Meeting the health literacy needs of clients: nurses have a responsibility to ensure their non-English speaking clients understand basic health information. Using a professional interpreter can be the best way to facilitate this.

As New Zealnd's population becomes more culturally and linguistically diverse, many nurses come into regular contact with people from non-English speaking backgrounds. This is a feature of my work as a public health nurse with the communicable disease nursing team at Hutt Valley District Health Board (DHB). Much of our work involves the follow-up of clients with notifiable infectious diseases Like tuberculosis, meningococcal disease, rheumatic fever and measles. In addition, we provide health education and health promotion to all refugees who settle in the region. In this work, we are regular users of interpreters, both face-to-face and by telephone.

The 2001 census showed that 6.4 percent of New Zealand's population identified as Asian ethnicity, 2.6 percent continental European and 0.7 percent from Africa, Latin America and the Middle East. (1)

Over the years, I have become very aware of the importance and need for the use of professional interpreters to enable professionally safe and meaningful communication to take place between the nurse, the client and other health professionals. Interpreting requires not only a sound knowledge of the appropriate Language, but also training in interpretation skills and the ability to convey, at times, complex technical information. In the past, communication with non-English speaking clients--eg with Pacific Island people who settled in Large numbers in New Zealand in the 1970s--was often done badly. Nurses and other health professionals from both the primary and secondary sectors did not always see the need for professional interpreters, often relying on untrained family members to do the interpreting for them.

The provision of interpreters in the clinical setting is part of recognising the health Literacy needs of clients. Health Literacy is defined as "the capacity of an individual to obtain, interpret and understand basic health information and services and the competence to use such information and services in ways which are health-enhancing". (2) Providing professional interpreters for non-English speaking people who use health services is one way of helping address the issue of health Literacy.

There is compelling evidence that Language barriers have an adverse effect on initial access to health services. (3) This includes consultations, health promotion/prevention activities and first contact with a variety of providers. Language rather than cultural beliefs and practices may be a more significant barrier to first contact with health services. Language barriers have been associated with increased risk of hospital admission, increased risk of intubation for asthmatics, differences in prescribed medication, increased numbers of reported adverse drug reactions and Lower rates of optimal pain medication. Quality of care can also be compromised when language barriers put at risk the ability to meet ethical standards, confidentiality, informed consent, patients' understanding of their condition and their compliance with subsequent treatment. Indirect effects of Language barriers include ethnic minorities being underrepresented in research and negative effects on health providers' effectiveness and satisfaction. When people end up in hospital as a result of poor diagnoses and/or poorly understood treatments, standards of care are compromised and health care costs increase.

Researching interpreter use

In 2002 I undertook a small research project as part of a review of interpreting services in secondary services at Hurt Valley and Capital and Coast DHBs. The process involved a written questionnaire to 54 unit managers at Hutt and Wellington hospitals. The aims of the questionnaire were to:

* establish the Level of interpreter use by staff;

* identify any problems in accessing appropriate interpreters (including issues relating to trained interpreters, gender, Language, religion and age of interpreters);

* identify any barriers to the use of interpreters. Forty-nine responded to the questionnaire, a 90.7 percent response rate. Participants were asked six questions regarding awareness of interpreting policies; problems with implementing policies; frequency of use; and identifying any access difficulties and other barriers to using an interpreter service.

The majority (91 percent) of clinical nurse managers were aware of their DHB's interpreting policies. The majority (67%) had no problems with implementing the policy. However, those that did (33%) identified access, appropriateness and cost of interpreters. The majority (59%) used interpreters less than once a month, while the next two groups used them at Least weekly or monthly. The majority of respondents (70%) did not experience any access issues. Those who did experience access difficulties identified issues around availability of interpreters, the use of untrained interpreters, using interpreters who were known to clients, gender issues for some interpreting jobs and accuracy of information being interpreted.

The majority of respondents (61%) did not experience any barriers to using interpreters, while 31 percent did experience barriers. The key barriers were the cost of using interpreters, due to limited or no budgets, and staff's Lack of knowledge about how to access interpreting services and how to use them.

The research clearly showed that, while the majority of respondents were aware of interpreting policies and some problems were identified with implementing them, there were still considerable barriers to using interpreters. These included cost, access issues and staff knowledge. A 2004 study of primary health care nurses showed considerable variation in the use of professional interpreters. (4) In addition, those who had had training in using interpreters were more likely to use interpreting services, while the inadequate training of nurses and interpreters affected the quality of the interaction when interpreters were used. Many nurses were happy to accept the status quo. They did not champion the need to improve services, instead relying on family members to interpret.

A key role for nurses

Nurses have a key role in helping address access barriers. They are often the first point of contact for non-English speaking clients and therefore should act as their advocates to enable them to be heard and understood. Nurses are often in clinical situations where they need to advocate for their clients to ensure their needs are met safely and professionally. Advocacy for the right to have access to a professionally trained interpreter is one such situation. Nurses have a responsibility to be informed about the importance of using interpreters and how to access services in their area. Knowing what their service area policy is on interpreter use and how to use face-to-face and telephone interpreting services is equally important. This may involve challenging existing practices where staff do not recognise the importance of using professionally trained interpreters. Barriers often cited for not using professional interpreters are cost, Lack of knowledge of their importance and how to access services.

