Abstract
EXECUTIVE SUMMARY
New Zealand’s increasingly diverse population means that many patients come from linguistic and cultural backgrounds that make it more difficult for them to effectively access the New Zealand health system. The clinical risks of inadequate medical communication are well-known and for limited English proficient (LEP) patients, this can result from both linguistic and cultural reasons including simple lack of knowledge about our health system.
One approach for addressing this problem has been patient liaison or navigator services aimed at specific ethnic groups, most commonly Maori or Pacific. The provision of effective professional interpreting services in New Zealand has also recently increased. However, research on interpreting in primary care conducted by the ARCH (Applied Research on Communication in Health) Group in 2012-13 found issues with the narrow role boundaries of interpreters; often patients and their health professionals want help with practical matters that lie outside the narrow bounds of interpreting, the kind of assistance that health navigators may provide.
Given the recent development of the Pacific Navigation Service for primary health care in Wellington (run by Compass Health and Well Health PHOs under contract to C&CDHB), it was decided to research this group as well as the hospital-based Pacific Health Unit in Wellington to investigate their experience with how their service interfaces with interpreting services. Investigating the experiences of patients and health professionals using the services was unfortunately beyond the scope of this study.
While there are well-developed Hauora Maori navigation services, these were not selected for study because the vast majority of Maori patients do not have limited English proficiency and the issue of their interface with interpreters does not therefore arise.
This study was conducted in 2015-16.
Aim
To investigate the interface between health navigators and interpreters in overcoming barriers to health care for patients with Limited English Proficiency (LEP) in the Wellington region.
Method
We reviewed the international literature on the topic. We conducted individual or group interviews with two managers and six staff of the community-based Pacific Navigation Service (PNS), with the manager and three staff of the Pacific Health Unit (PHU) of Wellington Hospital, and with an independent contractor involved in the process to establish the navigation service. For the purpose of this report, the staff of both services will be referred to as navigators, although this is not the formal title used in the PHU.
These interviews elicited views and experiences regarding (i) the barriers to LEP patients obtaining quality health care, and (ii) their own roles, including how these intersect with other support services for this population. We conducted a framework analysis of the interview transcripts, with additional analysis of emergent themes.
Key Findings
The literature review found a wide range of barriers to health care for patients from culturally and linguistically diverse backgrounds (CALD). These were related both to the design of the health system (for example, complexity, and opening hours and locations of facilities) as well as to characteristics of the communities (for example, language and cultural features). The benefits of having some kind of health worker who is a member of such communities has been recognised for some time as an effective way to help overcome these barriers. The review highlighted the great variety of terms used for similar roles, but key attributes are that these workers are trusted by patients and that they perform a wide range of tasks.
The interviewees identified a similar range of barriers to those raised in the literature, plus some additional points such as the often incompatible communication styles of health professionals and of Pacific people in general, and the way that cultural attitudes like a deep sense of pride and a sense of deference to authority common in Pacific cultures can impact on how Pacific people engage with the health system.
The range of roles performed by navigators was also similar to those raised in the literature. There was an emphasis on the holistic and wide-ranging nature of the job. There are issues with raising and maintaining awareness of the service and what it does with health professionals and the public, and with resourcing. There was also felt to be some mismatch between the holistic aims of the service and the referral criteria which often focus on a single indicator such as DNA (Did Not Attend).
Our research found there is a significant overlap between the roles of navigators and interpreters in the study area, with navigators routinely interpreting for patients, especially in the hospital. Overcoming a language barrier was felt to be a major part of the navigator role, but navigators emphasised that they often did this in a qualitatively different way to that of a professional interpreter. In particular, participants felt that it was important to do more than to only interpret the words of the health professional, often explaining more fully in ways that their community will understand. However, it was also noted that this would not be so necessary if health professionals communicated more clearly using simpler language and visual aids, for example. In order to interpret effectively, navigators felt that some degree of health knowledge was important, as well as the greater depth of relationship afforded by the ongoing contact that a navigator often has with a patient. It was noted that critical conversations (such as informed consent) should require the use of professional interpreters, possibly in addition to a navigator, but that clinicians did not always make use of these.
