When a patient’s first language in not English, it is tempting to use a relative or friend as an interpreter. But, as Radhika Holmström explains, this can lead to misunderstandings and even misdiagnoses.
‘When we arrived in England, when I was 16, I had to do all the interpreting for my family,’ says Maria (not her real name). ‘My sisters were younger and my parents didn’t speak a word of English, so I was the one helping us at appointments. I managed it, but I didn’t like it and I did make mistakes. There was a lot of pressure and I always worried I would get something wrong and mess up everything.’
It can be extremely tempting, at community level, to use family, friends or community members to interpret for patients. Often, it’s what the patients themselves assume will be needed and they may even feel more at ease with people they know. But in practice it can result in errors, including misunderstandings and even misdiagnoses.
The language barrier
Strictly speaking, there is a clear difference between translating and interpreting. Translation applies to written material, which in this case includes information such as patient leaflets, website copy, guidance about treatments and so on. Sometimes more personal information needs to be translated – for example, a patient’s medical notes and any documents they bring with them about their health and/or any medication they have been taking.
Interpreting refers to the spoken word – the verbal exchange between people that happens in any consultation or nursing visit. This can be problematic for many healthcare professionals, because it has to be ‘live’ and tailored to the particular person. It can be done by bringing in an interpreter to work in a face-to-face setting, or through a phone service, video link or Skype/Zoom call. Over the past year, a number of web-based interpreting solutions have started being used, including enhanced ‘Zoom-plus’ and Remote Interpreter, among others.
In practice, however, getting hold of interpreters can be problematic for nurses who are working outside hospitals. Booking a professional interpreter is expensive and arranging convenient timings can also be an issue. Phone-based services bring the same problems.
The other possibilities are bilingual nurses, or falling back on family and friends. So what are the drawbacks of the non-professional options?
A specialised skill
Interpretation by family and friends is not considered to be good practice as there are just too many personal, cultural and medical issues involved. The official guidance on the topic states that ‘patients should always be offered a registered interpreter’. Quite apart from the question of the patient’s right to privacy, healthcare interpreting is a specialised skill for good reason, explains Kavita Parmar, of translation and interpreting provider Word360. ‘Even with the best intentions, someone who is a native speaker may still not understand the terminologies; when it comes to using an interpreter you have that guarantee that the person knows the nuances and knows how to explain terms – including ones that may not be easy to translate.
‘Then there’s a whole issue of bias and conflicts of interest. In many cultures and languages, there are issues – for example, with a man explaining treatment to a woman. Family members may give their own advice.’
Some healthcare professionals predominantly rely on Google Translate, with each party typing their message for the other – this solution is also inadequate for healthcare purposes. Although machine translation is now becoming increasingly accurate, it still ideally requires ‘post-editing’ – checking by humans to ensure the translation is correct. In situations where accuracy is absolutely essential, such as when symptoms are being described or when a diagnosis is being made, there is no room for error and machine translation does not guarantee this.
A good interpreter is impartial, but they also can and do clarify things that get literally as well as metaphorically lost in translation. These can be simple, such as explaining food terms to the nurse, or involve nuances that only a professional would appreciate.
‘The importance of a professional interpreter is that first, they will have the specific knowledge that’s required for the topic,’ explains Jakub Sacharczuk, an interpreter and board member of the Institute of Translation and Interpreting. ‘They know the areas that can cause confusion and problems. Someone who’s not a professional may guess, and get completely the wrong message.’
Sacharczuk elaborates further on the skills that a trained interpreter has learned, and that a friend or community member will probably to lack. ‘Someone who isn’t a professional will usually use the third person – “he’s saying, she’s saying” and so on – and repeat it as reported speech. An interpreter will speak as if they were the patient, using “I”, removing themselves from the conversation and therefore removing that barrier. If someone tries to talk [directly] to me, I know to look down at my notepad and break eye contact. That breaks down the relationship between us, and diverts it to a relationship between the two people who’re meant to be communicating. This means they are much clearer.’
When things go wrong
Jane Cook, a Queen’s Nurse and a health specialist working with excluded communities, has certainly seen this sort of case. ‘I’ve been in situations, especially with asylum seekers, where I’ve witnessed a misdiagnosis,’ she says.
‘For example, I’ve seen a case where a patient had to “act out” what was wrong, and the GP made the wrong prescription (fortunately we were able to support her with a proper interpreter and get this corrected). I’ve also seen an incident where a GP called a local restaurant, because his patient came from the same part of the world. He thought he was being innovative in ringing and asking for an interpreter and they sent someone round but of course the whole issue of confidentiality wasn’t being taken into account. In addition you have all the issues of culture, gender and the person’s rights – quite apart from the quality of the interpreting.
And, as Cook points out, there can be even worse situations. ‘In the past we had the whole issue of Victoria Climbié [a child murdered by family members in London in 2000], whose aunt acted as her interpreter. It’s still a massive issue, you need to use trained interpreters, not relatives. And children should definitely not be used as interpreters, including as interpreters for friends at school. There may be a sensitive issue they don’t want their peers to know about, like domestic violence or family issues.’
Value for money
Arranging a professional interpreter or interpreting service may not be easy, meaning staff might think it is easier to turn to someone who is available and will ‘just do’, especially if time is a factor. But the effort is very much is worth it, Parmar argues.‘We live in a society that is multicultural and diverse, and having that extra layer of support for patients enables them to get the help that they need.
‘Interpreters are a very efficient way of getting information across at the right time; ultimately, it reduces the burden on the local community.’
Sacharczuk concludes: ‘I think there is a temptation to assume that someone who speaks the same language is good enough. I’ve been to hundreds of appointments and having a professional interpreter can really take the communication to a different level. It helps the practitioner really understand their patient.’
Here is NHS England’s guidance for commissioning interpreters and translators in primary care.
Tips for good practice
– Remember that the interpreter is the means of communicating with the patient.
– If the interpreter is physically present, they should sit with the healthcare professional, in the patient’s line of sight (the ‘interpreter triangle’).
– Speak to the patient, not to the interpreter.
– Check that the patient has understood, by asking them to repeat to you their understanding of what has been said.
See how our symptom tool can help you make better sense of patient presentations
Click here to search a symptom
Visit Nursing in Practice Reference for details on 140 symptoms, including easily searchable symptoms and categories, offering you a free platform to check symptoms or search by category during a consultation to look for guidance on next steps.
Interpretation by family and friends is not considered to be good practice as there are just too many personal, cultural and medical issues involved.