Patient Education and Counseling 91 (2013) 131–140

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Patient Education and Counseling

journal homepage: www.elsevier.com/locate/pateducou

Review

Working with interpreters in health care: A systematic review and

meta-ethnography of qualitative studies
Camille Brisset, Yvan Leanza *, Karine Laforest
School of Psychology, Laval University, Quebec City, Canada

A R T I C L E I N F O A B S T R A C T

Article history: Objective: To identify relational issues involved in working with interpreters in healthcare settings and to
Received 2 December 2011 make recommendations for future research.
Received in revised form 29 October 2012 Methods: A systematic literature search in French and English was conducted. The matrix method and a
Accepted 4 November 2012
meta-ethnographic analysis were used to organize and synthesize the data.
Results: Three themes emerged. Interpreters’ roles: Interpreters fill a wide variety of roles. Based on
Keywords: Habermas’s concepts, these roles vary between agent of the Lifeworld and agent of the System. This
Interpreters
diversity and oscillation are sources of both tension and relational opportunities. Difficulties: The
Migrant health
Communication
difficulties encountered by practitioners, interpreters and patients are related to issues of trust, control
Matrix method and power. There is a clear need for balance between the three, and institutional recognition of
Meta-ethnography interpreters’ roles is crucial. Communication characteristics: Non-literal translation appears to be a
prerequisite for effective and accurate communication.
Conclusion: The recognition of community interpreting as a profession would appear to be the next step.
Without this recognition, it is unlikely that communication difficulties will be resolved.
Practice implications: The healthcare (and scientific) community must pay more attention to the
complex nature of interpreted interactions. Researchers need to investigate how relational issues in
interpreted interactions affect patient care and health.
ß 2012 Elsevier Ireland Ltd. All rights reserved.

1. Introduction cultural backgrounds experienced in transcultural nursing [10]

were called on to act as interpreters. Many of the studies from
The combination of globalization and the different waves of which these reviews drew their conclusions, however, did not
immigration to Western countries has resulted in an increasingly differentiate between the effects of different types of interpreters
socio-culturally diverse population. Since many migrants do not on improved quality of care. In response, Karliner et al. [12] and
speak the official language of their host country, this linguistic gap Bauer and Alegria [13] questioned the specific impact of
has been shown to be one of the major causes of health disparities professional versus non-professional interpreters (which we call
[1]. The literature reports inappropriate diagnosis [2], poorer ‘‘ad hoc’’ interpreters) on clinical and psychiatric care. Both studies
adherence to treatment [3] and follow-up [4,5], more medication concluded that working with professional interpreters improved
complications [6], longer hospitalizations [7] and decreased quality of care. Interpretation is more than just a technique to
patient satisfaction [8]. One way to overcome these problems is make health service more accessible to patients who speak a
to work with interpreters. foreign language, however. As Tribe and Lane [14] mentioned in
Ever since this issue came to the attention of the scientific their review and guidelines on working with interpreters in mental
community in the 1980s, interest in it has continued to grow. health, interpretation also offers clinicians an opportunity to
When reviews were conducted all concluded that working with expand their knowledge and understanding of a range of clinical
interpreters was essential to reducing health disparities and perspectives. Investigating the relational issues involved in
improving quality of care; medical interpreters [9,10], bilingual providing interpretation during medical consultations appears
physicians and staff [9,11], and bi/multilingual nurses from various to be the next step in improving quality of care.
Although qualitative and quantitative studies have long been
shown to be complementary [15], the systematic reviews
mentioned above [9,12,13] seem to have neglected their respective
* Corresponding author at: École de Psychologie, Université Laval, Pavillon
Félix-Antoine Savard, Local 1416, 2325, rue des Bibliothèques, Québec (QC) GIV
contributions. The results of the selected studies are treated
0A6, Canada. Tel.: +1 418 656 2131x7312; fax: +1 418 656 3646. similarly, as if both types of research generated similar types of
E-mail address: [email protected] (Y. Leanza). results.

0738-3991/$ – see front matter ß 2012 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.pec.2012.11.008
132 C. Brisset et al. / Patient Education and Counseling 91 (2013) 131–140

