Background: With an increasing migrant population globally the need to organize interpreting service arises in emergency healthcare to deliver equitable high-quality care. The aims of this study were to describe interpretation practices in multilingual emergency health service institutions and to explore the impact of the organizational and institutional context and possible consequences of different approaches to interpretation. No previous studies on these issues in multilingual emergency care have been found. Methods: A qualitative descriptive study was used. Forty-six healthcare professionals were purposively recruited from different organizational levels in ambulance service and psychiatric and somatic emergency care units. Data were collected between December 2014 and April 2015 through focus-group and individual interviews, and analyzed by qualitative content analysis. Results: Organization of interpreters was based on patients’ health status, context of emergency care, and access to interpreter service. Differences existed between workplaces regarding the use of interpreters: in somatic emergency care bilingual healthcare staff and family members were used to a limited extent; in psychiatric emergency care the norm was to use professional interpreters on the spot; and in ambulance service persons available at the time, e.g. family and friends were used. Similarities were found in: procuring a professional interpreter, mainly based on informal workplace routines, sometimes on formal guidelines and national laws, but knowledge of existing laws was limited; the ideal was a linguistically competent interpreter with a professional attitude, and organizational aspects such as appropriate time, technical and social environment; and wishes for development of better procedures for prompt access to professional interpreters at the workplace, regardless of organizational context, and education of interpreters and users. Conclusion: Use of interpreters was determined by health professionals, based on the patients’ health status, striving to deliver as fast and individualized care as possible based on humanistic values. Defects in organizational routines need to be rectified and transcultural awareness is needed to achieve the aim of person-centered and equal healthcare. Clear formal guidelines for the use of interpreters in emergency healthcare need to be developed and it is important to fulfill health professionals’ wishes for future development of prompt access to interpreters and education of interpreters and users. Keywords: Emergency care, Health care professionals, Language interpreter practices, Migrants’ health, Organization * Correspondence: firstname.lastname@example.org Department of Social and Welfare Studies, University of Linköping, Campus Norrköping, S- 601 74 Norrköping, Sweden Department of Public Health and Caring Sciences, Uppsala university, Uppsala, Sweden Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Lundin et al. BMC International Health and Human Rights (2018) 18:23 Page 2 of 14 Background in a limited timeframe, in contrast to elderly healthcare Globally, the migrant population has increased in recent where healthcare is delivered in less structured activities in years, resulting in an increasing number of foreign-born longstanding contacts. persons not speaking the official language of the host country . Language barriers have significant impact in Theoretical framework healthcare for both the patient and the system and may This study is based on transcultural care , com- lead to health inequalities , patient safety risks , in- munication in institutions and organizations , and creased costs related to misdiagnosis and repeated visits, organizational routines [18, 19]. and ineffective use of resources , limited access to diag- Communication is fundamental for healthcare profes- noses, diagnostic testing, and treatment [5, 6], longer stays sionals, as is cultural understanding [16, 20]. Routines im- at the emergency department [7, 8], and migrant patients pact the care of the patient, and social structure and the may receive fewer explanations and follow-ups . culture of an organization are dimensions which affect To overcome language barriers and improve health- health professions and impact their actions [21, 22]. care and satisfaction for people who do not speak the of- Transcultural care can be described as the need to ficial language, the use of professional interpreters is provide care based on a person’s or group’s cultural be- recommended in previous literature review studies [9, liefs, values, and practices in order to promote or regain 10]. In Sweden all persons in contact with public author- health, and emphasizes that communication is funda- ities who need it have the right to an interpreter accord- mental for transcultural caring . Caring is also influ- ing to the Management Act  in order to prevent enced by the social structure and the cultural context disparities and to deliver equal care based on the indi- existing in an organization [16, 21]. Health professionals’ vidual’s active participation. routines impact patients’ health  and fundamental Previous studies in primary healthcare investigating ad- dimensions of nursing such as humanism (social, educa- verse events in the use of professional interpreters showed tional, ethical and spiritual dimensions) and its antithesis that the main problems were related to organizational is- (elements of bureaucracy, economic, political, legal, and sues and the interpreters’ limited language competence technological dimensions) impact nursing actions . . Besides our previous study focusing on use of inter- To describe identification with a certain custom or spe- preters in multilingual older persons , no investiga- cific country  the power relation between migrant tions have been found in the literature review concerning minorities and the majority, which defines specific indi- organizational issues in emergency care. viduals/groups as non-associated and others as related The main results of the recent study showed that in , the concept of ethnicity is used . How health- elderly care, interpreting practice was closely linked to care professionals use and discuss language interpret- institutional, interpersonal, and individual levels, and ation is also described as affecting the area of ethnicity guidelines for arranging the use of interpreters at work- at the workplace , and ethnicity can be understood places were lacking on different levels in the organization. as socially constructed boundaries between people with Professional interpreters were used on predictable occa- shared history or shared cultural values . Thus, hol- sions planned long in advance during office hours and istic and individualized healthcare recognizes human mainly in consultations with physicians or for individual rights to health including individual autonomy and care planning. In everyday care situations and on unpre- safety, such as having basic rights and freedom to access dictable occasions bilingual healthcare staff and family quality healthcare, and that individuals should be treated members were used. Health professionals also expressed a fairly, equally and impartially . need for translation of written documents such as menus, Communication can be described as a multifaceted test results, etc. phenomenon which makes a person’s identity visible and The use of professional interpreters was not adapted to shows how the other person is perceived on the individual the context of multilingual