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Spring 2008 | Vol 11 No 3

Focus

More than words

Health care interpreters play key role in quality care

By Kim Goggins

It’s 2 a.m. when a man walks into a B.C. emergency department. The Ethiopian man is obviously distraught and his hands are covered in blood. He is speaking so fast in broken English and Amharic that no one can understand him. After the physician treats the serious knife wounds to the man’s hands and witnesses what he perceives to be the man’s fear of whomever assaulted him, he makes arrangements to report the crime to police. If an interpreter had been called, the doctor would have learned that the wounds were self inflicted and arranged for the man to see a psychiatrist through this crisis.

Meanwhile, at a mental health clinic in Ontario, another misunderstanding is created, as a young girl struggles to interpret the ramblings of her Cantonese-speaking mother, whose rants jump from one topic to another. Rather than repeat what her mother is saying to the psychiatrist, the daughter paraphrases what she believes to be the important information, in the process leaving out details imperative to making an accurate diagnosis.

These two composite scenarios are examples of what can happen without a qualified mental health interpreter. What is surprising is that given Canada’s multilingual character, these sorts of situations still happen. According to the 2006 census, 41 per cent of newcomers to Canada speak neither official language. In Toronto, 46 per cent of residents report a mother tongue that is neither French nor English, and the city has the highest proportion of foreign-born residents of any city in the world, with more than 100,000 newcomers arriving each year.

As the country becomes increasingly multilingual, advocates insist that the need for properly trained interpreters is not a special request but a basic need, which requires policy recognition. Unlike the case in the United States, no nationally established policies to oversee the profession exist, says Axelle Janczur, president of the Healthcare Interpretation Network (HIN) and director of Access Alliance Multicultural Community Health Centre in Toronto. “There are still no generally agreed upon standards across the various sectors and that’s something we’ve been advocating for and talking about for some time,” she says.

Suzanne Barclay, director of the Provincial Language Service (PLS) within the Provincial Health Services Authority of British Columbia (PHSA), says there are still times when health care workers do not use the services of an interpreter. “It happens even in areas where a system is in place. Sometimes it may be a timing issue; sometimes it could be related to the perceived cost; or a health care professional may not know the process to request an interpreter,” she explains, adding that educating clinicians on the importance of using interpreters is a goal of the PLS.

Placing interpretation services at the forefront of care is crucial because research shows that language barriers reduce access to care and combined with ineffective interpretation can greatly affect the health and well-being of clients, due to misdiagnosis, incorrect treatment and wrong referrals.

In mental health, where diagnosis relies heavily on words, the importance of properly trained interpreters is crucial, says Dr. Jose Silveira, a psychiatrist and clinical director of Portuguese Mental Health and Addiction Services at Toronto Western Hospital. “It is absolutely critical that patients be treated in their own language,” says Silveira. “Currently, we do not have any objective tools that help us to confirm or refute a hypothesis we have about what somebody is experiencing, so we are completely dependent on the patient being able to convey their internal world to us. The vehicle through which that happens is language.”

More than just translating words, skilled interpreters serve as cultural brokers, conveying subtle nuances and explaining cultural customs, says Stella Rahman, co-ordinator of Cultural Interpretation Services at the Centre for Addiction and Mental Health (CAMH) in Toronto. She says interpreters’ perspectives on mental illness and addiction are just as important as language skills because they may affect the way they interpret.

But the availability of interpreter services alone does not guarantee high-quality client care. Health care practitioners need to be trained to work with interpreters. “It’s one thing to have a tool available to you; it’s another thing to know how to use it,” says Silveira. “Many health care providers have no idea how to use an interpreter.”

Rahman has personally interviewed each of the more than 130 freelance interpreters on her roster. Since the service was created in 2001, she has seen requests for service increase from 12 per month to more than 200 per month in 2007. Rahman’s interpreters need to prove they have completed competency exams in English as well as the targeted languages they would like to interpret, through the Interpreter Language Interpretation Skills Assessment Test, the Cultural Interpreter Language Interpretation Skills Assessment Test or those offered by the Ministry of the Attorney General and the Immigration Refugee Board.

Marie Serdynska, co-ordinator of the Multiculturalism Program at Montreal Children’s Hospital, has also seen a steady increase in requests from clinicians at the hospital, reporting 7,686 interpretations within the hospital’s most recent fiscal year, a 14 per cent increase over the previous year, and a 30 per cent increase in the last three years. In existence for two decades, the program has a bank of about 35 trained interpreters, but like Rahman, Serdynska will use an outside agency if needed.

In Toronto, Montreal and Vancouver – where almost two-thirds of the country’s immigrant population resides – interpreter services are in place, but standards vary across institutions, ranging from ad hoc interpreters to trained professionals who specialize in medical and mental health interpreting. British Columbia has a long history of community organizations providing interpreter services. In 1994, the province established health care interpreting standards. In 2003, it added a province-wide interpreter service through the PLS that has 400 interpreters – including 75 trained in mental health – within the PHSA and responds to more than 20,000 requests annually. The PHSA’s language access policy specifies that when a communication barrier exists between health care provider and client, a professional interpreter or language support should be called in.

“The PLS has been set up to meet the language service needs of the health system,” notes Barclay. “But not all health authorities are using our services. There is still work to be done to ensure that the five provincial health authorities implement a co-ordinated response rather than an ad hoc response.”

Throughout Canada, several colleges, including Vancouver Community College and Seneca and Niagara colleges in Ontario, offer language interpreter training certificate programs that cover such topics as ethics, cultural sensitivity and standards of practice. In Montreal, talks are underway between Dawson College and health care providers to offer a certificate program this autumn.

While there has been a patchwork approach to policies and standards throughout Canada, the National Standard Guide for Community Interpreting Services, released in November 2007, offers a framework on which to build the standards of spoken language interpreters, providing clear definitions of the competencies and skills required to ensure a consistent service. Creators of the guide, which include HIN, Critical Link Canada, the Language Industry Association and the Association of Canadian Corporations in Translation and Interpretation, see it as the first step towards the establishment of standards and accreditation of community interpreters in Canada.

Still, federal funding is needed for implementation, says Barclay. “Every group is trying to do that by cobbling little bits of funding together, but we do not have any national sources of funding that could really help us,” she says, adding that the federal Primary Healthcare Transition Fund that gave provinces and territories some money to introduce new approaches to health care delivery between 2000 and 2006 has dried up. The fact remains that interpreters need to become as integral a part of the health care system as diversity is a part of Canadian society.