Abstract
Background:
Healthcare professionals find breaking bad news difficult and upsetting. Increasing cultural diversity has led to a greater number of patients whose first language differs to that of the healthcare provider, with more patients requiring a translator to facilitate communication. Hospitals often ask non-clinical translators to facilitate breaking bad news. We sought to explore the experiences of translators within a specialist oncology centre.
Methods:
Following ethical and governance approvals, semi-structured interviews were undertaken with five translators recruited from the specialist oncology centre. Interviews were audiotaped and transcribed verbatim. The data were analysed thematically, with major themes and subthemes identified.
Setting:
Outpatient setting of a regional cancer centre.
Participants:
Translators serving a regional cancer centre.
Main outcome measures:
Qualitative data identified through thematic analysis.
Results:
Major themes included the significant emotional impact of translating distressing information, the challenges of accurately conveying information in a culturally congruent format and the need for formal briefing, debriefing and support. Subthemes included feeling guilty for divulging distressing news, being the focus of patients’ distress or anger, and feeling in conflict with the patient or family and issues surrounding confidentiality. Translators also felt a strong sense of advocacy for the patients and found encounters with death and dying emotionally challenging.
Conclusions:
The increasing use of translators in the care of patients with advanced cancer is increasingly resulting in lay people being subject to similar emotional pressures faced by clinical staff, yet without the necessary formal training or support mechanisms that are recommended for clinicians. This exploratory study highlights the training and support needs of non-clinical staff as identifying a unique set of communication challenges faced by translators.
Introduction
Effective communication is central to medical care; be it history taking, convening information or discussing treatment options. As such, one of the most challenging tasks facing doctors lies with breaking bad news or conveying any information which ‘results in a cognitive, behavioural, or emotional deficit in the person receiving the news that persists for some time after the news is received’.1,2 The importance of good communication has been widely recognised such that communication skills and breaking bad news are integral to all medical undergraduate curricula. Furthermore, communication skills are specifically assessed in postgraduate examinations of many professional colleges including the Royal Colleges of Medicine, 3 General Practice, 4 Paediatrics, 5 Emergency Medicine, 6 Obstetrics and Gynaecology 7 and Surgery. 8 Furthermore, it is believed that many clinical errors, complaints and litigation within the National Health Service (NHS) could have been avoided through better communication. 9
The NHS supports an increasingly multicultural and multinational population. In the 2011 Census, 13% of the population of England and Wales were born outside the UK. English was reported as the first language of 88% of foreign nationals, with 9.8% of the population reporting to be unable to speak English ‘well’ and 1.7% speaking no English at all. 10 Therefore, up to 11.5% of the population might need a translator when communicating with healthcare professionals, particularly in consultations regarding sensitive or distressing issues. In addition to non-English speakers, other patient groups may require the assistance of a translator; in 2011, 15,000 people living in England and Wales reported themselves to be using British sign language (BSL) as their main language. 10
While family members may take on the role of translator, there has been an increasing demand for professional translators, as evidenced by increased NHS spending in this area. 11 The use of professional translators has been highly evaluated by patients and the use of an independent and thus non-family member has several potential advantages. 12 First, it avoids any potential for bias with respect to the translation of information especially with respect to the possibly of family members wishing to withhold or modify information to the patient. Second, it obviates the family member from the sometime distressing role of conveying information and the emotional sequelae of being the bearer of such information.
The published literature has reported that breaking bad news is not only challenging but also a distressing task for some.13–16 There are several ways of addressing any distress that may arise from such encounters, which may include clinical supervision, formal debriefing, reflective practice and if necessary accessing formal support through occupational health. As such, there are several mechanisms in place to manage the consequences of distressing encounters for healthcare professionals, which will hopefully build upon their formal training and clinical experience to date. It is conceivable that where qualified doctors who encounter medical illness on a daily basis find communication distressing, so too will professional translators who have no formal healthcare training or routine exposure. There is currently no published research on the challenges faced by professional translators in the NHS, especially those involved in conveying distressing information. While we have a degree of understanding of the training and support needs of healthcare professionals involved in difficult communication, the comparable degree of distress and support needs of translators are unknown. We therefore undertook an exploratory study to identify whether there were any challenges faced by professional translators and whether a larger, multicentre study was warranted and feasible.
Methods
Sample
Ethical and governance approvals were gained in March 2010. Participants were recruited from a regional cancer centre serving a multicultural rural and urban population. A hospital database of available translators was screened for potential participants (n = 27). Those eligible (n = 14) were sent a letter of invitation, with accompanying study information and participation details. Inclusion and exclusion criteria are described in Figure 1. Reminder letters were sent after one month to non-responders.
Inclusion and exclusion criteria.
Five translators agreed to take part, who were aged between 23 and 60 years old and had 2–17 years’ translation experience. Two participants were BSL translators, two Bengali/English and one Polish/English.
