Interpreter-mediated Consultations Research Articles

The co-construction of empathic communication in interpreter-mediated medical consultations: A qualitative analysis of interaction

Current interpreter training programs pay increasingly more attention to the intricacies of the clinical context, such as doctors and patients’ communicative goals. However, to date, the conduit model remains influential when it comes to interpreters dealing with other participants’ emotions and their own emotions in interpreter-mediated consultations (IMCs). Consequently, establishing a good doctor-patient relationship by means of empathic communication (EC) might be jeopardized in IMCs. During EC, patients express their emotional or illness experiences to which doctors convey their empathic understanding. This study aimed to assess how doctors, patients, and interpreters verbally co-construct EC and the interpreter’s effect on this process. We analyzed 7 authentic IMCs using the Empathic Communication Coding System, as previously adapted for IMCs. We identified empathic opportunities (EOs) and empathic responses (ERs) as expressed by patients/doctors, and as rendered by interpreters. Our results showed that EC is the result of an interactive and collaborative process among all participants in IMCs. That is, the interplay between participants’ communicative actions determines how patients’ expressed lived experiences are addressed in IMCs. Our findings suggest that interpreters hold a central position in this process as they initiated EC about the patient’s illness experience and exerted control over the ways in which statements were rendered (e.g., interpreters omitted and altered original statements). In addition, our results indicated that EC in IMCs might be compromised by doctors and interpreters’ communicative actions.

Interpreter-mediated psychiatric assessments: Metacommunication as key.

Psychiatric assessments of non-native migrant patients facilitated by an interpreter pose specific communication challenges to all participants. In this study, we developed an original interdisciplinary approach to the verbal and non-verbal practices in this triadic activity. The aim was a data-based description of challenges for clinicians and interpreters, and the identification of relevant strategies. We filmed, transcribed and translated 10 interpreter-mediated consultations focused on the psychiatric assessment of the patient. Subsequently, we submitted the consultations to clinical, interactional sociolinguistic, and interdisciplinary analyses. We identified six challenges for interpreters and clinicians engaged in psychiatric assessments: barely comprehensible and confusing speech, speech about emotions and subjective perceptions, sensitive remarks in relational terms, conclusive clinician interventions, interruptions during interpreter renditions, and non-verbal communication. Attempts by the interpreter to avoid relational offenses (protection of positive face) and to defend the participants' autonomy (protection of negative face) play a major role in these challenges. So does an insufficient awareness of mutual needs by the clinician and the interpreter. We identified specific strategies of inter-professional metacommunication for each challenge. Clinicians and interpreters should be aware of the challenges they may face in triadic psychiatric assessments. They should take a reflexive stance towards their common practices and may consider using metacommunication tools to reach better communicational and clinical outcomes.

Doctors, Patients, and Interpreters' Views on the Co-Construction of Empathic Communication in Interpreter-Mediated Consultations: A Qualitative Content Analysis of Video Stimulated Recall Interviews.

Doctors and patients rely on verbal and nonverbal resources to co-construct clinical empathy. In language-discordant consultations, interpreters' communicative actions might compromise this process. We aim to explore doctors, patients, and professional interpreters' perspectives on their own and others' actions during their empathic interaction in interpreter-mediated consultations (IMCs). We analyzed 20 video stimulated recall interviews with doctors, patients, and interpreters using qualitative content analysis. Doctors and patients found ways to connect with each other on the level of empathic communication (EC) that is not limited by interpreters' alterations or disengaged demeanor. Some aspects of doctors and interpreters' professional practices might jeopardize the co-construction of EC in IMCs. The co-construction of EC in IMCs is not only subject to participants' communicative (inter)actions, but also to organizational and subjective factors. These results provide evidence of the transactional process between the behavioral, cognitive, and affective components of clinical empathy in the context of IMCs.

