RESEARCH ARTICLE Open Access

Language interpretation conditions andboundaries in multilingual and multiculturalemergency healthcareChristina Lundin1, Emina Hadziabdic1,2 and Katarina Hjelm1,3*

Abstract

Background: With an increasing migrant population globally the need to organize interpreting service arises inemergency healthcare to deliver equitable high-quality care. The aims of this study were to describe interpretationpractices in multilingual emergency health service institutions and to explore the impact of the organizational andinstitutional context and possible consequences of different approaches to interpretation. No previous studies onthese issues in multilingual emergency care have been found.

Methods: A qualitative descriptive study was used. Forty-six healthcare professionals were purposively recruitedfrom 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, andanalyzed by qualitative content analysis.

Results: Organization of interpreters was based on patients’ health status, context of emergency care, and access tointerpreter service. Differences existed between workplaces regarding the use of interpreters: in somatic emergencycare bilingual healthcare staff and family members were used to a limited extent; in psychiatric emergency care thenorm 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 informalworkplace routines, sometimes on formal guidelines and national laws, but knowledge of existing laws was limited; theideal was a linguistically competent interpreter with a professional attitude, and organizational aspects such as appropriatetime, technical and social environment; and wishes for development of better procedures for prompt access to professionalinterpreters 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 todeliver as fast and individualized care as possible based on humanistic values. Defects in organizational routines need to berectified and transcultural awareness is needed to achieve the aim of person-centered and equal healthcare. Clear formalguidelines for the use of interpreters in emergency healthcare need to be developed and it is important to fulfill healthprofessionals’ 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: katarina.hjelm@liu.se1Department of Social and Welfare Studies, University of Linköping, CampusNorrköping, S- 601 74 Norrköping, Sweden3Department of Public Health and Caring Sciences, Uppsala university,Uppsala, SwedenFull 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 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe 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 https://doi.org/10.1186/s12914-018-0157-3

BackgroundGlobally, the migrant population has increased in recentyears, resulting in an increasing number of foreign-bornpersons not speaking the official language of the hostcountry [1]. Language barriers have significant impact inhealthcare for both the patient and the system and maylead to health inequalities [2], patient safety risks [3], in-creased costs related to misdiagnosis and repeated visits,and ineffective use of resources [4], limited access to diag-noses, diagnostic testing, and treatment [5, 6], longer staysat the emergency department [7, 8], and migrant patientsmay receive fewer explanations and follow-ups [6].To overcome language barriers and improve health-

care and satisfaction for people who do not speak the of-ficial language, the use of professional interpreters isrecommended in previous literature review studies [9,10]. In Sweden all persons in contact with public author-ities who need it have the right to an interpreter accord-ing to the Management Act [11] in order to preventdisparities and to deliver equal care based on the indi-vidual’s active participation.Previous studies in primary healthcare investigating ad-

verse events in the use of professional interpreters showedthat the main problems were related to organizational is-sues and the interpreters’ limited language competence[12]. Besides our previous study focusing on use of inter-preters in multilingual older persons [13], no investiga-tions have been found in the literature review concerningorganizational issues in emergency care.The main results of the recent study [13] showed that in

elderly care, interpreting practice was closely linked toinstitutional, interpersonal, and individual levels, andguidelines for arranging the use of interpreters at work-places were lacking on different levels in the organization.Professional interpreters were used on predictable occa-sions planned long in advance during office hours andmainly in consultations with physicians or for individualcare planning. In everyday care situations and on unpre-dictable occasions bilingual healthcare staff and familymembers were used. Health professionals also expressed aneed for translation of written documents such as menus,test results, etc.The use of professional interpreters was not adapted to

the context of multilingual elderly healthcare [13]. How-ever, it has been found that professional interpreters wereunderutilized in emergency healthcare [14, 15] and thequestion is whether different problems/strategies are foundin other health care contexts with different characteristics.Are there differences in high versus low structured activitiesor limited timeframe versus longstanding contacts betweenemergency care and elderly care? In emergency care, the in-terpreter practice and its organization is distinctive in thatit usually occurs in less structured activities with high inten-sity and often with use of high-tech measures and delivered

in a limited timeframe, in contrast to elderly healthcarewhere healthcare is delivered in less structured activities inlongstanding contacts.