elderly healthcare . How- and the social level . It also makes it possible for the ever, it has been found that professional interpreters were individual to participate in society , where the individ- underutilized in emergency healthcare [14, 15]and the uals have legal and health literacy including a certain abil- question is whether different problems/strategies are found ity to understand, assess, access and communicate in other health care contexts with different characteristics. selected information about the care obtained, confronting Are there differences in high versus low structured activities social injustice either for themselves or their families in or limited timeframe versus longstanding contacts between order to achieve health and well-being . Increasing mi- emergency care and elderly care? In emergency care, the in- grant health literacy enables migrants to have a better ac- terpreter practice and its organization is distinctive in that cess to appropriate health care, which in turn promotes it usually occurs in less structured activities with high inten- social justice by increasing migrants’ social engagement, sity and often with use of high-tech measures and delivered inclusion and full citizenship. However, communication in Lundin et al. BMC International Health and Human Rights (2018) 18:23 Page 3 of 14 an institutional context differs and can be asymmetrical Setting when patients and healthcare staff do not have the same Emergency care institutions in somatic care departments aims, knowledge, or resources, particularly as health profes- (two emergency clinics (open 24 h) with observation sionals have their own agenda for assessment of informa- wards for maximum 48 h’ care)) and psychiatric depart- tion on which to base decisions and planning of care . ments (two psychiatric emergency clinics (open 24 h), one Organizational routines are progressive structures used including a psychiatric intensive care unit) and paramedics to accomplish organizational work aimed to deliver in ambulance care at two county hospitals in two different high-quality care with equitable outcomes for different cities in migrant-dense regions in Sweden were studied. ethnic groups in society . These can be defined as a The cities had approximately 88,000 vs 137,000 inhabi- repetitive, recognizable pattern of interdependent ac- tants, of whom 16.7 vs 17.8% were foreign-born . All tions , involving five actors dynamically and equally settings are characterized by high intensity, with brief en- operating with one another [18, 19]: (1) the individual, counters between staff and patient and often delivered in which includes the person’s identity, values, goals, and a high-tech environment . However, the encounters competence; (2) the interpersonal interaction including can differ from minutes up to days. Care in an emergency social skills, personality, power, and influence; (3) the care clinic or observation unit is focused on assessment of organizational context comprising technological, cul- an individual’s status and first-aid measures, triage and/or tural, and coordination structures; (4) the institutional referral of the patient for further care . Care delivered context with regulative, normative, and cultural- in the psychiatric clinic or psychiatric intensive care unit cognitive pillars; and (5) the environmental context with is mainly focused on acute measures connected to severe economic/political climate, legislative constraints, demo- dysfunction of mood, behavior, perception, or thoughts graphic changes, and development of technology [18, 19] that might be a threat to life, psychological integrity or ad- (for further details see ).Communication through an equate functioning. Care delivered in ambulance service is interpreter is thus a complex phenomenon . prehospital and limited to transportation to the hospital and life-sustaining measures. Like the majority of health care institutions in Sweden, Method all the emergency care institutions studied are run by the Aim county council with the exception of one of the ambu- The aim of the study was to describe language interpret- lance service units that is run by a private enterprise, al- ation practices in multilingual emergency health service though with the same regulations. The professional institutions. The study explored the impact of the interpreters they refer to are procured under the Public organizational and institutional context and possible Procurement Act  to guarantee the quality of the in- consequences of different approaches to interpretation. terpretation service, and the interpreter agencies used by The central research question of the study was: How do the hospitals are run by private enterprises outside the emergency care health professionals in Sweden influence health care system. In the studied areas the healthcare and culturally and linguistically diverse patients’ access to thus interpreting practice followed Swedish legislation: the language interpreters? Management Act , the Swedish Health and Medical Services Act , the Swedish Patient Act , and the Public Procurement Act . For further details see . Design A qualitative exploratory and descriptive study was used to Participants and procedure capture healthcare professionals’ experiences in a field not A purposive recruitment procedure was chosen to ensure previously explored and to describe their experiences in variation  in professions, gender, and experiences of their own natural state . Semi-structured interviews, working with interpreting situations in emergency care for individual and in focus-groups, with health care profes- foreign-born persons of different linguistic backgrounds sionals working in emergency care institutions, were con- and on different levels in the organization. Respondents ducted to investigate and understand the reality of were recruited after information meetings at the work- interpreter service when communicating with patients of place (n = 22) or by asking respondents during the inter- different linguistic backgrounds. Semi-structured interviews view period (snowball strategy, ) to invite those who allow informants to elaborate on experiences and thoughts, had not attended the information meetings held before while at the same time staying within certain topics de- the study (n =24). signed by the research team . In focus-group interviews Managers in the different emergency care institutions participants can open up through group interaction for dis- were contacted by telephone by the investigators (CL, EH) cussion where different perspectives, even more or less un- to give information about the study and get approval for conscious, can be revealed . the implementation. Verbal and written information about Lundin et al. BMC International Health and Human Rights (2018) 18:23 Page 4 of 14 the study was given. After their approval, the managers area [12, 37–39]. The questions in the interview guide were asked to invite health care staff who had experience focused on when interpretation became an issue, how of communication with non-Swedish-speaking persons in interpretation was conceptualized, what was supposed to emergency care to participate. A time was set for informa- be interpreted and the implications of different inter- tion meetings at the workplaces where the respondents re- pretation practices and challenges in improving equal ceived verbal and written information about the study. healthcare concerning interpreting service. The first Those interested in participating provided their contact