The Empathic Communication Analytical Framework (ECAF): A multimodal perspective on emotional communication in interpreter-mediated consultations

Empathic communication (EC) in healthcare occurs when patients express empathic opportunities, such as emotions, to which doctors respond empathically. This interactional process during which participants try to achieve specific communicative goals (e.g., seeking and displaying empathy) serves as a context in which doctors and patients perform verbal and nonverbal actions and collaboratively co-construct meaning. This applies to interpreter-mediated consultations (IMCs) too, where interpreters perform additional actions of a similar kind. However, there is a dearth of research on the ways in which participants perform these actions in the context of EC, and how these actions in turn help (re)shape the context of EC in IMCs (Theys et al., 2020). To date, any tools for studying EC investigate participants’ actions in isolation, without studying them in the context of EC or in relation to the participants’ awareness of their own and others’ ongoing interactions. In this article, we present the Empathic Communication Analytical Framework (ECAF). The tool draws on valid, complementary analytical tools that allow for a fine-grained, three-level multimodal analysis of interactions. The first level of analysis allows for instances of EC in spoken language IMCs to be identified and for participants’ verbal actions in the context of EC to be studied. The second level allows analysts to investigate participants’ verbal and nonverbal actions in the previously identified context of EC. The third level of analysis links the participants’ concurrent verbal and nonverbal (inter)actions to their levels of attention and awareness and shows how participants’ actions are shaped and in turn help to reshape the context of EC in IMCs. In this article, we present the various levels of the ECAF framework, discuss its application to real-life data, and adopt a critical stance towards its affordances and limitations by looking into one excerpt of EC in IMCs. It is shown that the three distinct yet interconnected levels of analysis in the ECAF framework allow participants’ concurrent multimodal interactions in the context of EC to be studied.

Teach-Back in Interpreter-Mediated Consultations: Reflections from a Case Study.

Background:Women with a refugee background and their families who have settled in a new country can be expected to have low health literacy, and this may be a contributing factor to poor perinatal outcomes.Brief description of activity:Effective communication is critical for meaningful engagement with patients. Teach-Back is an interactive tool that can assist health professionals confirm whether they are communicating effectively so they are understood and their patients can apply health information. However, evidence for its effectiveness in interpreter-mediated appointments is lacking.Implementation:An antenatal clinic caring for women with a refugee background provided an opportunity to explore the benefits and challenges of using Teach-Back with this population. Staff had access to informal on-site training on health literacy and Teach-Back, tried using Teach-Back in their clinical work, and were then asked to provide feedback on what it was like using Teach-Back.Results:This case study identified several challenges when applying Teach-Back in interpreter-mediated antenatal health care appointments associated with differing cultural nuances and cultural practices.Lessons learned:Building interpersonal and cross-cultural communication capabilities among health professionals is essential in advancing health literacy workforce practice to improve the health literacy of non-English speaking refugee communities. Although Teach-Back may have the potential to be a powerful tool in promoting the health literacy of these women during pregnancy, further research is required to ensure that its use promotes safe and equitable health care. [HLRP: Health Literacy Research and Practice. 2021;5(3):e256–e261.]Plain Language Summary:This article reports a case study of using Teach-Back in pregnancy appointments involving a midwife and an interpreter. Several challenges for using Teach-Back were identified due to differences in cross-cultural communication. Supporting clinicians and interpreters to work together to implement Teach-Back is required to improve cross-cultural communication and women's health literacy.

Communicative hurdles in multilingual interpreter-mediated consultations: what trainee data teach us

ABSTRACT This paper reports on an interprofessional training initiative for medical students and trainee interpreters. Relying on a mixed-method analysis of 10 video-recorded simulated consultations at Ghent University (Belgium), the paper investigates which factors impact on trainee interpreters’ (in)complete rendition of medical students’ communicative goals. Our analysis reveals that incomplete renditions can be attributed to (i) long turns including more than one communicative goal; (ii) long turns including large chunks of information; and (iii) a combination of old (i.e. previously given) and new information. Based upon these results, we formulate the following recommendations for the interprofessional training of trainee interpreters: (i) familiarise students with the Calgary Cambridge guide (ii) prepare them for the interpretation of longer turns (iii) teach them how to interrupt a doctor as a safeguard against inaccurate interpretation and (iv) instruct them how to find the right balance between inserting old and new information.