Theoretical frameworkThis study is based on transcultural care [16], com-munication in institutions and organizations [17], andorganizational routines [18, 19].Communication is fundamental for healthcare profes-

sionals, as is cultural understanding [16, 20]. Routines im-pact the care of the patient, and social structure and theculture of an organization are dimensions which affecthealth professions and impact their actions [21, 22].Transcultural care can be described as the need to

provide care based on a person’s or group’s cultural be-liefs, values, and practices in order to promote or regainhealth, and emphasizes that communication is funda-mental for transcultural caring [16]. Caring is also influ-enced by the social structure and the cultural contextexisting in an organization [16, 21]. Health professionals’routines impact patients’ health [22] and fundamentaldimensions of nursing such as humanism (social, educa-tional, ethical and spiritual dimensions) and its antithesis(elements of bureaucracy, economic, political, legal, andtechnological dimensions) impact nursing actions [21].To describe identification with a certain custom or spe-cific country [16] the power relation between migrantminorities and the majority, which defines specific indi-viduals/groups as non-associated and others as related[23], the concept of ethnicity is used [16]. How health-care professionals use and discuss language interpret-ation is also described as affecting the area of ethnicityat the workplace [24], and ethnicity can be understoodas socially constructed boundaries between people withshared history or shared cultural values [25]. Thus, hol-istic and individualized healthcare recognizes humanrights to health including individual autonomy andsafety, such as having basic rights and freedom to accessquality healthcare, and that individuals should be treatedfairly, equally and impartially [26].Communication can be described as a multifaceted

phenomenon which makes a person’s identity visible andshows how the other person is perceived on the individualand the social level [27]. It also makes it possible for theindividual to participate in society [17], where the individ-uals have legal and health literacy including a certain abil-ity to understand, assess, access and communicateselected information about the care obtained, confrontingsocial injustice either for themselves or their families inorder to achieve health and well-being [28]. Increasing mi-grant health literacy enables migrants to have a better ac-cess to appropriate health care, which in turn promotessocial justice by increasing migrants’ social engagement,inclusion and full citizenship. However, communication in

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an institutional context differs and can be asymmetricalwhen patients and healthcare staff do not have the sameaims, knowledge, or resources, particularly as health profes-sionals have their own agenda for assessment of informa-tion on which to base decisions and planning of care [17].Organizational routines are progressive structures used

to accomplish organizational work aimed to deliverhigh-quality care with equitable outcomes for differentethnic groups in society [16]. These can be defined as arepetitive, recognizable pattern of interdependent ac-tions [29], involving five actors dynamically and equallyoperating with one another [18, 19]: (1) the individual,which includes the person’s identity, values, goals, andcompetence; (2) the interpersonal interaction includingsocial skills, personality, power, and influence; (3) theorganizational context comprising technological, cul-tural, and coordination structures; (4) the institutionalcontext with regulative, normative, and cultural-cognitive pillars; and (5) the environmental context witheconomic/political climate, legislative constraints, demo-graphic changes, and development of technology [18, 19](for further details see [13]).Communication through aninterpreter is thus a complex phenomenon [13].

MethodAimThe aim of the study was to describe language interpret-ation practices in multilingual emergency health serviceinstitutions. The study explored the impact of theorganizational and institutional context and possibleconsequences of different approaches to interpretation.The central research question of the study was: How doemergency care health professionals in Sweden influenceculturally and linguistically diverse patients’ access tolanguage interpreters?

DesignA qualitative exploratory and descriptive study was used tocapture healthcare professionals’ experiences in a field notpreviously explored and to describe their experiences intheir own natural state [30]. Semi-structured interviews,individual and in focus-groups, with health care profes-sionals working in emergency care institutions, were con-ducted to investigate and understand the reality ofinterpreter service when communicating with patients ofdifferent linguistic backgrounds. Semi-structured interviewsallow informants to elaborate on experiences and thoughts,while at the same time staying within certain topics de-signed by the research team [30]. In focus-group interviewsparticipants can open up through group interaction for dis-cussion where different perspectives, even more or less un-conscious, can be revealed [31].