focus group was used as a test of the interview guide details by e-mail or in written form to the investigators  and led to minor changes by also asking about the and were then contacted to set a time and choose an ap- need for a policy on interpreting. propriate place for the interview. The interviews were led by two nurses experienced in The study population included 46 persons, 14 males and leading groups and qualitative studies in research on mi- 32 females, aged 21 to 65 years (median 37), with occupa- grants and use of interpreters (first and second author). tional background as nurses, nurse assistants, nurse- All interviews were held in secluded rooms chosen by paramedics, paramedics, physicians, and social workers and the informants at their workplaces. with work experience in emergency care from 1 to 28 years The interviews were conducted with 46 participants, in (median 4 years) (see Table 1). Eleven of the participants five focus-groups with 3–5 persons in each group (n =20) were in a leading position and working as managers and and in 26 individual interviews. The focus-groups were, as the rest as ordinary health care staff (employees). recommended, planned to be homogenous in terms of profession to develop a comfortable group dynamic and Data collection avoid negative influence of power imbalance between dif- Data were collected by semi-structured interviews, indi- ferent professions . Three groups included only regis- vidually and in focus-groups, between December 2014 tered nurses vs assistant nurses vs. managers and there and April 2015. An interview guide was developed based was one group with three assistant nurses and a registered on a previous study  and other investigations in the nurse. The focus-group interaction was friendly, lively, and well-balanced in gender-mixed groups and the discus- sions lasted 60–70 min. In the individual interviews the Table 1 Characteristics of the study population communication proceeded without problems or interrup- Variable Persons N =46 tions in a free-flowing way and lasted 30–60 min. Directly Gender (n) after the interviews, the interviewer made notes on the Female 32 content of the interviews, the group interaction, and feel- Male 14 ings developed during the interview . All interviews Age (years) 37 (21–65) were audio-recorded and transcribed verbatim by a pro- fessional secretary and one of the investigators (CL), and Country of birth then analyzed. Sweden 41 Ex Yugoslavia 3 Data analyses Finland 1 Data were analyzed with inductive qualitative content Iraq 1 analyses . The transcripts were read through and Professional level (n) checked for accuracy and coherency to promote high quality and to get a sense of the content as a whole . Nurse 21 Then, the texts were broken into smaller meaning units Assistant nurse 8 and codes were identified. Codes with similar meanings Physician 5 were grouped together and subcategories and categories Social worker 1 emerged based on patterns. Throughout the analysis Unit managers 6 process the investigators searched for contradictions, re- Operational manager 5 gularities, similarities, and patterns in the text support- ing the development of subcategories and categories. Emergency healthcare context (n) Categories were refined and developed until an accept- Ambulance care 8 able system was reached. Collection and analysis of data Somatic emergency clinic 26 proceeded concurrently and until no new information Psychiatric emergency clinic 12 was added in the data analysis [30, 31]. Work experience in health care (years) 13 (1–44) In order to increase credibility, investigator triangula- Work experience in emergency healthcare (years) 4(1–28) tion was used, by two of the authors independently cod- Median (range) ing and checking the content of the codes  which Lundin et al. BMC International Health and Human Rights (2018) 18:23 Page 5 of 14 showed high agreement. During the whole process of skills, personal qualities, professional approach, and analysis all co-authors also checked and confirmed the organizational aspects; and 4) recommendations to content and the relevance of subcategories and categor- improve the use of interpreting services in emergency ies. The authors have different experiences in research care. and practical work in healthcare but all are in research in the area of migrants’ health and using qualitative The use of interpreters is determined by the patient’s methods. Discussions were held until consensus was health status and access to interpreting service in the reached in the event of diverging results. By illustrating organization categories with illuminative quotations and by naming Type of emergency care determines the mode of categories as close to the text as possible, confirmability interpreting was ensured. By describing the investigation process A common habit in somatic and psychiatric emergency (audit trail), as thoroughly as possible, dependability was healthcare, as described by the respondents, was to use confirmed, and finally transferability can be strength- professional interpreters, while health professionals in ened by studying informants with different professions, ambulance care used family members. from different hospitals and different geographical areas, thus giving a precise description of the study A professional interpreter in the room is hard to beat. population. It is the best … the patient often feels much more secure, the interpreter gets a different kind of contact Results with the patient and might then get more information The organization of interpreting for healthcare staff in just through his presence. (Respondent=R29, emergency care institutions concerning encounters with Psychiatric emergency clinic (=Psychiatric EC)) persons with language barriers is described in four categories, with subcategories, summarized in (Table 2): 1) the use of interpreters is determined by the patient’s The advantage is that they (family members) are often health status and access to interpreting service in the on the spot. Sometimes they have contacted relatives organization; 2) utilization of interpreting services is by telephone and that works well too, as I described driven by informal or formal guidelines and different earlier with FaceTime that you just stand there talking national laws; 3) the use of a professional interpreter at and then pass the receiver between you. It is mostly the workplace depends on the interpreter’s linguistic relatives that we use. (R 22, Ambulance care) Table 2 Overview of categories with subcategories analyzed from interviews by healthcare staff working in multilingual emergency healthcare Category (No. of statements) Sub-category (No. of statements) The use of interpreters is determined by the patient’s health Type of emergency care determines the mode of interpreting (338) status and access to interpreting service in the organization (424) The patient’s health status and availability of an interpreter determine the type of interpreter used in the workplace (44) Healthcare staff in somatic and psychiatric emergency care prefer professional interpreters (24) Healthcare staff in the ambulance prefer family members on the spot (18) Utilization of interpreting services is driven by informal or formal Informal and formal guidelines and limited knowledge of existing laws govern guidelines and different national laws (412) utilization of interpreting services in the workplaces Interpreters are used in situations with communication deficiencies in somatic and psychiatric emergency care (136) Professional interpreters are not used in ambulance care or in urgent situations (16) Interpreters are not used if body language can be used for communication (12) The use of a professional interpreter at the workplace depends on the The professional interpreter’s linguistic competence, positive personal interpreter’s linguistic skills, personal qualities, professional approach, qualities, and professional approach facilitates work when communication is and organizational aspects (290) deficient (206) Professional interpreter perceived as positive and a tool facilitating communication (24) Professional interpreter perceived positively or negatively when organizational aspects (time, environment and technical equipment, and interpreter languages) of the use of interpreter work or not (18) Recommendations to improve the use of interpreting services in Developing the procedure for prompt access to professional interpreters in emergency care (67) the workplace (58) Education of health professionals in using a professional interpreter, and the professional interpreter’s role in various care situations (9) Lundin et al. BMC International Health and Human Rights (2018) 18:23 Page 6 of 14 Differences between workplaces were found: bilingual some healthcare situations when information transfer health professionals and family members could be used occurred concerning the patient’s healthcare status, es- to a limited extent in ambulance care and emergency pecially in ambulance care when they usually do not care, but in the latter case telephone interpretation by know what language they will meet. The patient feels se- professional translators was also used on unpredictable curity and trust in the family member, who is mostly occasions for short-term assignments, even outside of- available in unpredictable situations at short notice. fice hours. In some situations healthcare staff had a At thesametimehealthcarestaff can easily convey negative perception of having professional interpreters information to the relatives. Disadvantages could be present, due to threatening patients in psychiatry, being poorer-quality interpretation because of risk of break- exposed to unpleasant emergency situations, and limited ing the code of confidentiality and lack of language space in ambulance care. In psychiatric emergency care, competence. the norm was to have professional interpreters in the Using bilingual healthcare professionals was mainly felt room related to characteristics of the patient’s mental to be a good choice as they were “easily accessible and health status, e.g. depression, and delusion with paranoia already in place.” However, they could cause problems by that might lead to suspiciousness of telephone interpret- not being neutral when interpreting and “not keeping the ation and using family members. code of confidentiality,” and having limited language knowledge. In psychiatry we need to have an interpreter present all the time. There are no caring situations where you … can see advantages but it is a person … who is used think “we need to try to manage this without an to health care and … patient contact and knows the interpreter.” It doesn’t work. We’re not mind readers. language at the same time … as long as they don’t (R 24, Psychiatric EC) have a personal relationship to the family… (R 9, Somatic EC) However, both somatic and psychiatric emergency healthcare found it a problem to have professional inter- preters in the room because they were not easily access- The patient’s health status and availability of an interpreter ible at short notice but required long planning in determine the type of interpreter used in the workplace advance and in some cases led to prolonged healthcare Respondents described how the patient’s health status visits for the patient. affected the choice of type of interpreter and vice versa. Informal interpreters such as relatives or colleagues were Often you have to book time, and sometimes there are used when necessary if the patient was unconscious, se- no times available. Even if there is some sort of verely ill, unable to speak, or action had to be taken emergency line – if I have understood right – where without delay, or in the case of a heavy workload and you can get an interpreter within an hour or half an need of fast access to an interpreter. hour. And then I don’t know whether I can be in place. To help the patient receive information quickly and (R 13, Somatic emergency clinic (= Somatic EC)) thus save time, sometimes bilingual colleagues were used as interpreters to assess the patient’s health Most health professionals perceived benefits in using problems for referral to the right level or type of care. telephone interpretation in short-term, one-off emer- Diffuse conditions, complex care, and critical condi- gency care situations, and in situations experienced as tions require interpreters, in contrast to simple health sensitive by patients. problems. An interpreter by telephone is more easily If it’s severely ill patients, critically ill, then the accessible. Sometimes … the only alternative to get interpreter actually doesn’tmatter somuch, because an interpreter in the language we needed … it in those situations we have guidelines that … so we might be possible to get one faster for the same have to … drive to the nearest hospital as soon as reason. (R 13, Somatic EC) possible and then there’s no time and it doesn’t matter… (R 15, Ambulance care) In some cases, using telephone interpreters had been experienced as a hindrance in examinations as they were unable to observe body language and the technical … if there’s someone consulting for … aminor equipment functioned badly, making it difficult to hear. complaint or if you have to decide whether they Healthcare professionals could see advantages in using should go to another caregiver … then it’sfasterto calm and neutral family members as interpreters in go and get a colleague. (R 5, Somatic EC) Lundin et al. BMC International Health and Human Rights (2018) 18:23 Page 7 of 14 Healthcare staff in somatic and psychiatric emergency care R1:2: They (patients) have the right to, the Health and prefer professional interpreters Medical Care Act,… In somatic and psychiatric care situations health profes- sionals preferred a professional interpreter in place be- R1:4 … right to the same care and but not to an cause they perceived them to ensure interpreting word- interpreter, no. by-word, having a professional attitude, and remaining neutral and objective. R1:3: But they (patients) know that they have the right to an interpreter … A professional interpreter on the spot … is the best. That it should not be colored by relatives, relatives can R1:2 … but then whether it is regulated in law, on influence the conversation and you rely on a which occasions, to what extent, I can’tsay. professional interpreter to actually interpret … That’s (Somatic EC) what one is looking for… (R 27, Psychiatric EC) In psychiatric care some respondents said that there was a formal policy at the workplace stating that pro- Healthcare staff in the ambulance prefer family members on fessional interpreters were to be used, and not family the spot members. This in contrast to somatic emergency care In situations in the ambulance with no other choice with its informal recommendation to use telephone of interpreting service, in situations that occur in the interpreters or family members as quick and access- home or various social environments, the staff in am- ible alternatives. In ambulance care