The professional interpreter’s effect on empathic communication in medical consultations: A qualitative analysis of interaction

ObjectiveTo investigate how empathic communication is expressed in interpreter-mediated consultations (IMCs) and the interpreter's effect on it. MethodsWe coded 20 authentic video-recorded IMCs by using the Empathic Communication Coding System (ECCS). We compared patient-initiated empathic opportunities (EOs) and doctors' responses as expressed by patients and doctors and as rendered by interpreters. ResultsWe identified 44 EOs. In 2 of the 44 EOs there was a close match in the way the EOs were expressed by the patient in the first place and in the way they were rendered by the interpreter. Twenty-four of the 44 EOs that were passed on by the interpreter to the doctor and presented the doctor with an opportunity to respond, came with a shift in meaning and/or intensity. Twenty of the 44 EOs were not passed on by the interpreter to the doctor. ConclusionIn IMCs, EOs are subject to the interpreter's renditions and the doctor's actions during interaction. Practice implicationsDoctors and interpreters require skills to detect patient cues, assess them correctly, render them completely and in an appropriate manner (interpreters) and display communicative behaviours that take into account the intricacies of interpreter-mediated clinical communication and facilitate each other’s communicative goals.

The interpreter’s voice: Carrying the bilingual conversation in interpreter-mediated consultations in pediatric oncology care

ObjectivesThe objective of this study was to explore interpreters’ perceived strategies in the interaction in interpreter-mediated consultations between healthcare personnel and patients/families with limited Swedish proficiency in pediatric oncology care. MethodsThis study had an inductive approach using an exploratory qualitative design. A total of eleven semi-structured interviews were performed with interpreters who had experience interpreting in pediatric oncology care. ResultsThe interpreters' perceived strategies were divided into four generic categories; strategies for maintaining a professional role, strategies for facilitating communication, strategies for promoting collaboration, and strategies for improving the framework of interpreting provision. These four generic categories were then merged into the single main category of carrying the bilingual conversation. ConclusionsThe interpreters stretch their discretionary power in order to carry the bilingual conversation by using strategies clearly outside of their assignment. Practical implicationsThe study contributes to the understanding of the interpreter-mediated consultation in pediatric oncology care, and this can be used to improve the care of patients and families in pediatric oncology care with limited knowledge of a country’s majority language.

Informal interpreting in general practice: Are interpreters’ roles related to perceived control, trust, and satisfaction?

ObjectiveThe aim of this observational study was twofold. First, we examined how often and which roles informal interpreters performed during consultations between Turkish-Dutch migrant patients and general practitioners (GPs). Second, relations between these roles and patients’ and GPs’ perceived control, trust in informal interpreters and satisfaction with the consultation were assessed. MethodsA coding instrument was developed to quantitatively code informal interpreters’ roles from transcripts of 84 audio-recorded interpreter-mediated consultations in general practice. Patients’ and GPs’ perceived control, trust and satisfaction were assessed in a post consultation questionnaire. ResultsInformal interpreters most often performed the conduit role (almost 25% of all coded utterances), and also frequently acted as replacers and excluders of patients and GPs by asking and answering questions on their own behalf, and by ignoring and omitting patients’ and GPs’ utterances. The role of information source was negatively related to patients’ trust and the role of GP excluder was negatively related to patients’ perceived control. ConclusionPatients and GPs are possibly insufficiently aware of the performed roles of informal interpreters, as these were barely related to patients’ and GPs’ perceived trust, control and satisfaction. Practice implicationsPatients and GPs should be educated about the possible negative consequences of informal interpreting.