SettingEmergency care institutions in somatic care departments(two emergency clinics (open 24 h) with observationwards for maximum 48 h’ care)) and psychiatric depart-ments (two psychiatric emergency clinics (open 24 h), oneincluding a psychiatric intensive care unit) and paramedicsin ambulance care at two county hospitals in two differentcities in migrant-dense regions in Sweden were studied.The cities had approximately 88,000 vs 137,000 inhabi-tants, of whom 16.7 vs 17.8% were foreign-born [32]. Allsettings are characterized by high intensity, with brief en-counters between staff and patient and often delivered ina high-tech environment [33]. However, the encounterscan differ from minutes up to days. Care in an emergencycare clinic or observation unit is focused on assessment ofan individual’s status and first-aid measures, triage and/orreferral of the patient for further care [33]. Care deliveredin the psychiatric clinic or psychiatric intensive care unitis mainly focused on acute measures connected to severedysfunction of mood, behavior, perception, or thoughtsthat might be a threat to life, psychological integrity or ad-equate functioning. Care delivered in ambulance service isprehospital and limited to transportation to the hospitaland life-sustaining measures.Like the majority of health care institutions in Sweden,

all the emergency care institutions studied are run by thecounty council with the exception of one of the ambu-lance service units that is run by a private enterprise, al-though with the same regulations. The professionalinterpreters they refer to are procured under the PublicProcurement Act [34] to guarantee the quality of the in-terpretation service, and the interpreter agencies used bythe hospitals are run by private enterprises outside thehealth care system. In the studied areas the healthcare andthus interpreting practice followed Swedish legislation: theManagement Act [11], the Swedish Health and MedicalServices Act [35], the Swedish Patient Act [36], and thePublic Procurement Act [34]. For further details see [13].

Participants and procedureA purposive recruitment procedure was chosen to ensurevariation [30] in professions, gender, and experiences ofworking with interpreting situations in emergency care forforeign-born persons of different linguistic backgroundsand on different levels in the organization. Respondentswere recruited after information meetings at the work-place (n = 22) or by asking respondents during the inter-view period (snowball strategy, [13]) to invite those whohad not attended the information meetings held beforethe study (n = 24).Managers in the different emergency care institutions

were contacted by telephone by the investigators (CL, EH)to give information about the study and get approval forthe implementation. Verbal and written information about

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the study was given. After their approval, the managerswere asked to invite health care staff who had experienceof communication with non-Swedish-speaking persons inemergency care to participate. A time was set for informa-tion meetings at the workplaces where the respondents re-ceived verbal and written information about the study.Those interested in participating provided their contactdetails by e-mail or in written form to the investigatorsand were then contacted to set a time and choose an ap-propriate place for the interview.The study population included 46 persons, 14 males and

32 females, aged 21 to 65 years (median 37), with occupa-tional background as nurses, nurse assistants, nurse-paramedics, paramedics, physicians, and social workers andwith work experience in emergency care from 1 to 28 years(median 4 years) (see Table 1). Eleven of the participantswere in a leading position and working as managers andthe rest as ordinary health care staff (employees).

Data collectionData were collected by semi-structured interviews, indi-vidually and in focus-groups, between December 2014and April 2015. An interview guide was developed basedon a previous study [13] and other investigations in the

area [12, 37–39]. The questions in the interview guidefocused on when interpretation became an issue, howinterpretation was conceptualized, what was supposed tobe interpreted and the implications of different inter-pretation practices and challenges in improving equalhealthcare concerning interpreting service. The firstfocus group was used as a test of the interview guide[31] and led to minor changes by also asking about theneed for a policy on interpreting.The interviews were led by two nurses experienced in

leading groups and qualitative studies in research on mi-grants and use of interpreters (first and second author).All interviews were held in secluded rooms chosen bythe informants at their workplaces.The interviews were conducted with 46 participants, in

five focus-groups with 3–5 persons in each group (n = 20)and in 26 individual interviews. The focus-groups were, asrecommended, planned to be homogenous in terms ofprofession to develop a comfortable group dynamic andavoid negative influence of power imbalance between dif-ferent professions [31]. Three groups included only regis-tered nurses vs assistant nurses vs. managers and therewas one group with three assistant nurses and a registerednurse. 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 thecommunication proceeded without problems or interrup-tions in a free-flowing way and lasted 30–60 min. Directlyafter the interviews, the interviewer made notes on thecontent of the interviews, the group interaction, and feel-ings developed during the interview [31]. All interviewswere audio-recorded and transcribed verbatim by a pro-fessional secretary and one of the investigators (CL), andthen analyzed.

