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According to the UNHCR, 250 million people currently live outside their country of birth. The growing multicultural population poses a major challenge to healthcare professionals who aim to provide individualized, holistic care, which respects the individual’s autonomy. To ensure basic rights, healthcare interventions should be guided by the value of benefiting others; individuals should be treated honestly, equally, and impartially.
To investigate immigrant doctors’ experiences of using interpreters in the Swedish health-care system.
Twenty-eight doctors, 12 men and 16 women from Bosnia and Herzegovina, Croatia, Macedonia and Serbia participated in four focus group interviews (FGI). The interviews were audio recorded, transcribed and analyzed using content analysis method.
The best results in the present study were achieved in situations where a professional interpreter was involved. In some cases, the doctors were forced to use relatives or a colleague to interpret, which in many cases proved to be a mistake. The consequences of poor interpretation routines included payment by mistake, a patient paying an interpreter who refused to interpret, time spent waiting for another interpreter, as well as disturbances to the daily work schedule. Finding someone who could replace an interpreter who did not show up caused time shortage and increased stress.
Improved routines and more effective cooperation between interpreting services and health-care centers are needed in order to ensure that using professional interpreters guarantees appropriate, high quality care. Improvements are needed to provide satisfactory health-care to people with limited language skills. In order to achieve this, better education of interpreters is needed, especially regarding cultural diversity and medical terminology. These improvements present complex challenges, deserving empirical and critical reflection in order to improve the work situation for doctors.
Currently, there are about 250 million people living outside their country of birth, which means that one in every thirty people in the world is an immigrant (1, 2). This growing multicultural population poses a major challenge to healthcare professionals to provide individualized, holistic care, which simultaneously respects the individual’s autonomy (3-6). To ensure basic rights and freedom, healthcare interventions should be guided by the value of benefiting others; individuals should be treated honestly, equally, and impartially (7, 8). The main goal for Swedish healthcare is the delivery of high-quality care and good accessibility to care for all individuals and their families (7). According to the Swedish Health Act, all individuals have the right to good health and care on equal terms for the entire population. Healthcare shall be provided with respect for the equal worth and dignity of the human person (9). Therefore, these groups of immigrants have also the right to effective communication that enables access to good care. A survey showed that the language barrier between health-care professionals and patients could create discrimination and prejudice problems in health-care (10). In order to keep language from becoming an obstacle in healthcare, the use of certified interpreters is required. An interpreter is a person who professionally verbally translates and conveys what is said from the speaker’s language into the language understood by the listener during a conversation, lecture, or discussion, (11). In Sweden, there is a law (12) stating that people who do not understand or speak the Swedish language have the right to an interpreter in all contact with public authorities. The interpreter has an important role in health-care, facilitating communication between healthcare professionals and patients with language difficulties. However, lack of use of an interpreter may result in the patient’s basic needs being invisible, which may lead to an incorrect diagnosis and lack of compliance from the patient (13). Even in situations where there is an interpreter involved, there may be problems both for the healthcare professionals and for the participants. In a previous study, which explored healthcare professionals perceptions of using interpreters, results indicated that the interpreting situation may be problematic because of organizational aspects. Problems such as accessing interpreter agencies, interpreters not respecting booked consultations, and poorly functioning technical equipment (14). In other previous studies the authors have shown that healthcare professionals experience a lack of easily available interpreters (15, 16) complications in communicating with using an interpreter (17, 18) not least because of lack of training in the practical use of interpreters and also because of financial considerations (18, 19).
The aim of the present study was to investigate and explore immigrant doctors’ experiences regarding use of interpreters in the Swedish health-care system.
Twenty-nine doctors born in former Yugoslavia and working in Sweden were invited to participate in the study. One of the participants declined participation without explanation. In total, twenty-eight doctors participated in the study: 12 men aged between 36 and 54 years (mean 45 years) and 16 women 44-56 (mean 50 years), all of whom had lived in Sweden between 11 and 34 years (Table 1).
All contact with the informants was arranged in collaboration with a key person in the Bosnian, Serbian and Croatian associations of two cities in the west part of Sweden. Information concerning the aim and background of the study was printed and distributed to the informants prior to the interview, and repeated to them orally before the interview.
Four focus group interviews (20) were carried out with participants by the first author between August 2014 and June 2016. Interviews began with small talk and used open-ended questions, following an interview guide inspired by Kvale (21). The main question was
“Could you please describe how do you experience use of interpreters in the Swedish health-care system? “Can you please describe any positive and a negative situation where you have used an interpreter”? Over the course of the discussion, deepening of the content, clarification, and consideration were achieved by means of more target questions. The interviews were done in groups of six persons and held in the culture associations of Bosnians, Serbians and Croatians. A determined sampling procedure was used and included participants who had Serbo-Croat (Bosnian/Croatian/Serbian) as their native language, and had used interpreters on several occasions during the last year and at the different health-care services in Sweden. Verbal and written information about the study was given in Serbo-Croat by the author. The interviewer only interrupted for questions or for following up the information given. The interviews lasted between 90 and 120 minutes and were taped and transcribed verbatim.