Data collection
Semi-structured interviews were carried out over a 12-month period by HO, an experienced palliative care physician trained in qualitative interviewing. Interviews were conducted either in the participant’s home or in the hospital outpatient department according to preference. The interviews were guided by an interview schedule to ensure that the same issues were discussed each time. Interviews took no more than 30 minutes. While participants were required to have conducted translation within the past year, thereby identifying recent participation in translating, questions explored the whole of their experiences explored of translating over time. Data were elicited on the following:
experiences of translating for patients with cancer; challenges of the role.
Interviews were digitally recorded and transcribed verbatim. Field notes were also taken.
Data analysis
Data analysis was undertaken by two researchers (JP and SN) following a thematic approach. 17 Group results were analysed for consistent themes using techniques of coding and comparison. The researchers then developed a coding framework for emergent themes. This was an iterative process, moving between the data and the analytical concepts to develop codes and concepts grounded in the data. Higher-level abstractions of codes were decided and results were verified by the research team by independent review of a selection of transcripts.
Results
The first major theme identified the significant emotional impact of translating distressing information, which included the challenges of accurately conveying information in a culturally congruent format, being the target/focus of patient or family distress and the responsibility of advocacy. The second major theme highlighted the need for formal debriefing and support.
Significant emotional impact of translating
The major theme to emerge was the significant impact of translating distressing news between doctors and patients with cancer. Several subthemes were also identified.
In addition to being the person to deliver significant news to patients, translators were also the first to receive the subsequent response from patients. This led to an emotional connection and participants would often find it hard to ‘switch off’ following a consultation: ‘I would really take that home with me I would be really really upset and um really worried for the person’ (P5).
All participants felt a connection with patients, whom they translated for, describing themselves as feeling ‘emotional’ regarding their clients: …it did make me feel emotional. It did make me feel emotional because like I was just talking to the client five minutes ago about where he worked you know and he was really happy he was a happy man, he was really like enjoying his life. (P3)
‘So obviously I didn’t feel the same way as a daughter would feel but I can’t say that, you know, that I didn’t get emotional because I did because it was very sad’ (P1).
They also expressed considerable distress when patients they had worked with died, considering their feelings to be similar to a death of a loved one: So that was quite emotional when he passed away you know. (P3) And it’s just to me its like losing a member of your family because you know that’s who I’ve worked with. (P4)
The challenges of accurately conveying information in a culturally congruent format
Participants took their translator role very seriously and described a desire to convey information in an accurate, emotionally and culturally congruent way. They described difficulties in interpreting discussions in the first person especially if doctors were talking in the third person or speaking directly to the translator: …when the doctor talks, um, sort of “tell her this tell her that” then the patient will start to talk to me not the doctor or service provider, so I say I feel that you know there is no communication whatsoever between them. (P1)
It’s direct yeah. I try and make it out as no middle person there. It’s just there are just two people having a conversation, the client and service provider, the doctor and my client and that’s it. (P3) …I don’t say ‘oh please look at him’ or I don’t say to a service provider “look at the client” etc. (P2)
In addition to trying to convey information from doctor to patient appropriately, translators also acknowledged a challenge in conveying the feelings and responses of the patient: …you have to match their mood and what their voice would sound like so instead of saying um, ‘I feel really sad and there is no point to my life so I want to die’ you have got to say it to match their facial expression so that naturally, because you are acting in a way I suppose, so you would then automatically take on that emotion you know whereas if you say it in the third person you would be more neutral in your voice. (P5)
Being the target/focus of patient or family distress
The emotional responses of patients and family members to distressing news are well documented. Most doctors will have experience of dealing with anger and distress recognising them as appropriate responses to distressing information. As the person conveying distressing news, translators often found themselves on the receiving end of patient or family anger: ‘…she [the patient] was angry, that’s why she took out on me but still made me feel bad and upset, you know?’ (P2).
Both sign language translators reported being treated discourteously by patients they were translating for. They felt their role was not respected and reported being viewed in an impersonal way: I am not just a machine… (P4) …he’s just the interpreter he’s just a tool… (P4) …the deaf person signed so I had to say it – “you don’t need to know her name she is just a tool”. (P5)
The responsibility of advocacy
While participants recognised their role was primarily to translate, many of them also considered their role to also involve acting as a patient advocate: ‘…so the role of an interpreter has changed from just being there to communicate, to being a bit of an advocate sometimes or a supporter’ (P5).