How interpreters influence patient participation in medical consultations: The confluence of verbal and nonverbal dimensions of interpreter-mediated clinical communication

ObjectiveTo investigate i) how the patient’s participation in interaction occurs in interpreter-mediated consultations (IMCs) when the doctor provides information to the patient or tries to elicit information from them; ii) how the interpreter’s presence in the consultation influences the patient’s participation. MethodWe analyzed 20 authentic video-recorded IMCs using the A.R.T. framework, an analytical tool for the study of participation in video recorded interpreter-mediated interactions. ResultsWe coded 521 doctor utterances through which doctors either provided information or tried to elicit information from the patient. In 448 of them, the interpreter established a participation and engagement framework (PEF) with the patient while translating the doctor’s utterances. In 48 cases the interpreter established a PEF with the doctor and in 25 cases the interpreter avoided establishing a PEF with either of the participants while translating the doctor’s utterances. ConclusionWhen the interpreter established a PEF with either of the participants, they used verbal and nonverbal means that created the conditions in interaction in order to enable and/or rectify the patient’s participation. Practice implicationsDoctors and interpreters should become more aware of their own and each other’s actions in interaction and their influence on the patient’s participation in the consultation.

EmpathicCare4All. Study protocol for the development of an educational intervention for medical and interpreting students on empathic communication in interpreter-mediated medical consultations. A study based on the Medical Research Council (MRC) framework phases 0–2

Although empathy is associated with positive health outcomes, doctors do not often express empathy and they fail to sufficiently respond to patients’ emotional statements. In linguistically diverse healthcare settings empathic communication is compromised even more. This has received little attention in medical education and even less in interpreter education. This project aims to develop an educational intervention for medical- and interpreting students on empathic communication in interpreter-mediated consultations. We rely on the Medical Research Council (MRC) framework for the development and evaluation of complex interventions (phases 0–2). The project will yield valuable insights into the communicative and interactional processes and resources doctors, patients and professional interpreters use in the expression and management of empathic communication in interpreter-mediated consultations.

Investigating empathy in interpreter-mediated simulated consultations: An explorative study

ObjectiveTo explore i) the ways in which empathic communication is expressed in interpreter-mediated consultations; ii) the interpreter's effect on the expression of empathic communication. MethodsWe coded 9 video-recorded interpreter-mediated simulated consultations by using the Empathic Communication Coding System (ECCS) which we used for each interaction during interpreter-mediated consultations. We compared patients' empathic opportunities and doctors' responses as expressed by the patients and doctors and as rendered by the interpreters. ResultsIn 44 of the 70 empathic opportunities there was a match between the empathic opportunities as expressed by the patients and as rendered by the interpreters. In 26 of the 70 empathic opportunities, we identified 5 shift categories (reduced emotion, omitted emotion, emotion transformed into challenge, increased challenge/progress, twisted challenge) in the interpreter's rendition to the doctor. These were accompanied by changes in the level of empathy and in the content of the doctors' empathic responses. ConclusionThe interpreters' renditions had an impact on the patients' empathic opportunities and on the doctors' empathic responses in one third of the coded interactions. Practice implicationsCurricula with a focus on intercultural communication and/or empathy should consider the complexity of interpreter-mediated interaction and the interpreter's impact on the co-construction of empathy.

Difficulties in using interpreters in clinical encounters as experienced by immigrants living in Sweden.

To study a group of immigrants' experiences regarding interactions with primary health care through an interpreter. Approximately, 230million people are resettled outside of their own home country. Thus, more than 3% of the world's population are migrants. It is a major challenge for health care providers to satisfy immigrants' needs for individualised health care services. Qualitative study. Focus group interviews were conducted with four groups of immigrants (n=24) from Bosnia and Herzegovina, Croatia, Kosovo and Somalia. The group interviews were audio recorded, transcribed and analysed, and the text was categorised using the content analysis method. Participants' expectations of the interpreter-mediated consultations were high, but not always fulfilled. Interpreters being late, lacking professionalism or lacking knowledge in medical terminology and the use of health care professionals or relatives as interpreters were some of the problems raised. A well-organised, disciplined interpreter service with professional and competent interpreters is needed to overcome problems regarding clinical consultations involving interpreters. A satisfactory language bridge has a significant impact on the quality of communications. Interpreter services should be well organised, and interpreters should be linguistically, culturally and socially competent, as these factors may have a significant impact on consultation outcomes. Using relatives or staff as interpreters can sometimes be a solution but often results in an unsatisfactory clinical consultation.