Data analysesData were analyzed with inductive qualitative contentanalyses [30]. The transcripts were read through andchecked for accuracy and coherency to promote highquality and to get a sense of the content as a whole [30].Then, the texts were broken into smaller meaning unitsand codes were identified. Codes with similar meaningswere grouped together and subcategories and categoriesemerged based on patterns. Throughout the analysisprocess the investigators searched for contradictions, re-gularities, similarities, and patterns in the text support-ing the development of subcategories and categories.Categories were refined and developed until an accept-able system was reached. Collection and analysis of dataproceeded concurrently and until no new informationwas added in the data analysis [30, 31].In order to increase credibility, investigator triangula-

tion was used, by two of the authors independently cod-ing and checking the content of the codes [30] which

Table 1 Characteristics of the study population

Variable Persons N = 46

Gender (n)

Female 32

Male 14

Age (years)a 37 (21–65)

Country of birth

Sweden 41

Ex Yugoslavia 3

Finland 1

Iraq 1

Professional level (n)

Nurse 21

Assistant nurse 8

Physician 5

Social worker 1

Unit managers 6

Operational manager 5

Emergency healthcare context (n)

Ambulance care 8

Somatic emergency clinic 26

Psychiatric emergency clinic 12

Work experience in health care (years)a 13 (1–44)

Work experience in emergency healthcare (years)a 4 (1–28)aMedian (range)

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showed high agreement. During the whole process ofanalysis all co-authors also checked and confirmed thecontent and the relevance of subcategories and categor-ies. The authors have different experiences in researchand practical work in healthcare but all are in researchin the area of migrants’ health and using qualitativemethods. Discussions were held until consensus wasreached in the event of diverging results. By illustratingcategories with illuminative quotations and by namingcategories as close to the text as possible, confirmabilitywas ensured. By describing the investigation process(audit trail), as thoroughly as possible, dependability wasconfirmed, and finally transferability can be strength-ened by studying informants with different professions,from different hospitals and different geographicalareas, thus giving a precise description of the studypopulation.

ResultsThe organization of interpreting for healthcare staff inemergency care institutions concerning encounters withpersons with language barriers is described in fourcategories, with subcategories, summarized in (Table 2):1) the use of interpreters is determined by the patient’shealth status and access to interpreting service in theorganization; 2) utilization of interpreting services isdriven by informal or formal guidelines and differentnational laws; 3) the use of a professional interpreter atthe workplace depends on the interpreter’s linguistic

skills, personal qualities, professional approach, andorganizational aspects; and 4) recommendations toimprove the use of interpreting services in emergencycare.

The use of interpreters is determined by the patient’shealth status and access to interpreting service in theorganizationType of emergency care determines the mode ofinterpretingA common habit in somatic and psychiatric emergencyhealthcare, as described by the respondents, was to useprofessional interpreters, while health professionals inambulance care used family members.

A professional interpreter in the room is hard to beat.It is the best … the patient often feels much moresecure, the interpreter gets a different kind of contactwith the patient and might then get more informationjust through his presence. (Respondent=R29,Psychiatric emergency clinic (=Psychiatric EC))

The advantage is that they (family members) are oftenon the spot. Sometimes they have contacted relativesby telephone and that works well too, as I describedearlier with FaceTime that you just stand there talkingand then pass the receiver between you. It is mostlyrelatives that we use. (R 22, Ambulance care)

Table 2 Overview of categories with subcategories analyzed from interviews by healthcare staff working in multilingual emergencyhealthcare

Category (No. of statements) Sub-category (No. of statements)

The use of interpreters is determined by the patient’s healthstatus and access to interpreting service in the organization (424)