A qualitative content analysis method, in accordance with Graneheim and Lundman (2004), was chosen for analysis and interpretation of the collected data. The transcripts were read carefully in order to identify the informants’ experiences and conceptions. Then the analysis proceeded by extracting meaning units consisting of one or more words, sentences, or paragraphs, which contained aspects, related to each other and addressed specific topics in the material. Then meaning units that related to each other through their content and context were abstracted and grouped together into a condensed meaning unit, with a description close to the original text. The condensed text was further abstracted and labeled with a code. Thereafter, codes that addressed similar issues were grouped together, resulting in subcategories. Subcategories that focused on the same problem were brought together in order to create more extensive conceptions, which addressed an obvious issue (22). The results are presented with direct quotes from the interviews. As there was no physical intervention and as no information on individual health issues were involved in the study, there was no need to involve the ethical board according to Swedish law (23). The World Medical Association Declaration of Helsinki (24) was, however, considered carefully. The informants’ identities were protected, that is, their names and personal identity numbers were not stated on the recordings or any publications.
The analysis of the text in this study resulted in one theme and three main categories, and seven subcategories, depending on how the participants described their situation in the use of interpreters in the Swedish health-care encounter. The categories, together with the subcategories, are presented in Table 2.
The results and the quality of interpretation depended largely on who interprets and who is being interpreted. The participants in this study indicated that the best results were achieved in interpretation in situations where a professional interpreter was involved. However, even in this case there were evident shortcomings. In some cases, the participants in the study were forced to use relatives of the patients as well as an employee to take the role of interpreter. In many cases this proved to be a mistake.
All the informants emphasized that professional interpreters were the most important person in the interpretations process. In the event that the interpreter arrived on time, that he/she agreed with the patient, that the language and dialect were appropriate between the interpreter and patient, interpretation was successful. However, most often it was not so easy. For example, the interpreter was still traveling to the hospital and he/she was late, it was difficult to travel to the headquarters to interpret, the language interpreter and the patient did not speak the same language, the interpreter did not know enough medical terminology. These were just some of the reasons that contributed to the fact that the process of interpretation did not go as it should. A minority of respondents in the study also pointed out that the interpretation in their case was successful and without problems.
One doctor described their problems with interpretation as follows:
“First of all, I had problems getting in contact with the interpreter agency, later the interpreter was late, when he arrived at the hospital, we saw that the interpreter did not speak the same language as the patient ….and time was passing.”
Another doctor said:
“The interpreter asked me to clarify some medical terminology because he had problems with that.”
There were some doctors who were satisfied with the interpretation.
“I never had any problems with any interpreter, interpretation was good all the time.”
Guided by previous experiences, and because of the problems of professional interpreters, most of the informants in this study were forced to have a “plan B”. That plan was another solution and a way out of the situation in the event that the interpreter was late, did not come to the hospital or did not speak the same language as the patient. Plan “B” was always to have someone who could take the place of the interpreter. These plans proved to be good for some, and for some bad, but they always caused increased stress for all doctors.
One of the doctors said:
“I spent a lot of time asking and calling people who could and knew how to interpret, because I do not trust interpreters. Many times they forgot to come, or had planned it wrongly.”
“I’ve had several cases when I had to use relatives to interpret, but they cry during the interpretation or do not interpret things as they should …. I think that’s not a solution. “
There were those from whom no “plan B” was necessary because everything functioned:
“I have not had such problems because I have been satisfied with the interpretation and interpreters.”
For the majority of the respondents in the study the “plan B” was also to engage health-care professionals at their department, who were born outside Sweden and who speak the same language as the patient who needed an interpreter. In some cases, this also proved to be a wrong choice because the colleague could not leave his work and devote himself to the interpretation, which sometimes took several hours.
Most doctors described the difficulties here as follows:
“The interpreter was much delayed, the nurse who knew the language of the patient was sick, and the time was passing, time …. it was difficult.”
Another doctor said:
“The patient needed surgery, and the interpreter did not come at all, the nurse interpreted but she often asked me to explain what she needed to interpret, we did not have so much time… the quality of the interpretation process was questionable.”
The majority of the respondents in this study highlighted dissatisfaction with the organization of interpreting services, and the irresponsibility of some interpreters, as well as their insufficient knowledge of medical terminology. However, most of the respondents perceived a more difficult situation that the consequences of all the problems from the interpreter agency affected the patients first, and even the hospital. The consequences were expressed in the payment of interpreters who were sent by mistake, payment by the patient of an interpreter who refused to interpret, the time waiting for another interpreter, as well as the disturbance and obstacles in the daily work schedule of the department.
The consequences of poor or incomplete interpretation or interpretation lacking most of the information were mentioned by several informants. In many cases the situation was that the interpreter arrived, but the agency had made a mistake so the interpreter arrived but was sent back because they did not speak the same language or dialect as the patient, or they did not come at all. Even the cultural and religious aspects were noted. It sometimes took several hours to find an interpreter.