The aim of our study was to conduct a systematic review and 2.3. Abstraction of articles
meta-ethnography [16,17] of qualitative studies on interpreting
in healthcare settings to better understand the relational The articles were summarized and abstracted based on the
issues involved in interpreted consultations with different types following canvas: references, country where the research took
of interpreters, and to make recommendations for future place, type of interpreters, perspective, aim of the study, number
research. and type of participants, procedure, type of analysis, results and
Habermas’s distinction between the System and the Lifeworld discussion and conclusion. We considered four categories of
was used as an interpretative framework to organize and give interpreters: professional, ad hoc, professional versus ad hoc,
meaning to the results. These concepts have already been used and non-specified. In this paper, a professional interpreter is
profitably to understand communication in healthcare settings defined as a person who has received some kind of formal
[18–20], and especially in interpreted consultations [21,22]. The training in interpretation, while an ad hoc interpreter is an
System, which comprises the economy and the state, is untrained person called on to interpret (possibly a family
characterized by strategic action (oriented toward efficiency member, a minor child, a healthcare staff member, a non-
and success). The Lifeworld, which comprises the private and professional employee, a volunteer from a community organi-
public spheres, is characterized by communicative action zation or even a stranger in the waiting room). We also
(oriented toward making collective sense of a situation in order considered five different perspectives (i.e., whose experiences/
to come to a consensual understanding on the course of action to perceptions the author chose to present in his/her paper):
take) [23]. patient, interpreter, practitioner, administrative staff and
researcher. Simply because a study uses different categories
2. Methods of participants does not imply that all their experiences are
systematically and separately reported. In cases where partici-
2.1. Data sources pants’ experiences received little or no attention, the perspective
was coded as ‘‘researcher.’’ The objective of papers in the latter
We conducted a systematic qualitative literature search for category is to contribute to a more global understanding that
publications from the inception of each database to June 2010 in goes beyond specific experiences.
PsycInfo, EBSCO Medline, Current Contents, Web of Science, CSA The summaries of the 61 articles were reviewed for broad
Linguistics and Language Behavior Abstracts, SCA Sociological content analysis by a blind judge so that emerging themes could
Abstracts and the Cochrane Library, with ‘‘interpreter*’’ and not be influenced by prior knowledge of the subject.
‘‘health’’ as key words. After deletion of duplicates, our search To describe the quality of the selected studies, we developed a
produced 823 references (Appendix A). set of 18 criteria based on the COREQ checklist [25] and Malterud’s
Supplementary data associated with this article can be found, in guideline [26]. Since the way qualitative studies are reported
the online version, at http://dx.doi.org/10.1016/j.pec.2012.11.008. varies [25], we abstracted information that would allow the reader
to evaluate the quality of each study in the five following domains:
2.2. Inclusion/exclusion criteria author’s reflexivity, conception and analysis of the studies,
characteristics of the participants, technical characteristics of data
We included all qualitative peer-reviewed publications in and conducted analyses, and characteristics of results and
French and/or English. We considered as qualitative all research discussion (Appendix C).
whose (a) methods were intended to collect qualitative data (e.g., Supplementary data associated with this article can be found, in
semi-structured interviews) and (b) whose data were analyzed the online version, at http://dx.doi.org/10.1016/j.pec.2012.11.008.
qualitatively (e.g., thematic analysis) [24]. We therefore excluded,
without further review, books, chapters, dissertations, literature 2.4. Organizing the results
reviews, testimonies, and theoretical/philosophical texts. Articles
on working with sign language interpreters were also excluded. The 61 articles were organized using the Matrix method
An initial sorting by title, summary or quick review of the [27,28]. The Review Matrix is like a data sheet in which the rows
article was done independently by the third author and two correspond to the documents (the selected articles for the
research assistants. Our goal was not to obtain an inter-judge review), and the columns to the topics (the categories of
agreement, but the widest possible sample of articles. Out of a information used to summarize the documents), which allows
total of 823 publications, 66 met our criteria. The first and second for easy comparison between rows. Three steps are required
authors then jointly reviewed the full text of these articles, to create a matrix: organize the documents chronologically in
excluding a further 13. Eight were subsequently added based on order to appreciate how the issue has evolved in the field of
the snowball sampling technique, including secondary articles in research. Choose the topics: There are two major categories of
the selected articles’ references that met our inclusion criteria topics: the methodological characteristics of the study and the
(Fig. 1). content-specific characteristics (theoretical or conceptual mod-
el, types of results, etc.). The choice of categories depends on the
research question and the issues identified as important to
823 answering it. Summarize the documents: This is more than just a
Sorting by title, abstract, quick review summary; it requires critical thinking. What was the purpose of
Three judges the article? How did the authors proceed? What were their
Abstraction 66 results? What was the logic behind their interpretation? A
Sorting by full review
narrative of the study must be written in the reviewer’s own
Two judges
words.
53
Matrices were then created, one per emerging theme using the
Abstraction Inclusion by "snowbaling" technique following topics: references, publication year, country in which the
61 research took place, type of interpreters, perspective, number and
type of participants, aim of the study, method, results, and
Fig. 1. Articles selection chart flow. translation as described below.
 C. Brisset et al. / Patient Education and Counseling 91 (2013) 131–140 133

2.5. Translating and synthesizing the results and in Appendices B (for greater details) and C (for all other
research details). It is also important to recall that a meta-
Originally developed by Noblit and Hare [17], a meta- ethnography does not involve reporting original results, but rather
ethnography is a synthesis method for combining findings of our own interpretations of others’ results and interpretations.
qualitative studies in order to achieve a potentially higher level of Supplementary data associated with this article can be found, in
analysis [16]. This process, called translation in a meta-ethnogra- the online version, at http://dx.doi.org/10.1016/j.pec.2012.11.008.
phy, consists in comparing the results of one account with those of
others. Following the recommendations of Atkins et al. [16], we did 3. Results
a chronological comparison of our interpretation of Study 1 with
our interpretation of Study 2, our interpretations of Studies 1 and 2 3.1. Quality of studies
with our interpretation of Study 3, and so on. This step was carried
out by the first and second authors to ensure in-depth We noted great variability in the way authors reported their
understanding of the selected papers. findings (see Appendix C for details). Approximately half of the
All authors then synthesized the different translations by papers provide no information on participants’ socio-demographic
emerging theme. The juxtaposition of the syntheses allowed a line characteristics (but numbers are rarely omitted). In total, 25
of argument to emerge. In view of the large number of selected studies focus on professional interpreters only, 11 on ad hoc
articles, we decided to give one example of the appropriate interpreters only, while more recent studies (n = 13) take both
references in the syntheses. Since citing them all would burden the types into greater account. Seventeen of the studies do not specify
text, all are listed in Tables 1–3 (for a brief summary of findings), the type of interpreters, but five provide sufficient clues to classify

Table 1
Brief summary of selected studies on working with interpreters in health care ordered chronologically by type of interpreters, within the interpreter’s roles theme (n = 26).