informal guide- bulance services prefer a calm, objective relative who lines were also used, with the normal routine of using is on the spot. This is because they can give security available family members. A respondent in ambulance and can be an asset in a confused situation, also pro- care said that there is a written formal policy to use viding continuous information about the person. an interpreter but it was not adapted to their working conditions and thus could not be used. Booking an … sometimes it can be … a great advantage that interpreter becomes an issue for health professionals there can be relatives who know their father… in emergency care by self-established informal guide- Relatives have a different knowledge about the lines, a routine which the majority were pleased with. person … they can help on another level also with such things that often help us and that don’t It works well, the policy, although I don’thaveiton concern language … it has a dual function. (R 20, paper and … haven’t seen it … I think everyone at Ambulance care) theemergency unit whereIwork hasthepolicy established that there should be an interpreter in place or on the phone. (R 26, Psychiatric EC) Utilization of interpreting services is driven by informal or formal guidelines and different national laws Most of the respondents stated they had learned from Informal and formal guidelines and limited knowledge of older colleagues when and how to use a professional existing laws govern the utilization of interpreting services interpreter and a few from training or introduction at Knowledge about laws, policies, and guidelines regarding the workplace. interpreting service varies among health professionals, and the majority are not aware of any specific law or Yes, it’s some kind of local tradition … transmitted policy regulating the use. Most health professionals’ de- both by older colleagues, when you see how they work. cisions regarding professional interpreter use depend to But … also from other occupational categories. (R 13, a great extent on what they consider to be the patient’s Somatic EC) needs, and from the perspective that the person has a right to an interpreter to understand information given. Most health professionals expressed satisfaction with Most of the health professionals know about the law on the informal procedures available and had no need for procurement governing routines for booking a profes- other guidelines. If guidelines were available it was per- sional interpreter. ceived as contributing positively by increased used of interpreters and facilitation of equitable sharing. On R 1:4: No, not using an interpreter … no. the other hand, guidelines could restrict the use by be- ing too detailed in their recommendations. R 1:3: I was thinking of the law on patient safety, isn’t The majority of respondents knew how to order a there such a law? Aren’t interpreters included in that? professional interpreter, which was done from one or Lundin et al. BMC International Health and Human Rights (2018) 18:23 Page 8 of 14 two interpreter agencies that the workplace had agree- A few respondents stated that interpreters are needed ments with. Booking was done through a written in all care settings for correct exchange of information. document describing the process and was performed Many said that patients who need a professional in- by nurses, nurse assistants, and/or care administrators. terpreter usually have to wait longer, which may cause Physicians, managers, and staff in the ambulance worry for the patient, or the patient might cancel the service said they were never involved in booking a visit and refrain from care. On the other hand, a few professional interpreter and did not know how to do described how the visit might go faster using a pro- it. No restrictions in terms of costs for the order were fessional interpreter. perceived to hinder the use of a professional Conversation through a professional interpreter interpreter; instead the needs of the patient deter- was perceived as often becoming technical and im- mined the use. practical, and the social chatter intended to relax the person was excluded. Further, there was less support It is the responsible nurse, mostly … the nurse who for the patient with lack of emotional processing, does it … whohas amemosaying thisiswhatwe and the patient gets more compressed information do when we order an interpreter… But it’smore a and lacks the opportunity to ask follow-up questions matter of how you go about it, what number to call and become an active participant in healthcare. The and what the customer code number… Interpreter health care staff say that the entire health care situ- service, I think it’scalled. (R 4, Somatic EC) ation deteriorates because caring encounters are based on using language. Many respondents said that Some managers in emergency care described being the relationship between the caregiver and the pa- aware of issues concerning interpreter use when staff tient was negatively influenced when an unknown experienced difficulties, or they handled the billing or person in ordinary clothes was present in the room. issues of patient safety. That we can’t find a suitable interpreter or suitable I come into contact with it in that I pay the bills for dialect. Then care can be delayed … it takes more interpreters … sometimes when the staff have resources that we for example keep the patient on a difficulties … and discuss how we should act and bed for observation (R 24, Psychiatric EC) think. (R 11, Somatic EC) It’s not a good caring situation. There will be no Interpreters are used in situations with communication treatment or care… It feels frustrating that you deficiencies in somatic and psychiatric emergency care can’tgive them … because there is a lot of in Booking of a professional interpreter was determined conversation in our treatment, language is very by health professionals themselves, identifying in the important in caring. (R 29, Psychiatric EC) encounter with the patient the need for interpretation to be able to understand each other. Use of a profes- sional interpreter was most frequently related to Professional interpreters are not used in ambulance care or situations needing information exchange about the pa- in urgent situations tient’s health status, e.g. assessment of the patient’s In care delivered in the ambulance or in the home, acute condition by physicians and obtaining an anam- there is no time to get a professional interpreter in nesis, referrals to other institutions, exploration of the right language due to short, fast, and unpredict- symptoms, information about treatment or discharge able situations; instead family members or neighbors from the emergency unit. were used. R1:1: … if they don’t speak any Swedish but just … for patient contact in the home, but … we seldom shake their heads and … don’tunderstand … then use (professional) interpreters. The times we try to get you have to … order a (professional) interpreter. hold of a (professional) interpreter it’s through SOS Not when they get by in Swedish, then you don’t alarm and I find it difficult to get the help when we always order one … if the patient himself says that need it. Mostly when we’re out in contact with patients he wants an interpreter … it … oh … can surely be it’s so urgent that often you don’t have time to wait … questioned from an ethical point of view what is you have to solve the situation then by trying to make right and from a patient safety perspective also yourself understood anyway … we