It was acknowledged that some formal training in interpreting is desirable for navigators so that they can have some form of accreditation but there was frustration with the lack of a course tailored to their needs.
Interviewees described what they saw as shortcomings in the professional interpreters they had seen in action, and saw the strictly confined role of professional interpreters as an impediment to providing the help needed to get the best outcome for patients.
The concept of an explicitly combined navigator/interpreter role was supported, partly because this is what is happening in practice already. Training and formal recognition of this is desirable as well as the formal development of the scope of practice to clearly delineate the role.
Limitations of the study
The study only investigated the issue from the point of view of those involved in health navigation in a single area of New Zealand (Wellington). The views of interpreters, health professionals and service users were not investigated.
Discussion and Conclusions
Navigators in the Pacific services studied here have a challenging and complex role. It is evident that they are fulfilling a genuine need in their community. As a group, they need a broad range of skills and attributes, the core of which are strong community networks, sound health knowledge, and well-developed cultural and communication skills.
Interpreting is more strongly interwoven into the role of the navigator in these services than the researchers had initially expected. There is some tension between the fact that this is something that navigators do (and do well), and the fact that they do not receive significant interpreting training or official acknowledgement of this aspect of their role.
Pacific navigators felt Pacific patients may prefer to be assisted by a navigator (or indeed a family member) rather than a professional interpreter. Navigators expressed concerns about the confidentiality of interpreters and it is likely that their communities have a similar perception. Pacific navigators are perhaps more likely to be trusted by their clients due to their association with a health organisation. Navigators are also able to spend more time with patients than interpreters can, and this allows greater development of personal relationships and encourages the development of trust. The Pacific aversion to using telephones also works against the use of telephone interpreters which is a common way of delivering professional interpreting but not so much for navigation services. It should be noted that there are rare examples where professional interpreters are employed by some general practices that have large numbers of patients from a particular ethnic community, and such interpreters are also able to establish good relationships with patients and have a high degree of trust from their community.
Over and above this perceived Pacific dispreference for professional interpreters is the fact that Pacific navigators have a different view of the kind of language help that their community needs, compared to the strictly executed interpreting that is espoused by professional interpreting services. Pacific navigators believe that more is needed for their clientele to communicate health messages effectively and that professional training in health or social work is needed to be able to adequately support their clients. For this reason, they would be in favour of navigators receiving additional training in interpreting on a firm health or social work base, rather than interpreters receiving additional training in health. The desire for specific training in interpreting for navigators came with the proviso that such training needs to be tailored to the requirements of their role.
Reading between the lines of the many stories of unnecessary duplication or complexity caused by multiple staff interactions, we would suggest that LEP patients in general, including those within the Pacific community, can be better served by receiving assistance from a single person or team. Such a person or team is better able to get to know LEP patients and their circumstances and be able to assist with overcoming a range of barriers, including the language barrier. This needs to be officially recognised in policies and training.
With acknowledgement that multiple roles are performed by a single person or team comes a need for clear communication about these roles. There needs to be explicit discussion of role at a local level with patients, their families and clinicians to ensure that all understand what to expect and what the relevant boundaries are. It is also important that the navigation teams themselves continue their current reported practice of ongoing clarification of roles, as participants at times reported slightly different interpretations of their role boundaries, particularly with respect to assisting clients with non-health agencies.
We agree with the research participants about the importance of clear definitions for when a task is beyond the navigators’ scope of practice and should be referred on to an appropriate professional (such as a professional interpreter, social worker etc.). There may be a need for professional supervision to manage these boundaries.