First author (year), country Perspective Principals findings

Type of interpreters: non-specified

Kaufert (1984) [29], Canada I; R Four interpreter’s roles: language interpreter, informant, cultural broker, advocate
O’Neil (1989) [41], Canada I; Pr; Pa Role of advocate, differences between ‘‘explicit advocacy’’ and ‘‘implicit advocacy’’
Dysart-Gale (2005) [42], USA I; Pr Complementarities between the role of conduit (translator) and the role of advocate
Pugh (2009) [38], UK Pr Interpreters described as both an obstacle and a facilitator of the empathic process. Working with an
interpreter provides opportunities to foster a broader empathic understanding of the client

Type of interpreters: ad hoc

Hasselkus (1992) [37], USA I; Pr; Pa Three interpreter’s modes of communication: facilitator, intermediary and direct source. Interpreter’s
influence (power) on medical interviews. Issue of loyalties
Matthews (2000) [43], Australia I; Pr Four roles for bilingual practitioners: care provider in another language, reassurance and comfort provider,
empowerment encouragement and community support

Type of interpreters: professional

Hatton (1992) [44], USA I Four sub dimensions of appraisal: task appraisal, client appraisal, provider appraisal, and information
appraisal. Interpreters hold considerable power
Hatton (1993) [32], USA I; Pr Three interpreter’s roles: voice box, collaborator, excluder. Collaborator is the most efficient role to
establish effective relation with clients, collaborative interaction viewed as a ‘‘dance’’
Kaufert (1999) [34], Canada I; Pr; Pa Interpreters do not only provide for linguistic services, but play a major role by mediating conflicting
cultural and ethical values, guiding palliative decisions
Labun (1999) [45], USA/Canada Pr Role of shared brokering concerns practitioners (nurses) and interpreters, requires time in order to build
mutual trust
Drennan (1999) [30], South Africa I; Pr; AS Four interpreter’s roles: language specialist, culture specialist, patient advocate, and institutional therapist
Davidson (2001) [31], USA R Interpreters act as co-diagnostician invisible and institutional gatekeeper
Singy (2003) [40], Switzerland Pr Two sorts of translation: ‘‘idéal de traduction [perfect translation]’’ with interpreters as translation
machine, and ‘‘traduction idéale [ideal translation]’’ with interpreters as an actor
Miller (2005) [36], USA I; Pr Two interpreter’s roles: ‘‘black box’’ (translation machine) and ‘‘therapy conduit’’ (normalization of
psychotherapy). Interpreters can also serve as cultural liaisons between therapists and clients
Norris (2005) [46], USA I Practitioners and interpreters qualities: honest, trustworthy, show compassion, take the time to discuss
important issues. Interpreters’ skills: negotiating role conflict, having multiple roles
Leanza (2005) [35], Switzerland I; Pr; R Four interpreter’s roles: system agent, community agent, integration agent, and linguistic agent
Angelelli (2006) [47], USA I Four interpreters’ roles: message converter, message clarifier, cultural clarifier and patient advocate. Need
for interpreters to set limits (role confusion)
Dysart-Gale (2007) [48], USA R Interpreters have no problem transmitting basic information, but are frequently called upon to abandon
neutrality
Hsieh (2007) [49], USA I Five strategies for the co-diagnostician role with the effort to conserve practitioners’ time and to bridge
cultural differences
Hsieh (2008) [50], USA I Four interpreter’s roles: conduit, advocate, manager, and professional
Hsieh (2010) [33], USA Pr Interpreters’ emotional support: personified by physical presence, being a human being and a professional,
represents the extension of practitioner’ care, and accomplished through the alliance

Type of interpreters: professional versus ad hoc

Greenhalgh (2006) [21], UK I; Pr; Pa Seven themes: interpersonal relationships, time pressure, system agent and informative guide to health
system, community agent, interprets as an instrument, power and control, role dissonance
Rosenberg (2007) [39], Canada I; Pr Professional and ad hoc interpreters must translate the discourse, professional interpreters have to serve as
culture brokers, and ad hoc interpreters must fulfill caregiver roles
Rosenberg (2008) [51], Canada I; R Professional interpreters create a safe environment for the patient, and mediate between cultures. Ad hoc
interpreters ensure diagnosis/treatment, interact with care system and fulfill family role
Hilfinger Messias (2009) [52], USA I Three main results: embodying and challenging the conduit role, experiencing role dissonance and
conflicting expectation, crossing and expanding role borders.
Hadziabdic (2009) [53], Sweden Pa Three recurring themes: issue of trust, informative guide to the health system, and issue of neutrality

I: interpreter; Pr: practitioners; Pa: patients; AS: administrative staff.

134 C. Brisset et al. / Patient Education and Counseling 91 (2013) 131–140

Table 2
Brief summary of selected studies on working with interpreters in health care ordered chronologically by type of interpreters, within the difficulties theme (n = 34).