Some participants described a feeling of responsibility to ‘pick up the pieces’ after a difficult consultation, especially when patients did not have anyone else with them at the consultation. Participants described situations where their involvement exceeded that of translating in a consultation, with activities including providing support outside of the clinical environment: …I drove him home…I explained to him this is how it happened. (P2) I do these kind of things they will come to my house, I will take them or they bring letters… (P3)
While this was acknowledged as exceeding their stated role, they considered it a necessary action since they were the patients who had no other available support at the time: …they are all so distraught, I know its not my job but I am the only person who can actually communicate with them, you know. (P4) If I can see they are really upset about something I’d say do you want to go for a coffee. (P5)
Formal briefing, debriefing and support
Briefing
Participants reported little if any preparation time before translating a consultation. It was felt that a small time spent briefing them prior to meeting the patient would help support them emotionally and also enhance their ability to translate appropriately: …it would be very helpful if I received you know the brief information before going there just to prepare myself like emotionally and linguistically as well. (P1) … and taken to one side and spoken to say you know that ‘we have got family coming in and we have got bad news’… you know if we are emotionally prepared then that might help. (P5)
Debrief and support
Having identified the significant emotional impact of their role, participants highlighted the lack of support available for them when faced with distressing situations. All translators commented that there was no specified formal support available: ‘…they didn’t offer me any support’ (P2) and ‘There was no support whatsoever…’ (P4).
While some attempted to access support themselves, they identified the challenges of discussing confidential information with their usual support networks: no, no I didn’t speak to anyone. Because then again all my clients are confidential you know so I should always keep that in mind. (P3) …you must never discuss work with anybody else so you are frightened of breaking this code of confidentiality that you have… (P4)
Some translators felt they had to access emotional support following a distressing consultation. However, doing this led to feelings of distress that they may have compromised patient confidentiality: ‘I had to you see and that does break the rules it does of course of code conduct but then I needed to tell someone…’ (P2).
Discussion
The importance of translators in delivering high-quality healthcare in an increasingly diverse population cannot be over-emphasised. A national survey of patients with cancer performed by the Department of Health found that patients from minority ethnic communities reported problems in understanding explanations of their diagnosis, prognosis and treatment options, and a lack of confidence in their doctor compared to the rest of the population. 18 Access to interpreting services improves patients’ understanding, increases healthcare utilisation and improves both patient and healthcare professional satisfaction. 19 With an increasingly diverse population, translators are likely to remain a valuable resource within healthcare.
This exploratory study sought to understand the challenges faced by non-medical translators in conveying distressing clinical news to patients on behalf of a medical professional. Despite the small number of participants there was marked congruence between their responses and reflections of their experiences. Furthermore, their experiences are consistent with Australian data conducted through focus groups where translators identified themes such as challenges of translating accurately, acting as an advocate and maintaining personal distance versus proving support. 20
The overarching findings of this study suggest the role of a translator far exceeds that of directly conveying information relayed by a doctor or other healthcare professional. They perceive themselves to be exposed to distressing clinical information and the focus of patient distress without formal training or subsequent support. The desire to act as advocate should, thus, come as no surprise since they are likely to view the consultation through the eyes of a lay person and identify more readily with the non-clinical domains of patient distress. It is plausible that the increased satisfaction patients receive with the use of translators may be due in part to the previously unrecognised role of advocacy that translators are assuming. Further research to try and dissect translation from advocacy would be useful to identify the breadth of supportive roles demanded of translators and to establish the degree of training and support required for them to deliver this.
This study has the limitations associated with any research with a small sample size. Within a highly homogenous participant group, a small number of patients are usually sufficient to achieve saturation and conclusive results. However, the breadth of languages and cultures covered by translation services represents a culturally and linguistically heterogeneous population, and it is likely that larger numbers will be required to achieve saturation. The participants represented the experiences of only three languages or communication modalities (two Bengali, one Polish and two BSL), and therefore the findings are not transferable to translators working in other languages and with different cultures. While data saturation was not reached, the strong concurrence between responses and the similarity to findings in the Australian study warrant expanding the study to recruit a wider group of translators, to include the breadth of diverse cultures and communication within the country.
From our experience we were able to successfully recruit 20% of listed interpreters. In view of this, a pool of at least 100 interpreters would need to be approached in order to consent a total of 20 translators. In order to ensure diversity of translators, it would also be necessary to recruit from varied geographic locations, which have different diverse populations.
In addition to identifying the need for further research into the challenges facing translators, this exploratory study also raises an important point regarding the doctor–translator relationship. Translators identified that some patients viewed them as no more than a tool and it is possible that clinicians hold this view as well. There is no mention of the clinician taking on a supportive role for the translator, neither is there any reference to access to support of debriefing following a distressing consultation. It is possible that additional familiarisation with a translator’s background and increased cognizance regarding support needs would enhance the professional relationship.
Conclusion
The growing diversity of our population suggests that the need for translators in all walks of life will continue, if not increase. The increasing need for hospital-associated translators, especially through non-clinical individuals, should be met with access to training, support and opportunities for debrief. Furthermore, the opportunities for health professionals to gain a greater understanding of the role of translators will facilitate better communication with patients, thus improving overall care. This exploratory study has highlighted the importance of understanding the role of professional interpreters and warrants a larger scale study in order to obtain data from as many cultural and linguistic backgrounds as possible. While this study has identified several commonalities among the participants interviewed, it is possible that a larger sample size will provide specific insights pertinent to individual cultures and languages. In view of this, a multicentre study is being planned.