CHIA California Healthcare Interpreters Association

CHIA has 4 parts
-Standardized Protocol
-Ethics or Ethical Principles,
-Roles of the Interpreter
-Ethical Decision-Making Process
CHIA: Standard Protocol
Defined as – frame work that guides the interaction between interpreter, provider, and patient. There are three.
CHIA: Standard Protocol: Protocol 1:
Pre-Encounter, Pre-Session, or Pre-Interview
1. Interpreter must provide their name, language of interpreting, and if necessary, any affiliation with any organization
2. State confidentiality clause
3. Inform ALL parties of the elements required for a smooth encounter, such as:
a. The interpreters requirement to interpret EVERYTHING that is said.
b. The importance of the provider and patient directly addressing each other.
c. Parties must pause to allow for interpreting to occur.
d. Explain that the interpreter may need to intervene for clarification.
4. Ask if the provider needs to brief the interpreter about anything in advance of the upcoming interaction, and to share any concerns that the interpreter may have.
CHIA: Standard Protocol: Protocol 2: During the encounter, Session, or Interview
1. Interpreter must position themselves to maximize and encourage direct communication between patient and provider.
2. Remind patient and provider, through hand gestures or verbally, to communicate directly.
3. Use the first person (“I”) as the standard form of interpreting. Use discretion in switching to “third person” when first person causes confusion or is culturally inappropriate.
4. Attend to verbal and non-verbal cues that may indicate that the listener(s) are confused or do not understand and check if clarification is needed.
5. Manage flow of communication. Examples; avoid side-bar conversations with either party, pace the amount of information presented, prevent parties from speaking at the same time.
6. Intervene for clarification when the interpreter does not understand the terminology or the message.
7. Clearly indicate when interpreter is speaking on own behalf when intervening for any purpose. Example; when clarification is needed by or from either patient or provider. Start with ” The interpreter needs/ feels/ does not understand, etc.
8. Consider interrupting the communication process when extreme circumstances require private discussion with either patient or provider. Examples; Multiple family members present, patient safety is in jeopardy, or during sensitive matters requiring private conversation.
CHIA: Standard Protocol: Protocol 3: Post-Encounter, Post-Session, or Post-Interview
1. Inquire about any questions or concerns that any party may have for each other, and ensure that the encounter has indeed ended.
2. Provide directions or accompany the patient to subsequent appointment. (Let me clarify. You may escort, direct, walk with patient to next appointment if in the same building. DO NOT drive the patient, or wheel them across the street.
3. Facilitate the scheduling of follow-up appointments, and remind the patient or receptionist to request an interpreter.
4. Document the provision of interpreter services as required by organization’s policies.
5. Debrief provider or supervisor, when appropriate, about concerns that arise during the session.
CHIA: Health and Well-Being of the Interpreter
CHIA recommends that interpreters work in teams of two when sessions last more than 45 minutes.
For every hour of continuous interpreting, interpreters should be given a 10 – 15 minute break. (for example: during conference interpreting)
After emotionally charged subjects; like the diagnosing of a terminal illness, a bad prognosis, or a death announcement; interpreters should take a time-out from interpreting. This can be accomplished by removing yourself from work for a few minutes, a debriefing with an employee, counselor, or speaking directly with your supervisor. For freelance interpreters this may include speaking to other interpreters, seeking guidance from an organization that you are affiliated with, or seeking therapy.
CHIA: Interpreter Roles (4)
There are four primary roles to an interpreter:
1. Message Converter
2. Message Clarifier
3. Cultural Clarifier
4. Patient Advocate
When choosing which role to fulfill, the most important considerations is: DO the actions of the interpreter, in that role, support the relationship between patient and provider in the context of the health and well-being of the patient.