First author (year), country Perspective Principals findings

Type of interpreters: non-specified

Kaufert (1984) [29], Canada I, R Conflicts arise when clinicians consider interpreters’ role as a ‘‘language translator’’. Dissonances within
interpreters are observed
Vissandjee (1998) [76], Canada Pr Filtering information appears to be the result of the cultural context, the essence of the clinical encounter,
the nature of diagnosis and the interpreter’s age. It can be ‘‘voluntary’’ or ‘‘involuntary’’
Drennan (2002) [70], South Africa Pr; I Clinicians report discomfort and frustration in working with interpreters; they prefer bilingual nurses.
Institutional discourses reproduces the racist discourse that prevails in society
Raval (2003) [61], UK Pr Tensions when working with a summary of what is said. Difficulties to ask questions for diagnosis, to
transmit complex words, to establish therapeutic alliance and collaborative relation
Nailon (2006) [69], USA Pr Difficulties: lack of interpreters’ availability, and accuracy of the translation. The interpreter’s ‘‘positive’’
non-neutrality perceived as favorable, being non-neutral as unacceptable
O’Donnell (2007) [58], UK Pa Interpreting services are organized for primary cares mainly. Need for interpreters with GPs and in
pharmacy. Some patients felt that interpreters did not fulfill their duties appropriately
Fatahi (2008) [63], Sweden Pr Triadic communication is complex, and practitioners expect interpreters to be neutral and translate like a
‘‘machine’’
Wiking (2009) [78], Sweden I, Pr, Pa Communication difficulties due to technical problems, lack of time, difficulties in expressing the patient’s
problem and relationship issues between the three actors. Issues of satisfaction

Type of interpreters: ad hoc

Cohen (1999) [79], UK Pr To deal with the lack professional interpreters’ availability: the use of call center or ad hoc interpreters,
including children
Drennan (1999) [68], South Africa Pr; I Four derived themes: alienation, language problem, problem of the patient, access to services:
Free (2003) [60], UK I Children/adolescents as interpreters because they represent a trustworthy person and they may have a
better understanding of the family ills. Several advantages and disadvantages
Yang (2008) [56], New Zealand I Ethical issues about using students as interpreters: patient’s confidentiality and autonomy, school
obligations, role conflicts, and understanding the interpreter’s roles.
MacFarlane (2009) [59], Ireland Pa Two important elements with ad hoc interpreters: language skills and the relation of trust.
Larrison (2010) [75], USA I, Pr, Pa Ad hoc interpreters report high levels of involvement with the patient and intense reciprocal relationships
with the community. Frictions with practitioners and satisfaction from patients

Type of interpreters: professional

Gerrish (2004) [71], UK I, Pr, Pa Interpreting services are inadequate for patients, family members often act as interpreters resulting in
fewer hospital visits. Several factor influence nurses’ decisions to call an interpreter
Fatahi (2005) [74], Sweden I Several problems related to the difficulty in balancing the triadic relationship. Difficulties with
communication when there are cultural differences in disease, health and care representations
Hudelson (2005) [72], Switzerland I Difficulties related to the differences in the disease and care representations. Problem underlying
communication difficulties is the practitioners’ lack of awareness of the sociocultural differences
Norris (2005) [46], USA I Practitioners and interpreter’s qualities: honesty, compassion for the patient and his family, and
availability to discuss. Interpreter’s abilities: negotiating role conflicts, endorsing several roles
Miller (2005) [36], USA I, Pr Interpreters’ behaviors can be frustrating for therapists. Common for patients to have a stronger initial
alliance with the interpreter. Patients’ past can have an painful resonance for interpreters
Singy (2005) [73], Switzerland I, Pr, Pa Necessity to use an interpreter when there are communication difficulties. Interpreters want to be co-
workers. The ideal interpreter is neutral/professional; respects confidentiality and is available
Leanza (2005) [35], Switzerland I, Pr, R Communication with parents and children is more difficult with an interpreter. Difficulties for interpreters
to build a two-way communication between practitioners and patients
Hsieh (2006) [80], USA I Different sources of conflict. Establishing boundaries, (re)defining relationships and identities, and
managing communication strategies can help in conflict resolution
Diamond (2008) [81], USA Pr Communication as a way to gather clinical data, unawareness of the disadvantages of not using a
professional interpreter as factors underlying medical residents’ decision to use an interpreter
Hsieh (2009) [65], USA I, Pr Trust is conceptualized in: interpreter’s skills as perceived by the practitioner; shared goals; professional
role boundaries; and schema of collaboration
Hsieh (2010) [64], USA I, Pr Interpreters and clinicians experience conflict about their expertise and authority in three ways.
Practitioners emphasize on their power, control and authority, in and out of the consultation