One doctor described it as follows:
“I had a patient who needed emergency surgery… we were trying to help the patient, but the people from the agency were so calm and nonchalant. We had to wait and the whole situation became more complicated because we had to wait. “
Another described their experiences as follows:
“A woman had to have her leg amputated… we should have had a female interpreter, but twice a man came… it disrupted our daily work schedule… it happens.”
One doctor from the gynecology department stated:
“Despite the fact that the interpreter and the patient spoke the same language, the interpreter did not belong to the same culture or religion as the patient and communication was impossible for the patient”.
The consequences that affected the health-care system were recorded by the majority of respondents in this study in terms of difficulties in changes to their daily work schedule and dissatisfaction when the interpreters’ agency made mistakes that the health-care sector had to pay for.
One respondent noted:
“There should be better organization of the interpreters’ agency, because if one link in the chain breaks during the day, everything else is disturbed.”
“I think it is a mistake for interpreters to get paid even if they are sent by mistake or the patient does not accept their obligations ….it should be the interpreters’ agency that makes sure that the right interpreter translates the right language for the right patient.”
Most patients in the study also stated that there were practical questions before and after the interpretation if no interpretation was provided or if it was incomplete. Practical questions were expressed in the form of losing valuable time and increased stress in the event that the interpreter did not come, and when it was impossible to find someone who could take on the role of interpreter.
All participants in the study agreed that time is very important and that everything needs to run its course and happen according to the plan. All confirmed that delay by one person in the process, brings the entire process into question.
One doctor noted:
“There are things in our work that must be completed on time… if it is delayed then the whole day is spoiled.”
All informants in the study suffered additional stress. The majority of respondents in the study emphasized that in addition to the stress they suffer during their working hours and work, they experienced additional stress because they had to wait for interpreters who came late, which, for the respondents in the study, delayed their work, that should have been completed earlier. Thinking of a plan “B” and arranging for another person to interpret also caused additional increased stress.
One doctor stated:
“There is stress all the time… interpreters are late… everything is late, but stress is greater Stress is not late… isn’t that, interesting?”
Most participants in this study would rather use a professional interpreter. However, the participants mentioned that interpreters frequently did not arrive at all or they came too late, they were not well versed in medical terminology or they did not speak the same language or dialect as the patient. The participants stated that this was a major problem, and as a result interpretation was frequently left to relatives or hospital staff. As a result the interpretation was often unsatisfactory since these people do not have professional training in interpreting and lack the necessary skills (25). Good communication is vital in clinical consultations since they are the first stage of the diagnosis and treatment process (26). Previous studies have already demonstrated how important the interpreter’s competence in clinical consultation is (18, 27, 28). The present study showed the frequent lack of professionalism and lack of knowledge of medical terminology.
It also emerged for the first time from this study that medical professionals must frequently resort to a plan B in order to deal with problems relating to the interpreters’ agency. Problems are often caused as a result of resorting to plan B, using a relative or health-care professional instead of a professional interpreter, and this may lead to errors or difficulties in communication for both the patient and the professionals. In addition, the need to have a plan B leads to further stress for all those involved. It has already been reported that relatives or friends frequently find it difficult to remain impartial and neutral when interpreting, and they often lack the necessary language skills (29). It is necessary to provide a high quality professional health-care specialist interpreter to ensure that all patients have equal access to health care services (30). Use of health-care professionals and relatives as interpreters may be a solution when there is no alternative, but it has many disadvantages (31). A well-organized health care system has a considerable impact on the provision of improved health care for all the patients. The findings of this study differ from a previous study (32) where health-care professionals considered the quality of interpreting provided by patients’ relatives and bilingual employees to be satisfactory, even though they recognized the difference in quality of the work of professional and non-professional interpreters. The findings here add weight to the importance of professional interpreters, and providing interpretation in different dialects and the same language, in order to ensure good communication and satisfactory interpretation. They must have the necessary language and professional skills (33) and language services need to be integrated into organizational routines (32). Healthcare professionals need to have sufficient time to complete all their work, to devote sufficient time to their patients and the tasks involved, but time is limited. When they need to worry about finding other people to act as interpreters, additional stress is involved and health-care professionals need to re-organize their days, and do work which they otherwise would not need to do. The findings of the present study are in accordance with a previous study where the authors identified the important factors that generate mental stress, including difficulties in balancing priorities and following rules and recommendations, that seem to be contrary to best care, and the need for interdisciplinary teamwork (34).
The availability of interpreters, employment of interpreters appropriate for the language or dialect, use of medical terminology, and the ethnic and religious aspects are vital for a good communication outcome and patient safety. Clearer and more effective cooperation between interpreting services and health-care centers is needed in order to ensure that using professional interpreters guarantees appropriate, high quality care. Improvements are needed to provide satisfactory health-care to people who have limited language ability. In order to achieve this, better education of interpreters is needed, especially regarding cultural diversities and medical terminology. These improvements present complex challenges, deserving empirical and critical reflection so that doctors are able to get on with their work.
• Authors Statement: All authors were included in preparing of the present study.
• Conflict of interest: none declared.