Around 80-90% (2014-2019) of consultations in the Immigrant Health Service occur with the assistance of an interpreter. For RCH staff, please also see Interpreter services and booking an interpreter.

In Australia, interpreters are accredited through the National Accreditation Authority for Translators and Interpreters ( NAATI). (Note 1). Recognition is granted in languages where NAATI does not have testing available for proficiency.¹ In practice this means interpreters for newly emerging communities may have relatively limited experience working in the Australian healthcare system. Interpreters may have their own speciality (e.g. health, legal or general interpreting); however they are bound by a common code of practice which emphasises confidentiality - see AUSIT Code of Ethics. AUSIT (The Australian Institute of Interpreters and Translators) is the national association for the translating and interpreting profession. 

It is never appropriate to use a child or family member for interpreting -  information transfer cannot be guaranteed; it places a significant burden on the person interpreting (who may be exposed to sensitive/inappropriate information) and it changes the dynamics and power balance of the consultation.

Working with an interpreter is a skill like any other clinical skill. It takes time and practice to become fluent in working with interpreters. There is a learning curve for both health staff and the interpreters. The following points have been compiled based on our experiences in Immigrant health and are aimed at enhancing clinical care for children/families who speak languages other than English (Note 2).

Practical issues

Bookings

• Make sure patient details are updated with language preferences - patients presenting for their first visit may not have an interpreter booked if the referral has not indicated an interpreter is required. 
• Consultations with an interpreter take twice as long. Everything has to be repeated. This needs to be factored into booking times.
• Ask the patients preferred language and book appropriate language services. People may speak several languages but still prefer an interpreter to think through concepts and explain in their first language. Even people with good conversational English may lack the vocabulary required to discuss health issues.
  
• Consider if an interpreter of the same gender as the patient will be required (e.g. for gynaecological issues). This is usually possible, but the Interpreters office may require extra notice.
• Ensure interpreting assistance if there is someone in the consultation who does not speak the same language you do. If the children and adolescents speak good English but the parents do not, or if only one parent has proficient English, it is disrespectful and disempowering not to use an interpreter for parent(s).
  

Before the consultation - set-up

• Waiting area: Interpreters should have a place to wait near the medical staff (away from the patient waiting area). This preserves boundaries, and is respectful of the interpreters professional role. It also allows opportunities to brief the interpreters prior to the consultation
• Introduce yourself to the interpreter, and brief the interpreter prior to the consultation. Doctors will generally know the background and have some plan for what will be covered in the consultation. It is extremely difficult for interpreters if they are unaware of what might evolve, especially if the visit covers challenging issues. Appropriate briefing is respectful, and will help the consultation.
• Arrange seating and aim for a triangle between patient, interpreter and clinician - consider any other issues (e.g. enough chairs, previous code grey/possible need for exit)

During the consultation

• Face the patient, maintain eye contact with the patient and talk to them directly; you do not need to ask the interpreter to interpret what you have just said; they will take your cue and start talking when you pause. In general, simultaneous interpreting (often used in legal interpreting) is not used in the health context.
• If working with a phone interpreter use a speaker phone.
• Introduce yourself and the interpreter to the patient and explain how the consultation will work and both your roles. It is helpful to offer to stop and clarify at any time if there is any issue with understanding (for both the patient and the interpreter). It is also helpful to state explicitly that if there is anything they (the patient) do not want to talk about it they do not have to answer or continue.
• In any situation where you would define confidentiality, define both medical and interpreter confidentiality. Interpreters for 'emerging languages' may be known to the patient and explaining that interpreters are also bound by strict confidentiality is important. Rarely, there may be situations where patients may prefer a phone interpreter. This 'double definition' of confidentiality is essential when working with adolescents.
• Use clear and simple language and avoid medical jargon. Speak clearly and pause after 1 - 2 sentences, avoid speaking quickly. This is good practice with all patients; with time and practice, working with an interpreter regularly can enhance your ability to provide understandable information.
• There will be times when a brief summary turns into a lengthy conversation in the patients' language. Interpreters are directed to interpret what has been said exactly, however in our experience this is a simplistic view of the complexity of communication across languages and cultures. There may not be any direct translation into the patient's language and the interpreter may have to explain in a different way. Our practice is to ask what has been said; and if there is any concern, it is helpful to get the patient to explain what they understand (and request the interpreter interpret as closely as possible at this point).
• There are times when it is appropriate to ask the interpreter to find the terminology for a health problem with the patient. For example when explaining thiamine deficiency to a Karen family; getting the interpreter to ask the family if they know the name for the 'problem of swelling caused by only eating rice' established the word for 'beri beri' in Karen; and the fact that the family were aware of this problem. Tapping into preexisting health knowledge is not only respectful, it is fascinating and will enrich your own understanding.
• Leave time for questions. Questions are an excellent gauge of the patients understanding of any discussion.
• Work with the same interpreter for repeat consultations if possible - this makes it easier to continue discussions and is more familiar for the patients.
• Interpreters are often needed during other parts of the hospital visit e.g. pharmacy and X-ray. All families are entitled to the same  quality of service as all other families at RCH. Giving informed consent for radiology procedures and understanding medication instructions are an essential part of the continuum of care at RCH.
• Check whether you are 'leaning closer..speaking louder' and stop! Any conversation should be at normal volume and language does not need to be simplified (unless you would routinely, such as when speaking to a young child).

After the consultation

• Debriefing: it is good practice to provide an opportunity to talk briefly with interpreting staff after the consultations, especially in complex clinical situations. Interpreting staff may have emotional reactions to the content of the consultation. In refugee background communities, the interpreters may have been through similar migration pathways, and hearing clients stories may be a source of significant stress. Debriefing also allows opportunities for feedback, clarification, and learning about the cultural content from the interpreters' perspective.

Accessing interpreters

• At RCH - interpreters are provided through the Interpreter NESB Department. Further information on bookings.
• Private specialists - Private specialists providing Medicare rebateable services can book onsite interpreters free of charge through the Translating and Interpreting Service (TIS), provided through the Department of Home Affairs. TIS onsite interpreters are available 0900 - 1630 on weekdays. Ideally bookings should be made in advance, however bookings are accepted up to 24 hrs before the visit, depending on availability. Private specialists can register for free interpreting services with TIS National. The Doctors Priority Line is available 24 hours a day, 7 days a week for phone interpreting for medical practitioners providing Medicare services in private practice. Private practice reception staff can also access free TIS services to arrange appointments.
• Community health - In Victoria, interpreters in community health services (CHS) are usually funded through the CHS internally.
• General Practitioners in private practice - can access TIS the same way as private specialists above.
• Patients/families - can access an 'I need an interpreter card'. Supplies are available through the RCH Interpreters NESB services office. At RCH they can call the interpreter office and request interpreting assistance. 

Other resources

• Centre for Ethnicity and Health - Tip sheet (great resource) and Guideline on developing a comprehensive language service response
• Department of Education and Training - Resources on working with interpreters
• Foundation House - Promoting the engagement of interpreters (2013) and Tip sheet (Early years program)
• Lost without translation (MDA article on Medical Defense implications of not using interpreters where needed - 2008)
• TIS resource - Working with interpreters
• Translated health resources and bilingual health professionals are available - see  clinical psychologists and  psychology,  Dietitians and  Speech pathologists
  
• Victorian Department of Health and Human Services resource: How to work with interpreters and translators (2017) and tipsheet (2011).

Note 1: Technically interpreting is talking, translating is writing in another language.

Note 2: We have used an assumption that English is the default language of the consultation; this may not always be the case with multilingual health professionals.