Type of interpreters: professional versus ad hoc

Edwards (2005) [57], UK Pa Importance of language skills in both languages, and of the interpreter’s. Patients’ experiences with
professional interpreters are negative, and they prefer family members and friends
Lee (2005) [62], Australia Pr Three themes emerged: distrust and suspicion toward interpreters, time constraint, and perceived cost of
the service
Greenhalgh (2006) [21], UK I, Pr, Pa Recurring themes: trust and relationship’s quality; time pressure; interpreter as an informative guide;
interpreter as a Lifeworld agent or an instrument; power and control; role conflict
Robb (2006) [54], Canada I, Pr, Pa Trust is a complex issue in triadic relational dynamics. Trust has influences on the nature of
communication and the results of the consultation
Rosenberg (2007) [39], Canada I, Pr Practitioners feel the loss of what makes them healers, as the information went through a third person and
into another language.
Gadon (2007) [77], USA Pr Differences between ad hoc and professional interpreters in cost, availability, accuracy in translation and
management of confidentiality. Practitioners first choose relatives and colleagues
Saleh (2009) [55], Australia Pr Most practitioners prefer translation by paragraph and professional interpreters. There seems to be a
discomfort among practitioners when family members are chosen as interpreters
Engstrom (2010) [82], USA Pr Communication can be improved when interpreters act as cultural mediators or hampered by the lack of
training for interpreters and by the interpreter-client relationship
Fatahi (2010) [83], Sweden Pr Nurses prefer professional interpreters. Issues of gender, time constraint, neutrality, knowledge of medical
vocabulary, and discipline arise. Need to train nurses on intercultural communication

I: interpreter; Pr: practitioners; Pa: patients; AS: administrative staff.

 C. Brisset et al. / Patient Education and Counseling 91 (2013) 131–140 135

Table 3
Brief summary of selected studies on working with interpreters in health care ordered chronologically by type of interpreters, within the communication analysis theme
(n = 8).

First author (year), country Perspective Principals findings

Type of interpreters: non-specified

Moro (1994) [87], France R Interpreter can make connections between the two languages by removing cultural differences or
submitting to it. Necessity to consider the interpreter counter-transfer

Type of interpreters: ad hoc

Davidson (2000) [88], USA R Interpreters are, due to time constraint, rather acting as informal gatekeepers who keep the interview ‘‘on
track’’ and the practitioner on schedule, than advocates or ambassadors for patients
Elderkin-Thompson (2001) [89], USA R Several miscommunication problems have been identified
Aranguri (2006) [85], USA R The presence of an interpreter increases the difficulty of achieving good practitioner–patient
communication

Type of interpreters: professional

Davidson (2001) [31], USA R Interactions with interpreters did not last longer than those with same language, while they should have;
55% of direct questions were not transmitted to the practitioner
Pham (2008) [86], USA R Four mutually exclusive categories of speech alteration which mainly have a negative but also impact on
the consultation
Farini (2008) [90], Italy R Conflict prevention is achieved through four structures of interaction. Patients have very few opportunities
to answer the physicians’ questions or to pose questions or doubts

Type of interpreters: professional versus ad hoc

Leanza (2010) [84], Canada R Lifeworld is frequently interrupted by practitioners, trained interpreters or family members; and these
interruptions differ in their functions. Specific risks of working with family interpreters

I: interpreter; Pr: practitioners; Pa: patients; AS: administrative staff.

them. Seventeen provide very little information on the profession- quantitative studies [12]. Patients’ perspective appears to be
al interpreters’ training, and 12 specify authors’ motives and secondary. The researcher’s perspective occurred mostly in studies
preliminary hypothesis. Data were collected mainly through using medical consultation recordings as primary research
interviews/focus groups (n = 46) and audio or video recordings material.
of consultations (n = 12); diverse analysis methods were employed
(phenomenology, grounded theory, etc.). 3.3. Emerging themes

3.2. Description of selected qualitative studies Three themes emerged from the meta-ethnography: (1)
interpreters’ roles, or the behaviors and skills associated with
The earliest of the 61 selected articles was published in 1984. being an interpreter, as expressed by interpreters or expected by
After a period of two decades during which little research was done institutions, practitioners and patients, (2) difficulties related to
in this area, a steady increase began after the year 2000 (Fig. 2). The working with an interpreter and (3) communication characteristics
US is the most productive country in terms of publication (n = 26), of interpreted consultations. This third theme refers to studies that
followed by the UK (n = 9), Canada (n = 8), Sweden (n = 5) and differed from the others in that they were interested in the ‘‘real’’
Switzerland (n = 4). Our data also show three publications for practice of working with an interpreter rather than protagonists’
Australia and South Africa, one for France, Ireland, Italy and New- discourses and representations.
Zealand, and a joint US-Canada publication. The most prolific Among all the articles, 26 focused on interpreters’ roles, 34 on
countries are host countries for immigration. difficulties and eight on communication characteristics. Six
With respect to perspective, the studies give equal weight to discussed both roles and difficulties, and one, difficulties and
interpreters’ and practitioners’ point of view; this is not the case for communication characteristics.

Fig. 2. Number of publications per year, in total and by country.

136 C. Brisset et al. / Patient Education and Counseling 91 (2013) 131–140

Kaufert (1984/1999) Language interpreter Informant

Culture broker
Advocate
Drennan & Swartz (2002) Language specialist Institutional therapist
Culture specialist
Patient advocate
Hatton & Webb (1993) Voice box Collaborator
Excluder
Davidson (2001) Covert co-diagnosticien
Institutional gatekeeper
Miller (2005) Black box Therapy conduit
Leanza (2005) Linguistic agent System agent Lifeworld agent Integration agent
Hsieh (2008) Conduit Professional Manager Advocate

System Lifeworld

Fig. 3. Summary table of the proposed typologies.