Type of emergency care determines the mode of interpreting (338)The patient’s health status and availability of an interpreter determine thetype of interpreter used in the workplace (44)Healthcare staff in somatic and psychiatric emergency care prefer professionalinterpreters (24)Healthcare staff in the ambulance prefer family members on the spot (18)

Utilization of interpreting services is driven by informal or formalguidelines and different national laws (412)

Informal and formal guidelines and limited knowledge of existing laws governutilization of interpreting services in the workplacesInterpreters are used in situations with communication deficiencies in somaticand psychiatric emergency care (136)Professional interpreters are not used in ambulance care or in urgentsituations (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 theinterpreter’s linguistic skills, personal qualities, professional approach,and organizational aspects (290)

The professional interpreter’s linguistic competence, positive personalqualities, and professional approach facilitates work when communication isdeficient (206)Professional interpreter perceived as positive and a tool facilitatingcommunication (24)Professional interpreter perceived positively or negatively when organizationalaspects (time, environment and technical equipment, andinterpreter languages) of the use of interpreter work or not (18)

Recommendations to improve the use of interpreting services inemergency care (67)

Developing the procedure for prompt access to professional interpreters inthe workplace (58)Education of health professionals in using a professional interpreter, and theprofessional interpreter’s role in various care situations (9)

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Differences between workplaces were found: bilingualhealth professionals and family members could be usedto a limited extent in ambulance care and emergencycare, but in the latter case telephone interpretation byprofessional translators was also used on unpredictableoccasions for short-term assignments, even outside of-fice hours. In some situations healthcare staff had anegative perception of having professional interpreterspresent, due to threatening patients in psychiatry, beingexposed to unpleasant emergency situations, and limitedspace in ambulance care. In psychiatric emergency care,the norm was to have professional interpreters in theroom related to characteristics of the patient’s mentalhealth status, e.g. depression, and delusion with paranoiathat might lead to suspiciousness of telephone interpret-ation and using family members.

In psychiatry we need to have an interpreter presentall the time. There are no caring situations where youthink “we need to try to manage this without aninterpreter.” It doesn’t work. We’re not mind readers.(R 24, Psychiatric EC)

However, both somatic and psychiatric emergencyhealthcare found it a problem to have professional inter-preters in the room because they were not easily access-ible at short notice but required long planning inadvance and in some cases led to prolonged healthcarevisits for the patient.

Often you have to book time, and sometimes there areno times available. Even if there is some sort ofemergency line – if I have understood right – whereyou can get an interpreter within an hour or half anhour. And then I don’t know whether I can be in place.(R 13, Somatic emergency clinic (= Somatic EC))

Most health professionals perceived benefits in usingtelephone interpretation in short-term, one-off emer-gency care situations, and in situations experienced assensitive by patients.

An interpreter by telephone is more easilyaccessible. Sometimes … the only alternative to getan interpreter in the language we needed … itmight be possible to get one faster for the samereason. (R 13, Somatic EC)

In some cases, using telephone interpreters had beenexperienced as a hindrance in examinations as theywere unable to observe body language and the technicalequipment functioned badly, making it difficult to hear.Healthcare professionals could see advantages in using

calm and neutral family members as interpreters in

some healthcare situations when information transferoccurred concerning the patient’s healthcare status, es-pecially in ambulance care when they usually do notknow what language they will meet. The patient feels se-curity and trust in the family member, who is mostlyavailable in unpredictable situations at short notice.At the same time healthcare staff can easily conveyinformation to the relatives. Disadvantages could bepoorer-quality interpretation because of risk of break-ing the code of confidentiality and lack of languagecompetence.Using bilingual healthcare professionals was mainly felt

to be a good choice as they were “easily accessible andalready in place.” However, they could cause problems bynot being neutral when interpreting and “not keeping thecode of confidentiality,” and having limited languageknowledge.

… can see advantages but it is a person … who is usedto health care and … patient contact and knows thelanguage at the same time … as long as they don’thave a personal relationship to the family… (R 9,Somatic EC)

The patient’s health status and availability of an interpreterdetermine the type of interpreter used in the workplaceRespondents described how the patient’s health statusaffected the choice of type of interpreter and vice versa.Informal interpreters such as relatives or colleagues wereused when necessary if the patient was unconscious, se-verely ill, unable to speak, or action had to be takenwithout delay, or in the case of a heavy workload andneed of fast access to an interpreter.To help the patient receive information quickly and

thus save time, sometimes bilingual colleagues wereused as interpreters to assess the patient’s healthproblems for referral to the right level or type of care.Diffuse conditions, complex care, and critical condi-tions require interpreters, in contrast to simple healthproblems.