Gaze and body orientation as an apparatus for patient inclusion into/exclusion from a patient-centred framework of communication

Dialogue interpreter training has traditionally focused on the way in which the interpreter manages, and maintains, verbal interaction between the primary participants while it seems to overlook the importance of specific non-verbal aspects that are inherent in mediated interaction. This article presents an alternative method for the training of medical interpreters by drawing on research on non-verbal communication in interpreter-mediated consultations with a view to drawing attention to the interpreter’s impact on the patient’s inclusion in a patient-centred framework during mediated consultations. More specifically, it provides evidence of non-verbal interaction that might open up new trajectories in the interpreters’ training by foregrounding the impact of the interpreter’s and others’ direction of gaze and body orientation on the accomplishment and maintenance – or lack thereof – of a patient-centred framework of communication. The present article reports on findings that emerged from the analysis of selected excerpts of authentic interpreter-mediated consultations within the framework of a training experiment. Coded instances of interaction are analysed by relying on Goffman’s ‘ratification process’, Goodwin’s ‘participation and engagement frameworks’ and Norris’ ‘modal density foreground–background continuum’. Hospital ethical approval and participants’ written informed consent were obtained prior to the collection of data.

Interpreter-mediated diabetes consultations: a qualitative analysis of physician communication practices

BackgroundPatient-provider communication, in particular physicians’ ability to listen to their patients, and support them in making difficult lifestyle changes, is an essential component of effective diabetes care. Clinical communication around diabetes can be especially challenging when language barriers are present, and may contribute to poor diabetes management and outcomes. Clinicians need to be aware of and address potential communication difficulties associated with interpreter-mediated consultations. The purpose of our study was to explore how physicians communicate in interpreter-mediated consultations with diabetic patients, and how their communication behaviors may impact diabetes communication and care.MethodWe analyzed transcripts from 8 audio recorded, outpatient consultations at the Basel University Hospital general medicine outpatient clinic involving Turkish-speaking patients, German-speaking physicians, and Turkish-German interpreters (both community interpreters and family members).ResultsClinicians used closed questions when asking about symptoms and glucose control. When providing information and explanation, they spoke in long and complex speech turns. They often directed their speech to interpreters or became sidetracked by family members’ questions or requests for information. Patients’ participation in the consultation was minimal, and limited to brief answers to clinicians’ questions.ConclusionsClinicians need to be aware of common pitfalls that diminish patient-centeredness during interpreter-mediated consultations, and learn strategies to avoid them. Attention to established guidelines on triadic communication is recommended, as is hands-on training with interpreters.

The challenge of communication in interpreted consultations in diabetes care

Seale is right to observe that this is the first published empirical study of interpreter-mediated consultations in UK primary care; in the past 10 years, with several colleagues I was unsuccessful in getting funding for such a study.1 The paper is shocking to the extent that it shows in one UK setting — but there …

Challenges of mediated communication, disclosure and patient autonomy in cross-cultural cancer care.

Background:Evidence concerning the influence of ethnic diversity on clinical encounters in cancer care is sparse. We explored health providers' experiences in this context.Methods:Focus groups were conducted with a purposeful sample of 106 health professionals of differing disciplines, in 18 UK primary and secondary care settings. Qualitative data were analysed using constant comparison and processes for validation.Results:Communication and the quality of information exchanged with patients about cancer and their treatment was commonly frustrated within interpreter-mediated consultations, particularly those involving a family member. Relatives' approach to ownership of information and decision making could hinder assessment, informed consent and discussion of care with patients. This magnified the complexity of disclosing information sensitively and appropriately at the end of life. Professionals' concern to be patient-centred, and regard for patient choice and autonomy, were tested in these circumstances.Conclusion:Health professionals require better preparation to work effectively not only with trained interpreters, but also with the common reality of patients' families interpreting for patients, to improve quality of cancer care. Greater understanding of cultural and individual variations in concepts of disclosure, patient autonomy and patient-centredness is needed. The extent to which these concepts may be ethnocentric and lack universality deserves wider consideration.