3.3.1. Interpreter’s roles: the pendulum affect languages, minorities, refugees, etc. Some researchers
Interpreters’ roles are described as soon as the earliest address issues of what we consider as control, but were compiled
publications, and various typologies are proposed to organize in their paper under ‘‘power’’. Each aspect is inseparable from the
them (Table 1 and Fig. 3). Apart from Kaufert and Koolage [29], and other two.
Drennan and Swartz [30], all studies were based on experiences At one vertex of the triangle, the challenge is to establish a
with professional interpreters [31–36]. Our purpose here is not to relationship of trust (i.e., a beneficial relationship [54]) among the
itemize them, but to attempt to grasp the complex reality this three protagonists, which appears to be an uneasy task for all
represents. When we synthesized the different typologies, a involved. Although practitioners identify an alliance with profes-
continuum emerged. To qualify each end of the continuum, we sional interpreters as a factor influencing the quality of the
used Habermas’s concepts of the Lifeworld and the System [23]. In relationship [36], they do not trust professional interpreters and ad
their different roles, interpreters oscillate between the Lifeworld hoc interpreters in same way [39], and the presence of any
and the System. Authors’ descriptions of typologies are not static: interpreter may result in a sense of loss of intimacy with the
the oscillation is necessary for communication to occur. We find patient [55]. Within this dynamic, professional interpreters
the pendulum metaphor particularly apt for describing theses experience ethical dilemmas [56]: situations in which a moral
changes in interpreters’ positions along the continuum. choice must be made between equally unpleasant or mutually
Interpreters’ roles are associated with different interrelated exclusive alternatives. We consider issues of loyalty and confi-
relational issues. None of these issues is specific to one type of dentiality [57] to be sources of ethical dilemmas. How should an
interpreter in particular and most of them are also related to the interpreter behave if certain elements of the patient’s information
difficulties theme. These issues are described in terms of conduit are ignored by the practitioner? Should s/he provide information
metaphor (the interpreter must translate the information word for on a patient that could be of importance but that was not
word, like a machine) [32], neutrality [32], commitment/loyalty mentioned by the patient during the consultation? Should s/he
[37], empathy [38], intrapersonal conflict [34], control or power inform the community of the patient’s illness if s/he displays
[21], trust [39], and recognition [40]. All are connected to the inappropriate behavior (such as a patient with AIDS who has
pendulum and its oscillations. It is not surprising, therefore, that unprotected sex)? From the patient’s point of view, trust and
interpreters report conflict in having to manage their many emotional closeness constitute an important dimension [58].
different roles: this is the result of tensions between neutrality Although patients trust professional interpreters to have a sound
and commitment/loyalty (to the System or to the Lifeworld). The knowledge of the system, and prefer to have them deal with
more committed they are to the patient and the more empathy they administrative matters, they prefer ad hoc interpreters because
express, the less neutral they will be, and the more practitioners they are not strangers [57]. Too much emotional proximity with an
will have a sense of loss of control or power over the consultation. interpreter is not appreciated [59], however, except in cases when
Building trust and respect (recognition) is a prerequisite to adolescents interpret for a family member [60].
establishing a collaboration that allows all protagonists to find Control, which we define as the ability to orient the course of
their place in the relational dynamic. action during consultations and verify the accuracy and validity of
These oscillating roles and relational issues occur in specific dialogs, is another vertex of the triangle. Certain authors refer to
institutional contexts. Although this point is not mentioned in this ability as power [21]. Practitioners may be afraid of losing it
connection with the interpreter’s role, it becomes evident in the [61], or worried that the interpreter will dominate their relation-
discussion of difficulties. ship with the patient [62] or that the patient will hide behind the
interpreter, remaining passive and ‘‘invisible’’ [63]. In order to
3.3.2. Difficulties: the Trust-Control-Power triangle maintain control of the consultation, they develop different
Our meta-ethnography reveals that difficulties mainly arise strategies. They may limit the consultation, end it abruptly, or
within what we have called the ‘‘Trust-Control-Power’’ or TCP decide who may be present in the consulting room [21]; this
triangle (Table 2). Trust and control issues take place within the behavior is applied to both types of interpreters. Practitioners may
relation (and its dynamics) between patients, interpreters and also exert control over time, space and content, mainly to exclude
practitioners. These issues are notably the expression of power the Lifeworld [21]; this applies mainly to professional interpreters.
struggles occurring in broader contexts, such as healthcare Practitioners value and insist on the neutrality of professional
institutions and the society at large, with its political choices that interpreters and require them to develop an understanding of
 C. Brisset et al. / Patient Education and Counseling 91 (2013) 131–140 137