District health boards have policies outlining the rationale, process and procedure for interpreter use in the organisation. Nurses should be familiar with these policies, as they can be a useful tool in advocating for the use of interpreters within their service.

Other international and national documents advocate for access to public services that are safe and able to be understood. They include:

* The Universal Declaration of Human Rights (1948) Article 21, (2) states that "everyone has the right of equal access to public service in his country". (5)

* NZNO's Standards of Nursing Practice, Standard 2, states that: "within their scope of practice, nurses are responsible for the safety and well-being of their client group". (6)

* Right 5 of the Code of Health and Disability Services Consumer Rights 1996 states that: "you have the right to be listened to, understood and receive information in whatever way you need. When it is necessary and practicable an interpreter should be available". (7)

Nurses need to feel empowered in their patient advocate roles. Information about interpreter use will help give nurses confidence in this role. Nurses need to know how and when to use interpreters, to enable them to fulfil their professional and ethical obligations to their clients, and be able to take a lead role in this advocacy. The following checklist is a useful tool to help nurses assess what may be required in their own clinical practice or area of work to increase their own and others' knowledge and awareness of interpreting issues. Questions a nurse should be able to answer include:

* Does our service/unit have an interpreting policy?

* Is there anything I need to do to influence change in my area of work?

* Does this patient require an interpreter?

* Do I know how to access interpreting services? * Is there anything I need to know when using face-to-face or telephone interpreters?

There are also a number of useful educational resources to assist nurses. Let's Talk includes information on hiring trained interpreters--their role, when to use, advantages of using them, use of face-to-face or telephone interpreters, requesting an interpreter, risk of using untrained interpreters, and working with interpreters. (8) This is available on line at http://www.ethnicaffairs.govt.nz/oeawebsite.nsf/wpg_URL/ Resources-Guidelines-Lets-TalkGuidelines-for -Government-Agencies-Hiring-Interpreters?Open Document.

It is very important to use interpreters well. Tips for face-to-face encounters include arranging seating in a triangle or circle shape; talking to the client, not the interpreter; using short "bites" of dialogue; and not shouting--clients and interpreters are not deaf! At our service, we frequently use telephone interpreters, eg for our Burmese clients and other smaller ethnic communities. This functions by linking an Auckland-based interpreter into the consultation or home visit via a speaker phone. Our nurses even have speaker facilities on their cell phones. When using interpreters via telephone, clarification may be required more often, as the advantages of body language (as found in face-to-face encounters) are lacking.

Language Line, a free telephone interpreting service provided by the Office of Ethnic Affairs, is used by 37 government agencies, including some health services, to provide accessible telephone interpreting services to non-English speaking clients accessing their services. For more information, see the website www.languageline.govt.nz.

The website www.ethnicaffairs.govt.nz provides a referral and information service for ethnic communities and policy advice to government. For refugee health information, visit www.refugeehealth.govt.nz. This provides many good links and access to online information on a range of health-related issues.

In an increasingly multi-ethnic and diverse community, nurses will encounter many situations where the use of a professional interpreter will be necessary to ensure safe clinical outcomes for clients. Many health providers, both in the primary and secondary sectors, are unaware of how to use interpreters effectively and what services and training are available. Nurses are in a prime position to advocate for the linguistic needs of clients and this includes the need for interpreting services.

References

(1) The Office of Ethnic Affairs. (2003) Portraits: Youth. Wellington: Department of Internal Affairs.

(2) Joint Committee on National Health Education Standards (1995) National Network of Libraries of Medicine. Consumer Health Online Manual. Retrieved 14/11/05 from http://nnlm.gov/scr/conhlth/hlthlit.htm.

(3) Bowen, S. (2001) Language Barriers in Access to Health Care. Ottawa: Health Canada.

(4) Gerrish, K., Chau, R., Sobowale, A. and Birks, E. (2004) Bridging the language barrier: the use of interpreters in primary care nursing. Health and Social Care in the Community; 12: 5, 407-413.

(5) Department of Public Information at United Nations (1998) Article 21 Universal Declaration of Human Rights. Retrieved November 14 2005 from http://www.un.org/rights/50/decla.htm.

(6) NZNO. (1993) Standards of Nursing Practice, Standard 2. Wellington: NZNO.

(7) Health and Disability Commissioner (1996) The Code of Health and Disability Services Consumer Rights, Right 5. Wellington: author.

(8) The Office of Ethnic Affairs. (1995) Let's Talk. Wellington: Department of Internal Affairs.

Joy Wilson, RN, BA, is co-ordinator of communicable disease nursing and refugee health adviser with Hutt Valley District Health Board's Regional Public Health Service.