seldom use that way maybe a (professional) interpreter ought to be but it’s not allowed to take more than five minutes at ordered more often. (Somatic EC) most. (R 22, Ambulance care) Lundin et al. BMC International Health and Human Rights (2018) 18:23 Page 9 of 14 Professional interpreters are not used if body language can clear picture and can translate correctly … be used for communication important that we get what the patient is and not Professional interpreters are not used in short encoun- an interpretation of what the patient says. (R 13, ters in healthcare or in nursing care, e.g. meal situa- Somatic EC) tions or assessment of pain. Instead body language, family members, or bilingual colleagues are used by the Sometimes even the patient’s own feelings could be seen nurses for initial assessment of the patient to sort out as a barrier, e.g. when feeling unwell and being com- the cause of the visit or on admission to the emergency pletely silent, or when emotions like fear and anger hin- unit. der the ability to listen. The majority of health care staff in psychiatric and If a patient comes in an emergent situation it’sthe nurse somatic emergency care haveapositiveattitudetothe who meets the patient and then we try with body use of professional interpreters at the workplace, but language, English, Swedish, Google Translate, relatives, to some do not have any expectations or do not discuss get information about what the acute need is. The the use of interpreters, particularly in the ambulance problem and the reason why they are here. (R 25, units where professional interpreters are rarely used. Psychiatric EC) Professional interpreter perceived as positive and as a tool … check vital parameters … point to where it hurts facilitating communication and show with facial expressions… (R 5) (Somatic EC) The professional interpreter is described by many as a tool overcoming communication deficiencies and as a In urgent situations or in case of severely ill patients or solution to the language problem with lowered consciousness the patient’s status was assessed by bodily parameters and observations and thus Ithink … everyone thinks it’s positive that it professional interpreters were not used. exists… There’snoone whothinksit’stroublesome, no. I don’tknow, Ihaven’t heard anything at least. see that there is something … very serious so maybe you Sure, some might think it’s hard to talk by phone… start to look at all the vital parameters and ECG … It’s a bit uncomfortable to talk to someone who isn’t before you can … start asking questions … to see if there there for you to see. (R 4, Somatic EC) is something super-super-fast that needs to be done. (R 3, Somatic EC) Professional interpreter perceived positively or negatively when organizational aspects (time, environment, and The use of a professional interpreter depends on the technical equipment and interpreter languages) of the use interpreter’s linguistic skills, personal qualities, professional of interpreters work or not approach, and organizational aspects When the professional interpreter is available on time The professional interpreter’s linguistic competence, positive and stays as long as needed, and when the technical personal qualities, and professional approach facilitates equipment functions well and the interpretation occurs work when communication is deficient in an undisturbed environment, health professionals felt Interpretation was described by the respondents to be that these organizational and practical aspects func- of good quality when the professional interpreter had tioned and the interpreting situation was good. In the good language competence, in Swedish, the native lan- case of women seeking help for gynecological problems, guage, and health care terminology, and paid attention some found it beneficial to have a female professional to cultural expressions, translated word-for-word with a interpreter. flow, and had good conversation technology, was neu- When technical problems occur, or there is lack of tral, could keep the code of confidentiality, and control space making it difficult to maintain confidentiality, or him/herself in the emergency situation. Another influ- when the professional interpreter who has been ordered encing factor was the professional interpreter’sability speaks the wrong language, the interpretation situation to establish a trustful and empathetic relationship, best does not function. done with a professional interpreter on the spot, which also gave the possibility to observe body language. There are all the peripheral factors. That you have to be sitting in a good place, where there is plenty of … it’s fundamental in the interpreter’s profession space, that you have allocated time for the that you know the language really well. Both interpretation, and that you can be undisturbed. (R Swedish and the other language. So that you get a 14, Somatic EC) Lundin et al. BMC International Health and Human Rights (2018) 18:23 Page 10 of 14 Recommendations to improve the use of interpreting … what one can think about is the patient perspective services in emergency care on interpretation, that we’re probably not always so Developing the procedure for prompt access to professional good at asking for their point of view. (R 30, interpreters in the workplace Psychiatric EC) The healthcare professionals indicate that the use of pro- fessional interpreters would be facilitated and improved with fast access to professional interpreters by a hotline If anything would make it easier for me it would be to phone round the clock, and many wished for better ac- have slightly clearer guidelines on how they are cess to the most common languages as well as to all trained, what kind of degree of confidentiality they languages. have, can you reach more people without adding your own values in an interpreter conversation at our … that there was some kind of quick track to the workplace, it’s more that kind of information I would interpreter service … it goes really fast in many … in wish. (R 25, Psychiatric EC) many cases they call them back at once when you have the phone … for the most common languages they could guarantee an interpreter in five minutes. (R 8:3, Discussion Ambulance care) This study explored language interpretation practices in multilingual emergency healthcare by studying different Some discussed how better technology and technical so- health professionals describing their actions when organ- lutions could improve professional interpreter use and izing language interpreting. Thus, comparisons with pre- the organization of interpreting would be facilitated if vious studies will only be partial. The main results the administrative staff helped to book a professional in- showed that language interpretation services in emer- terpreter. For health professionals in ambulance care, it gency care are organized based on the patient’s health would help if the SOS alarm staff booked a professional status, and the context of emergency care and access to interpreter in advance, so that the interpreter was avail- the interpreter service in the organization determine the able from the first contact onwards, and all types of pro- use. Bilingual healthcare staff and family members were fessional interpretation were thought to help to make it used, but to a limited extent, in somatic emergency care, better for patients and health professionals in ambulance in contrast to psychiatric emergency care where the care norm was to have professional interpreters present. In ambulance