CHIA: Message Converter
While fulfilling this role the interpreter must:
-Manage the flow of communication between all parties
– Listen to both speakers
-Observe body language
-Convert the meaning of all messages from source language to target language without unnecessary additions, deletions, or changes in meaning of the original message
-Intervene (verbally or non-verbally) when speakers fail to allow time for the interpreter to interpret, or if they speak to quickly
-Manage turn-taking by indicating to all parties that they will be heard in sequential order and to allow individuals to finish speaking
CHIA: Message Clarifier
Interpreters acting in this role must:
-Be alert for possible words or concepts that may cause or lead to misunderstanding
If there is evidence that any party (patient, provider, or interpreter) are confused by a word or phrase, the interpreter may need to do the following:
-Interrupt the communication process by using a word, comment or gesture to signal the speaker
-Alert the parties that the interpreter is seeing signs of confusion from one or more than one of the parties and identify the word, phrase or concept
-Ask that the speaker restate the word, use a simpler word or concept, or to describe the word
-Explore ways to assist the speakers in describing words or concepts when there is no linguistic equivalent. Use analogies or “word pictures” (pictographs).
-While performing any of the roles of the interpreter, when the interpreter is no longer converting messages, it is critical that the interpreter state that they are speaking for themselves.
-When intervening or clarification is needed, the interpreter should speak in the third person stating: “The interpreter would like to say…” or “The interpreter notices/feels/does not understand…..”
-The interpreter should allow for communication to occur naturally, allowing adequate time for the provider and patient to communicate common understandings. Unless communication is seriously impaired, the interpreter should wait for other parties to ask for the interpreters help in clarifying words or concepts that were not understood.
CHIA: Cultural Clarifier
Goes beyond clarifying words. This role includes a range of actions that typically relates to the interpreters ultimate goal of facilitating communication between two people who do not share a common culture.
-Interpreters should be alert to cultural words, concepts, or non-verbal cues that can lead to misunderstanding. This is what triggers the interpreter into this role.
The patient may perceive the line questions or comments made by the provider inappropriate. Likewise, the provider may perceive answers or comments made by the patient as inappropriate or not relevant to what was asked. When there is evidence that any of the parties (patient, provider, or interpreter) are confused by a cultural difference, the interpreter should:
-Interrupt the communication process with a word, comment, or gesture when appropriate
-Speak in the third person stating: (As the interpreter I feel/ think there maybe potential for potential danger for misunderstanding/miscommunication”
-Suggest or point out cultural concerns that could be impeding mutual understanding
-Assist the patient in explaining the cultural concept to the provider, or the provider in explaining the “biomedical concept”.
-When requested, the interpreter must explain the cultural custom, health belief, or practice of the patient to the provider. Also, assist the provider in explaining the”biomedical concept”.
CHIA: What is “Biomedical Concept”
-The absence of disease
The human body = machine
Disease =consequence of the breakdown of the machine
The doctor = repairs the machine
-The limitation is that this concept minimizes the role of environment, social, psychological and cultural determinants of health.
CHIA: Patient Advocate
Interpreters should not be responsible for everything that everyone does or does not do. If the interpreter notices that something is starting to go wrong, it is reasonable that it be brought to the attention of someone who can correct it before it becomes a problem.
Remember. Limited-English speakers face cultural and linguistic barriers such as:
-Accessing and utilizing all levels of the healthcare system
-May be unfamiliar with the U.S. healthcare system
-May be unfamiliar with their rights and what services are available to them
-May find it difficult to advocate for their right to the same level of care as English-speaking patients
Given this backdrop, sometimes the interpreter is the only person who can advocate on behalf of the patient. This role is not without its risks to both the patient and the interpreter. Advocating requires a high level of skill and should remain an optional role.
CHIA: What is Patient Advocacy?
Patient advocacy can be defined as – active support of change in the interest of patient health and well being.
An individual patient’s health and well-being is at the core of the role of patient advocate. Interpreters need a clear rationale for the need to advocate on behalf of the patient.
Questions an interpreter should ask themselves before deciding to enter the role of patient advocate:
-What changes are required to meet the needs of the patient?
-What options exist for the patient?
-Who can potentially carry out the positive changes?
-Is the patient in agreement with this course of action?
In undertaking the role of patient advocate, interpreters must balance their ethical duty of remaining impartial and respecting patient autonomy.
Note: autonomy is defined as: The patients right to make decisions about their medical care without the influence of a healthcare provider. Patient autonomy allows for health care providers to educate the patient but does not allow the health care provider to make decisions for the patient.
Advocacy does not need to be on a grand scale. It could be something small and simple like suggesting that an interpreter be scheduled for follow-up. The level of intervention depends on the comfort level of the interpreter in carrying out the action.