communication needs based on their area of specialization. They having difficulty accurately translating it. Reduction is condensing
also verify the content of what is being interpreted (for example, by the content, which usually occurs when the practitioner or patient
monitoring the differences in the lengths of the patient’s responses talks for a long time without giving the interpreter an opportunity
and their interpretation), especially in the presence of ad hoc to speak. Editorialization involves various combinations of the
interpreters [21]. These strategies can be contradictory for above transformation processes. Small talk, or socially oriented
interpreters. Although they are required to be neutral and invisible conversation initiated by interpreters to further relationships
(to act like a ‘‘translation machine’’ at the System end of the rather than communicate established medical facts, could be
pendulum), they may also be expected to provide emotional considered another transformation process, since it adds text to
support and cultural brokering [64] (at the Lifeworld end of the the conversation [85].
pendulum). There are also contradictions in terms of continuity. These transformations do not have solely negative effects on the
Having the same interpreter for the same patient is seen as an consultation. They can also temper the practitioner’s language,
advantage in establishing a relationship based on trust [65], but it making it less confrontational or abrupt, help to clarify medical
is also viewed as a disadvantage—or even an obstacle to control— jargon, provide emotional support for the patient’s family, and
when interpreters may begin to claim a certain medical expertise improve the patient–practitioner relationship [86]. Small talk
[64]. helps establish emotional closeness and trust between patients
The final vertex of the triangle is power. Healthcare consulta- and practitioners, creating opportunities to have a ‘‘friendly’’
tions can be considered as social spaces [66,67] in which social conversation, which can in turn encourage the patient’s interest in
issues, like minority–majority power struggles, are bound to arise. learning more about his or her disease. As a result, the patient may
Some authors have shown how such issues can influence feel more comfortable revealing more sensitive details through an
interaction during an interpreted consultation [68]. Power appears interpreter, especially if the interpreter is a family member [85].
as institutional constraints (such as time imperatives [63], cost of In terms of the interpretation practice itself, results also show
professional interpretation services [62], or continuity/having the that professional interpreters’ interventions tend to swing more
same interpreter for the same patient [69]), and even as a toward the System end of the pendulum, while those of ad hoc
reproduction of the dehumanizing discourse of race in context of interpreters’ tend toward the Lifeworld end (referring to the
historical racial segregation, and thus an obscuring of interpreters’ interpreter, not the patient) [84].
presence and work [70]. Institutional recognition constitutes
another set of problems: lack of support from line authority and 4. Discussion and conclusion
the medical staff [61], need for discussion rooms [46] and lack of
training for both practitioners and interpreters [71]. Since most of 4.1. Discussion
the institutional problems are reported by practitioners with
regard to professional interpreters, this colors the way in which 4.1.1. Contexts of publication
interpreters’ experience their activity. A distinct profile emerged when selected studies were
Professional interpreters also report difficulties in matching considered based on country of publication. In the case of the
their communicative behaviors with those of the other two three most productive countries, the increase in publication is
protagonists (similar information-seeking patterns with patients clearly connected to their political situations. In the US, the
and practitioners) [65] and of patient–practitioner’s communica- increase in the number of publications coincided with Executive
tion styles (for example, when a gesture that is supposed to Order 13166, signed in August 2000 by President Clinton, requiring
encourage the patient’s adherence to recommended treatment is all federal agencies to comply with Title VI of the 1964 Civil Rights
perceived as an insult) [72]. On a more personal level, they feel Act [91], which stipulates that the health system cannot
psychological tension, frustration [73] and exclusion [74]. Similar discriminate among users on the basis of color, ethnicity (‘‘race’’)
feelings of frustration are reported by ad hoc interpreters [75], who or country of origin. As language is inseparable from these
also mention anxiety [76] and low self-esteem [29] (although the characteristics, the health system is also required to provide the
latter two are not associated with a specified type of interpreter); necessary linguistic services. In the UK, the increase coincided with
and by practitioners [77], who also report exclusion [36] and the reform of British institutions. In the late 1990s, the British
competition [36]. government introduced a new policy allowing non-English
Intrinsically linked to practitioners’ responsibilities toward speakers to use their own language when using public services;
their patients, the TCP triangle illustrates the relationship’s since 1998, many agencies have published brochures in minority
dynamics and its difficulties: there is a need for balance. If one languages [92]. In Canada, data point to an early and constant
of the protagonists attempts to take control, or if the institutional interest—albeit not prolific—starting with First Nations issues in
(or broader) context instrumentalizes or is unfavorable to 1984 and moving on more recently to immigration. It is surprising
interpreters, the quality of relationships can be affected. Any trust how little research has been done on interpretation, particularly in
that has been established may be diminished, negatively view of the 1985 Canada Health Act: the objective of the Canadian
influencing quality of care. Health Care Policy objective is to ‘‘protect, promote and restore the
physical and mental well-being of residents of Canada and to facilitate
3.3.3. Communication characteristics: all about control reasonable access to health services without financial or other
During the analysis of communication characteristics (Table 3), barriers,’’ including language barriers [93].
other relational difficulties emerged. Control is no longer specific
to practitioners, but concerns interpreters as well. Ad hoc 4.1.2. Relational issues
interpreters are more controlling than their professional counter- Our systematic review revealed many relational issues sur-
parts: both control the organization of the consultation, but only ad rounding interpreted consultations that temper what other
hoc interpreters control the patient’s agenda [84]. authors have inferred, especially in comparing ad hoc with
This control is exercised by transforming the communication professional interpreters. Karliner et al. [12] have, for example,
content in various ways [31,85,86]. Omission occurs when emphasized how working with professional interpreters can
interpreters omit a portion of the content, especially when they improve quality of care for patients with limited English
are summarizing what has been said. Revision is what happens proficiency. They came to three important conclusions: (1) fewer
when interpreters modify the content, particularly if they are errors in translation, (2) greater satisfaction among patients and/or
138 C. Brisset et al. / Patient Education and Counseling 91 (2013) 131–140