service professional interpreters were seldom Good instrument when interpreting, either good used; instead persons available at the moment, such as telephones with good sound but also perhaps a video family members, friends etc., were used, along with ob- link … as you talk to someone over the telephone you servation of body language. Booking of a professional in- just as easily could be able to look the interpreter the terpreter was mainly based on informal, collectively face … a face that also sees the patient. (R 3, Somatic constructed guidelines and routines at the workplace EC) and sometimes on formal guidelines and different na- tional laws, but knowledge of existing laws was limited. Some staff believe a “joint policy” on (professional) The ideal was a professional interpreter with high lin- interpreter use could lead to improvement, provided guistic competence and a professional attitude, and that the policy does not regulate interpreter use for organizational aspects such as appropriate time and certain care situations. (R 30, Psychiatric EC) technical and social environment. Finally, wishes for the future included the development of a better procedure for prompt access to professional interpreters at the Education of health professionals in using a professional workplace, regardless of organizational context, and edu- interpreter, and the professional interpreter’s role in various cation of interpreters and their users. care situations In this study, healthcare staff determined the use of Some said that the interpretation situation would im- professional interpreters in multicultural emergency care prove if the patient’s perspective was considered more based on the patient’s health status, the kind of emer- often, if a professional interpreter was used more fre- gency care, and access to the interpreter service in the quently used during nursing care situations, if staff were organization to assess as fast as possible the individual’s trained in how to act and use a professional interpreter, need of care, in contrast to multicultural elderly care and if the professional interpreter is trained to have a where the use of professional interpreters was deter- professional attitude and to adapt to the caring unit’s mined by medical consultations with physicians or for specific requirements. individual care planning activities . Communication Lundin et al. BMC International Health and Human Rights (2018) 18:23 Page 11 of 14 can be described as a multifaceted phenomenon and the time, e.g. relatives and bilingual staff, were used to a through communication the person’s identity is made higher extent. This is in contrast to multicultural elderly visible and shows how the other person is perceived on care where no dissimilarities were found between differ- the individual and the social level . It also makes it ent sectors such as community home elderly care, nurs- possible for the individual to participate in society. Fur- ing homes, and nursing homes for dementia patients ther, communication in an institutional context is asym- . This is possibly related to organizational routines metrical when patients and healthcare staff do not have [18, 19] and organizational cultural competence . An the same aim, knowledge, or resources . This study important aspect here is the characteristics of the envir- found that communication through interpreters is a onment and context in which care is delivered. Ambu- complex process that depends on several factors such as lance service may differ from somatic and psychiatric patients’ health status, context of emergency care, and emergency care particularly due to the limited space, but access to interpreting service, but also on informal and also limited timeframes in which care is given and can formal guidelines governing the workplaces. However, in thus act as barriers to access, availability, and use of in- an emergency situation neither shared decision-making terpreters. Thus, use of interpreters needs to be adapted nor participation in communication might be possible to the environment and context. In the present investi- due to the patient’s health status, e.g. being unconscious, gation, however, interpreter use was determined by indi- having extreme pain, etc., and the urgency of the situ- vidual healthcare staff based on collectively constructed ation . Thus, an asymmetrical power relation might informal guidelines at the workplace and sometimes dis- need to be accepted temporarily to help the individual cussed with workmates; it thus mainly covered only the retain or regain health. Communication is central for individual and interpersonal levels of organizational rou- caring, but in such situations it might not be fully pos- tines described in the theoretical framework [18, 19]. sible to provide transcultural care where the individual’s There is a need for development of the three other needs and cultural beliefs are taken into account  levels: the organization, the institution, and the environ- and person-centered, safe, and equal care can be deliv- ment. Unclear routines affect how health professionals ered in accordance with Swedish law [35, 36] and human deliver care, and absence of guidelines and common ob- rights  including the legal and health literacy . jectives entails a risk that unconscious behaviors based Health professionals in this study described how they se- on staff ’s own standards and attitudes might negatively lected certain situations for interpreting, in contrast to affect healthcare encounters  with migrants. Rou- care for people who speak the official language of the tines enable coordination, ensure some stability of be- country. This can be explained as caring routines and havior, and when tasks are routinized they can be might be helpful for a person in a stressful situation  performed subconsciously, thereby economizing on lim- but it can contribute to further development of unequal ited cognitive energy . Improved knowledge and de- care [35, 36]. The findings emphasize the need for legal velopment of strong routines can shape common and health literacy and social justice to help reduce in- practice that improves the delivery of service  such equalities in accessing healthcare by empowering mi- as interpreters. grant patients to understand and critically engage in As in previous studies [13, 37], it was considered pref- their healthcare . Patients in need of an interpreter erable to get an interpreter with high linguistic compe- received less support in dealing with emotions, often tence and a professional attitude, and satisfactory had to wait longer, and had more compressed informa- organizational aspects such as appropriate time and tion and lack of opportunities to ask follow-up questions technical and social environment. In emergency care the than native-born people, which is similar to findings interaction with an interpreter showing trust, confidence from a review study concerning emergency healthcare and empathy is important and fundamental for the qual- which found that patients in need of an interpreter were ity of the conversation, and the interpreter needs to less satisfied, received inferior care, had limited diagnosis learn how to contribute to the alliance in healthcare and and treatment, and fewer follow-ups . An interesting thus also learn about the context in which healthcare is finding in this study is that no one mentioned economic delivered . This needs to be developed in existing aspects of the booking or use of an interpreter. Thus, guidelines for authorized