometimes [providers] don’t treat patients different from the English‐speaking patient, …they

really do a full package of [advice]…and some [providers] assume that [the interpreter] will do

the role to educate…the patient…instead of direct word‐to‐word interpretation; it is up to my

interpretation what else to tell the patient. [Providers rely on interpreters to say what

they haven’t said] ”


•

Interpreters note communicating non‐medical features of U.S. healthcare, such as financing:

“Patients are very grateful that you are there, and ask even more questions than they would have, like I can’t afford to pay for this…how much will this cost? And just because I have general

knowledge about the resources for assistance we have here, I tell the nurse on the unit that we do

provide these services.”

•

While interpreters felt empowered through QBS training, there were challenges to remaining

transparent and overcoming provider insensitivity

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The skill of balancing provider and patient expectations in the context of their trained role

seems essential to the QBS interpreter•

Despite best efforts to remain objective,

interpreters are often drawn into advocate roles by both patients and providers.

Discussion

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Prompts to advocacy could be negative (insufficient information, cultural insensitivity) or

positive (dedication to provide excellent service) and originate from provider or patient.

•

QBS interpreters, as direct observers of LEP patient‐provider interactions, can serve as useful

informants of organizational needs as it pertains to cultural and linguistic competency.

Discussion

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Selection Bias: Participants in the survey and focus group activities self‐selected

and may differ from those who opted out of the initiative.

•

Surveys included few questions, which limits the interpretation of findings

•

Findings are limited to QBS staff at two Adventist HealthCare facilities

Limitations

Conclusion

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QBS training could be a valuable asset for increasing staff morale and patient satisfaction

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QBS interpreters often encounter situations in practice, which span beyond the primary conduit role

described in training•

As internal members of an institution, interpreters are

challenged to serve as managers of the patient‐ provider interaction, while balancing a host of social

and political pressures that could impact the work environment or patient care

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More research is needed to develop appropriate tools to aid QBS interpreters in overcoming

these challenges

Future Directions

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Providers need to be engaged to determine educational needs

as it pertains to

interpretation and cultural sensitivity

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LEP patients should be engaged directly to evaluate patient satisfaction and outcomes of care

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QBS interpreters should continue education and training cultural change agents

“I've learned that people will forget what you said, people will forget what you did, but people will never forget

how you made them feel.”

~ Maya Angelou

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