If it’s severely ill patients, critically ill, then theinterpreter actually doesn’t matter so much, becausein those situations we have guidelines that … so wehave to … drive to the nearest hospital as soon aspossible and then there’s no time and it doesn’tmatter… (R 15, Ambulance care)

… if there’s someone consulting for … a minorcomplaint or if you have to decide whether theyshould go to another caregiver … then it’s faster togo and get a colleague. (R 5, Somatic EC)

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Healthcare staff in somatic and psychiatric emergency careprefer professional interpretersIn somatic and psychiatric care situations health profes-sionals preferred a professional interpreter in place be-cause they perceived them to ensure interpreting word-by-word, having a professional attitude, and remainingneutral and objective.

A professional interpreter on the spot … is the best.That it should not be colored by relatives, relatives caninfluence the conversation and you rely on aprofessional interpreter to actually interpret … That’swhat one is looking for… (R 27, Psychiatric EC)

Healthcare staff in the ambulance prefer family members onthe spotIn situations in the ambulance with no other choiceof interpreting service, in situations that occur in thehome or various social environments, the staff in am-bulance services prefer a calm, objective relative whois on the spot. This is because they can give securityand can be an asset in a confused situation, also pro-viding continuous information about the person.

… sometimes it can be … a great advantage thatthere can be relatives who know their father…Relatives have a different knowledge about theperson … they can help on another level also withsuch things that often help us and that don’tconcern language … it has a dual function. (R 20,Ambulance care)

Utilization of interpreting services is driven by informal orformal guidelines and different national lawsInformal and formal guidelines and limited knowledge ofexisting laws govern the utilization of interpreting servicesKnowledge about laws, policies, and guidelines regardinginterpreting service varies among health professionals,and the majority are not aware of any specific law orpolicy regulating the use. Most health professionals’ de-cisions regarding professional interpreter use depend toa great extent on what they consider to be the patient’sneeds, and from the perspective that the person has aright to an interpreter to understand information given.Most of the health professionals know about the law onprocurement governing routines for booking a profes-sional interpreter.

R 1:4: No, not using an interpreter … no.

R 1:3: I was thinking of the law on patient safety, isn’tthere such a law? Aren’t interpreters included in that?

R1:2: They (patients) have the right to, the Health andMedical Care Act,…

R1:4 … right to the same care and but not to aninterpreter, no.

R1:3: But they (patients) know that they have the rightto an interpreter …

R1:2 … but then whether it is regulated in law, onwhich occasions, to what extent, I can’t say.(Somatic EC)

In psychiatric care some respondents said that therewas a formal policy at the workplace stating that pro-fessional interpreters were to be used, and not familymembers. This in contrast to somatic emergency carewith its informal recommendation to use telephoneinterpreters or family members as quick and access-ible alternatives. In ambulance care informal guide-lines were also used, with the normal routine of usingavailable family members. A respondent in ambulancecare said that there is a written formal policy to usean interpreter but it was not adapted to their workingconditions and thus could not be used. Booking aninterpreter becomes an issue for health professionalsin emergency care by self-established informal guide-lines, a routine which the majority were pleased with.

It works well, the policy, although I don’t have it onpaper and … haven’t seen it … I think everyone atthe emergency unit where I work has the policyestablished that there should be an interpreter inplace or on the phone. (R 26, Psychiatric EC)

Most of the respondents stated they had learned fromolder colleagues when and how to use a professionalinterpreter and a few from training or introduction atthe workplace.