interpreters in Sweden, which care in the studied area is focused on humanism rather mainly focus on interpretation technique, translating than bureaucratic values . correctly and neutrally  and not on the interpreter’s In the present study the use of professional inter- professional attitudes or organizational routines. Know- preters was related to the organizational context, with ledge about existing national laws and policies for using more frequent use in somatic and psychiatric emergency and booking interpreters in Sweden differed but was in care than in the ambulance service, where professional general limited among the respondents, and the use of interpreters were not used and instead those available at interpreters was seldom on the agenda for managerial Lundin et al. BMC International Health and Human Rights (2018) 18:23 Page 12 of 14 staff in emergency care. However, no national guidelines that need to be rectified concerning organizational, insti- exist with the exception of those mentioned above for- tutional, and environmental factors and the importance of mulated by Kammarkollegiet  and the Management transcultural awareness to achieve the aim of person- Act , stating the right to get an interpreter in contact centered and equal health care. The main task is to de- with public authorities, and the Public Procurement Act velop clear formal guidelines for the use of interpreters at  regulating what companies interpreter service can the workplaces, including the procedure for the use de- be procured from, and so this finding is not surprising. pending on the patient’s desire, health status and type of Sweden, like many other European countries, has be- emergency healthcare, but also to fulfill the health profes- come a multicultural society with a high influx of mi- sionals’ wishes for future development of prompt access grants in recent years, with an increasing demand for to interpreters, education of interpreters and of users of interpreters , particularly in healthcare, which is un- interpreters as regards how to perform interpretation. met due to lack of interpreters . Political interven- Acknowledgements tions are needed to solve this. There is an obvious We are grateful to Dr. Alan Crozier, professional translator, for review of the knowledge gap to fill here. language. The authors also thank Dr. Anna Bredström and Dr. Sabine Gruber at the Institute of Research on Etrhnicity, Migration and Society (REMESO), Department of Social and Welfare Studies, at Linköping University for the Limitations of the study collaboration that led to this study. This study was supported by grants from It might be seen as a limitation that a mix of individual Vetenskapsrådet (The Swedish Research Council), Sweden, reference number: 521-2013-2533. interviews and focus-group interviews was used for data collection. However, it has been claimed that the same Funding information can be reached by focus-group interviews as This study was supported by grants from Vetenskapsrådet (The Swedish Research Council), Sweden, reference number: 521–2013-2533. by individual interviews, although more time is needed for the individual interviews . On the other hand, it Availability of data and materials is a strength to combine different methods for data col- Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. lection, and this strengthens the findings . Not in- cluding patients’ and interpreters’ views in the study Author’s contributions could be seen as a limitation but was impossible due to Study design: CL, EH and KH; Data collection: CL and EH; Data analysis: CL under supervision of EH and KH. Drafting the manuscript: CL under the available resources for this investigation; this needs supervision of EH and KH who also made critical revisions to the paper for to be further investigated. important intellectual content. Obtaining funding: KH, CL and EH. All authors The focus-group interviews were held without an obser- read and approved the final version of the manuscript. ver present, which can be seen as a limitation  but as a Author information small group design  was applied, the interviewers had Emina Hadziabdic is a Senior Lecturer and postdoctoral fellowship. Her the same professional background as the respondents, and research focuses on Migration and Health, especially on communication through interpreters investigated from different perspectives: the individuals, were also familiar with leading and documenting interac- healthcare staff and families, using different qualitative and quantitative data tions in groups, in both research and education, the influ- collection methods: individual and focus group interviews, reviews of official ence of this is considered negligible . documents, qualitative systematic reviews and self-administered question- naires. Further, she uses different qualitative and quantitative methods for The main limitation of a qualitative study is that the data analysis in her research. findings cannot be generalized or explain cause-effect re- Katarina Hjelm, is a professor in Nursing Science. She is a diabetes specialist lationships [30, 31], but the main aim of this study was nurse and nurse tutor with a PhD in Community Medicine. Her dissertation concerned migration, health and diabetes and led to two main areas of to explore reality in order to arrive at a deeper under- research: 1) Migration and health and 2) Chronic disease management, standing of the phenomenon, and the findings are trans- particularly diabetes mellitus and chronic leg ulcers, but also COPD, stroke ferable to other contexts similar in characteristics and and IBD. International comparative studies have been implemented and thus international health is a third area of research. She has a particular interest in can contribute new knowledge in developing similar studying the influence on health-related behavior of beliefs about health organizations. and illness in migrants of different origin and other aspects of communica- tion in health care, e.g. use of interpreters. Migration and health is her central area of research. Conclusions Christina Lundin is a lecturer in Nursing Science. She is a nurse, midwife and In conclusion, the data seem to show that health profes- nurse tutor with a degree of Master in Medical Science in Reproductive and sionals act as gatekeepers for migrants’ access to inter- Perinatal Health Care. Her Master’s degree was about Swedish urban women’s symptoms and management of mastitis. She has a degree in preters and fail to apply Swedish laws. The use of Providing Professional Guidance in Health Care for healthcare staff and is professional interpreters in multicultural emergency care interested in professional development and problem-based learning. She has was determined by health professionals based on the particular interest in studying the influence of communication in health care organizations, e.g. use of interpreters. patient’s actual health status, and they did whatever was possible to deliver fast and individualized care as needed Ethics approval and consent to participate and based on humanistic values. However, there are This study has been conducted in accordance with Swedish law  and shortcomings in the institutions’ organizational routines ethical considerations according to the Declaration of Helsinki . Written Lundin et al. BMC International Health and Human Rights (2018) 18:23 Page 13 of 14 informed consent was obtained from the participants before the interviews 14. 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