practitioners than with ad hoc interpreters, and (3) a decrease in interpreters’ ethical principles (such as neutrality and its applica-
utilization disparities and an increase in positive clinical outcomes tions) should also be a priority.
(as compared to patients with no language barrier). We would like
to discuss these three conclusions in light of our own review. 4.1.3. Future orientation of research
First, discourse transformation processes are not necessarily as Our review points the way down to three avenues of research.
negative as is usually claimed in quantitative research [94–96]. In First, the perspective of the patient requires further exploration
fact, they can be essential to communication. Even though they alongside that of the interpreter and healthcare practitioner. This
imply greater control on the part of the interpreter, they are would be particularly useful in drafting recommendations for
necessary to express empathy, find equivalent meanings, and working with ad hoc interpreters. As we have shown, the latter can
coordinate speech [97]. In fact, translation ambiguities and be valuable asset in a consultation context, but not without strict
‘‘errors’’ are even used as clinical material in specialized guidelines. Second, the themes studied in the field of healthcare
psychotherapy settings to help build meaningful therapeutic interpretation (roles, difficulties and communication character-
narratives [87]. Of course, to ensure healthcare quality, these istics) are usually explored separately. Connecting communication
speech transformations should be done overtly, and not covertly characteristics to difficulties and/or roles in future studies would
like an automated invisible process. give us better understanding of the communication process and
Second, levels of satisfaction based on the type of interpreter help formulate relevant recommendations for different interpret-
are not as linear as expressed by Karliner et al. [12]. Regardless of ing situations. One possibility is to record consultations and
who is interpreting, emotional proximity clearly plays a crucial interview protagonists in the same study (instead of one or the
role. Patients are ambivalent as to how much interpreter’s other), and to use the recordings as a basis for the interviews [49].
involvement is appropriate [75]; their satisfaction is a function Third, although healthcare interpretation is practiced all over the
of emotional distance and involvement. Similarly, some practi- world, only one European comparative research project has been
tioners search for just the right amount of involvement from conducted to our knowledge [98,99]. Such international studies
interpreters, and they rely on them to develop and maintain appear invaluable to differentiate between what is universal and
interpersonal connections through which their own concern for what is socio-culturally specific; to further our understanding of
the patient and care requirements can be communicated [69]. This the interpreting activity in a socio-political and institutional
brings us to our third point. context; and therefore to find new ways of working with
While Karliner et al. [12] made an important contribution, their interpreters and formulating more pertinent recommendations.
review failed to consider the comparison between patients with ad
hoc interpreters and patients who speak the same language as the 4.1.4. Limitations
practitioner with respect to utilization disparities and positive Our review was limited by several factors. We are well aware
clinical outcomes. Our review confirms that there are many issues that our interpretations were influenced by the choice of databases
involved in working with ad hoc interpreters (such as the loss of (since the US is the most productive country in terms of
patient agenda). Nonetheless, it also shows that ad hoc interpreters publication) and by our differentiation criteria for professional
are appreciated by patients and can be seen as allies in the interpreters and ad hoc interpreters. Training options vary wildly,
healthcare process by practitioners. From this perspective, they ranging from a few hours to a Master’s degree [100,101], and some
represent an important resource in multi-linguistic healthcare that professional interpreters are more ‘‘professional’’ than others.
might, with adequate practitioner training and guidelines, help Although it would have been useful to distinguish between
diminish utilization disparities and even improve clinical out- interpretation in mental and physical health settings and between
comes. In the final analysis, since institutions and practitioners will methodologies, this would have greatly increased the number of
always have to deal with ad hoc interpreters, the pros of informal categories used in our analysis. It is also important to mention that
interpreting should be better acknowledged. since our three themes are not mutually exclusive, their
The perspective of interpreters and the complex nature of their boundaries can overlap.
activities receive little recognition from institutions. Interpreters
are swung from left to right on the pendulum of the various roles 4.2. Implication for practice
they fill and are required to navigate in many difficult situations
with very little support—situations that go well beyond the Practitioner training should include techniques in working with
demands of basic translation. The contradictions that result from both professional and ad hoc interpreters, focusing on the
the practitioner’s need for control create ambivalence around the differences in communication dynamics as well as the advantages
interpreter’s roles and how they should be managed. Interpreters and the limitations of both types of interpreters in different
are also faced with a number of ethical dilemmas surrounding situations. Professional interpretation courses should include
confidentiality and trust that are rarely recognized by the System. training in cultural mediation.
One way to help resolve this situation would be to empower
interpreters within the institution, which would balance power 4.3. Conclusion
and control relationships in the TCP triangle. Institutional
recognition would give confidence to interpreters, practitioners It is our opinion that future studies should give greater
and patients, and help build trust between them. Institutional importance to the patient’s perspective on interpreted consulta-
support (in the form of supervision, for example) is clearly tions and take the complex nature of these consultations into
necessary to help interpreters manage difficult situations (such as greater account. The themes that emerged from our literature
loyalty issues). review are clearly interrelated: they should not be treated
The next step to improve the impact of interpretation on quality separately. Correlating interpreters’ roles and communication
of care appears to be the acknowledgment and improvement of characteristics, or interpreters’ roles and difficulties, would give us
interpreters’ working conditions. There is clearly a need for action/ a better understanding of the complex reality of interpretation and
participation research to incite change in institutional contexts or how relational issues affect its impact on patient care and health.
to test innovative training tools or programs (training practitioners Interpreters are more than communication helpers and
and interpreters to work as a team, and training practitioners to Lifeworld representatives in the System: they are witnesses of
manage different situations and types of interpreters). Testing how our institutions deal with socio-cultural and linguistic
 C. Brisset et al. / Patient Education and Counseling 91 (2013) 131–140 139

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