While individual navigators need to perform multiples roles, it is also true that the full breadth and depth of skills required by navigators cannot be expected to be present in any one individual but needs to be distributed across a team. This is especially true in terms of language skills. Allocating cases on the basis of best fit of navigator to case, as currently happens within each service, makes sense in this context. For example, cases may be assigned to specific navigators according to their training (nurse or social worker) or previous experience as well as according to their languages so that clients are matched with the most appropriate staff member for their situation.
The Pacific community is the only community (or more accurately, set of communities) with LEP patients in the Wellington area that has a formal navigation service. Our findings suggest that Pacific patients are effectively assisted to overcome a range of barriers, including the language barrier, by these services. We would suggest that other CALD/LEP communities beyond the Pacific community would also benefit from such a service in combination with interpreting services.
However, while Pacific navigators firmly believe that it is best for navigators to add interpreting skills to their training, rather than trying to train interpreters as navigators, this may not be the case in other CALD communities. Further consultation within such communities or those working with them (interpreters and health professionals) will be required to determine how services should best be designed for them. However, the views of the participants in this study suggest that meaningful health knowledge in those taking on such roles is likely to be a key element.
It is also important to delineate the most important barrier(s) affecting the outcome for each presenting client, and tailor the navigator intervention to that barrier. Again, a comprehensive service with well-trained staff covering a range of skills, training and experience would seem to be the best way to make this possible, since there are so many potential barriers to care.
The configuration of services – i.e. whether a service is based in a hospital or in the community or spans both – also needs to be sensitive to the best way to address particular barriers. For example, addressing DNA rates at hospital clinics and providing language services to inpatients is best done from within a hospital based service. Following up on families with outstanding immunisations is best done by a community based service. Navigation for a person with a complex condition (cancer or multiple co-morbidities) is best done from a service that is case-based that can span all sectors.
The participants highlighted the effectiveness of working in such a way that the diverse needs of clients are met by a team with diverse skills. This strengthens an argument for developing more overlap or integration between the two services (community- and hospital-based) as this would create an even larger pool of skills to draw from. In addition, a more integrated service would also enable greater continuity of care across the settings which would further capitalise on the benefits of stronger individual relationships. Better integration with other services in the community is also desirable.
Also worthy of reconsideration may be the current focus on individual clients. Although not a question specifically addressed in this research, participant responses suggested that a household focus could be more useful and cost-effective in addressing barriers for a number of individuals in a single household. Given the family structure of many Pacific households (and probably other CALD communities), a household approach may be more culturally appropriate as well as improving efficiency.
Overall, we believe the strengths of the current Pacific navigation services should be built on and lessons learned from their experiences are likely to be useful when considering similar services to assist other CALD communities. Further research into the views of other stakeholders in this area would be very desirable.
Recommendations/Implications
The following recommendations are suggested by our findings. Recommendations 1-3, it should be noted, are already happening to some degree but are important to highlight so that greater consistency across staff can be achieved.
(1) The scopes of practice for the various types of navigators (depending on training and experience in other professions such as nursing and social work) need to be clearly defined and clear guidelines about when to refer on and to whom should continue to be developed.
(2) Navigators need to be fully aware of the wide range of roles they perform and to have a clear idea of their individual scope of practice.
(3) Navigators need to be aware of what role they are taking with any particular client at any particular time. This should be discussed with patients and health professionals to ensure clarity. They also need to be able to clearly assess when what is required is out of their scope of practice and to bring in additional help, such as professional interpreting services.
(4) Systems for training and accrediting navigators as interpreters should be investigated with a view to explicitly incorporating interpreting into the navigator role.
(5) Ways of providing navigation in tandem with interpreting should be explored for other communities, with consideration given to appropriate training, recruitment and funding.
(6) Further work needs to be done to improve the communication skills of health professionals, including the use of visual aids, writing notes and rephrasing.
(7) Professional interpreters need to be made aware of the existence of such health navigation services as there are and trained in when to call them in.