CHIA: Ethical Dilemma
Often viewed by the patient as their only link to the healthcare system, interpreters may find themselves receiving unsolicited heath-related information. This may or may not occur in the presence of a provider. In most circumstances after becoming recipients of this information, interpreters abide by the first ethical principle of confidentiality.
What causes an ethical dilemma?
-When patients share information that was unsolicited but do not wish or intend for that information to be shared with the provider.
Should the interpreter take action and share the information with the provider?
Should the interpreter remain silent?
To answer these questions, interpreters should consider several other questions like:
-How will revealing this information, without patient approval, affect the level of trust between patient and interpreter or, greater yet, between the interpreter and the community?
-What if the information revealed by the patient is critical for the patient’s health or safety and therefore important for the provider to know?
-Will there be a negative impact on the patients health and well-being if the interpreter remains silent?
-Why should the LEP not be allowed to withhold information like an English-proficient?
At the heart of the dilemma, is that the interpreter does not have the medical expertise to make such an informed decision.
Before making a decision and taking action, including maintaining silence, interpreters should consider the previous questions but also rank possible out comes.
The good news is that interpreters are not left without guidance. Enter The Ethical Decision-Making Process
CHIA: Ethical Decision-Making Process
When applying the ethical decision-making process, interpreters must address the dilemma in the following way:
1. Ask questions to determine whether there is a problem.
2. Identify and clearly state the problem, considering the ethical principles that may apply and rank them in applicability. (in order of importance)
3. Clarify personal values as they relate to the problem.
4. Consider alternative actions, including benefits and risks.
5. Decide to carry out the action chosen
6. Evaluate the outcome and consider what might be done differently next time.
CHIA: 1. Ask questions to determine whether there is a problem
-Explore the issue further to understand the patient’s concerns
-Address any possible misconceptions before deciding how to proceed
In other words: What is the problem? Is there actually a problem? Was there a misconception or did the patient receive bad information or were they misinformed?
CHIA: 2. Identify and clearly state the problem, considering the ethical principles that may apply and rank them in applicability.
Interpreters must consider their duty to the following:
-Respect patient autonomy, remain impartial, and uphold confidentiality.
-Determine if there is some degree of flexibility in deciding how and what information, if any, to share with the provider.
-Weigh considerations with the overall picture in mind. The patients health and well-being. It is generally accepted that if the information is relevant to the patient’s care, that information should be shared with others involved in that patients care being that they are also bound by confidentiality.
-Assess any impact on the level of trust between interpreter and patient once the information is revealed.
CHIA: 3. Clarify personal values as they relate to the problem
Interpreters may be influenced by one or more of the following:
-Spiritual beliefs
-Traditional culture
-Acculturation; interpreters need to expend more effort to understand the patient who is less acculturated (the cultural and psychological change that results from the meeting of two cultures.)
-Personal honesty
-Guilt or shame
CHIA: 4. Consider alternative actions, including benefits and risks
These actions include:
-Remaining silent and the outcomes that are associated with remaining silent
-Telling the doctor and the outcomes of that decision
This also takes into account when to divulge the information
-During the session or outside of the session
CHIA: 5. Decide to carry out the action chosen
This includes:
-Keeping the information confidential by saying nothing.
-Telling the doctor with patient consent.
-Telling the doctor without patient approval.
-The potential outcomes (positive or negative), backlash, or fallout between the patient and interpreter, interpreter and provider, or all of the above.
CHIA: 6. Evaluate the outcome and consider what might be done differently next time.
Includes:
-Reflecting on the outcome of the action.
-Did the patient benefit from the action taken.
-Will the interpreter engage in such action in the future.
ALWAYS keep in mind that as interpreters, our actions should be consistent with the ultimate goal of supporting the patients health and well-being.
CHIA: Other types of information
When information is related to:
-Domestic Violence
-Child Abuse
-Suicide
-Intent to harm self or others
Other factors must be considered in the process of determining appropriate course of action. Some of the factors are:
-Mandated Reporting (assigned or determined by the state)
– HIPAA
– Organization Policies (Hospital, Clinic, County, State)
– Federal Law
– State Law

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