Yes, it’s some kind of local tradition … transmittedboth by older colleagues, when you see how they work.But … also from other occupational categories. (R 13,Somatic EC)

Most health professionals expressed satisfaction withthe informal procedures available and had no need forother guidelines. If guidelines were available it was per-ceived as contributing positively by increased used ofinterpreters and facilitation of equitable sharing. Onthe other hand, guidelines could restrict the use by be-ing too detailed in their recommendations.The majority of respondents knew how to order a

professional interpreter, which was done from one or

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two interpreter agencies that the workplace had agree-ments with. Booking was done through a writtendocument describing the process and was performedby nurses, nurse assistants, and/or care administrators.Physicians, managers, and staff in the ambulanceservice said they were never involved in booking aprofessional interpreter and did not know how to doit. No restrictions in terms of costs for the order wereperceived to hinder the use of a professionalinterpreter; instead the needs of the patient deter-mined the use.

It is the responsible nurse, mostly … the nurse whodoes it … who has a memo saying this is what wedo when we order an interpreter… But it’s more amatter of how you go about it, what number to calland what the customer code number… Interpreterservice, I think it’s called. (R 4, Somatic EC)

Some managers in emergency care described beingaware of issues concerning interpreter use when staffexperienced difficulties, or they handled the billing orissues of patient safety.

I come into contact with it in that I pay the bills forinterpreters … sometimes when the staff havedifficulties … and discuss how we should act andthink. (R 11, Somatic EC)

Interpreters are used in situations with communicationdeficiencies in somatic and psychiatric emergency careBooking of a professional interpreter was determinedby health professionals themselves, identifying in theencounter with the patient the need for interpretationto be able to understand each other. Use of a profes-sional interpreter was most frequently related tosituations needing information exchange about the pa-tient’s health status, e.g. assessment of the patient’sacute condition by physicians and obtaining an anam-nesis, referrals to other institutions, exploration ofsymptoms, information about treatment or dischargefrom the emergency unit.

R 1:1: … if they don’t speak any Swedish but justshake their heads and … don’t understand … thenyou have to … order a (professional) interpreter.Not when they get by in Swedish, then you don’talways order one … if the patient himself says thathe wants an interpreter … it … oh … can surely bequestioned from an ethical point of view what isright and from a patient safety perspective alsomaybe a (professional) interpreter ought to beordered more often. (Somatic EC)

A few respondents stated that interpreters are neededin all care settings for correct exchange of information.Many said that patients who need a professional in-terpreter usually have to wait longer, which may causeworry for the patient, or the patient might cancel thevisit and refrain from care. On the other hand, a fewdescribed how the visit might go faster using a pro-fessional interpreter.Conversation through a professional interpreter

was perceived as often becoming technical and im-practical, and the social chatter intended to relax theperson was excluded. Further, there was less supportfor the patient with lack of emotional processing,and the patient gets more compressed informationand lacks the opportunity to ask follow-up questionsand become an active participant in healthcare. Thehealth care staff say that the entire health care situ-ation deteriorates because caring encounters arebased on using language. Many respondents said thatthe relationship between the caregiver and the pa-tient was negatively influenced when an unknownperson in ordinary clothes was present in the room.

That we can’t find a suitable interpreter or suitabledialect. Then care can be delayed … it takes moreresources that we for example keep the patient on abed for observation (R 24, Psychiatric EC)

It’s not a good caring situation. There will be notreatment or care… It feels frustrating that youcan’t give them … because there is a lot of inconversation in our treatment, language is veryimportant in caring. (R 29, Psychiatric EC)

Professional interpreters are not used in ambulance care orin urgent situationsIn care delivered in the ambulance or in the home,there is no time to get a professional interpreter inthe right language due to short, fast, and unpredict-able situations; instead family members or neighborswere used.

… for patient contact in the home, but … we seldomuse (professional) interpreters. The times we try to gethold of a (professional) interpreter it’s through SOSalarm and I find it difficult to get the help when weneed it. Mostly when we’re out in contact with patientsit’s so urgent that often you don’t have time to wait …you have to solve the situation then by trying to makeyourself understood anyway … we seldom use that waybut it’s not allowed to take more than five minutes atmost. (R 22, Ambulance care)

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Professional interpreters are not used if body language canbe used for communicationProfessional interpreters are not used in short encoun-ters in healthcare or in nursing care, e.g. meal situa-tions or assessment of pain. Instead body language,family members, or bilingual colleagues are used by thenurses for initial assessment of the patient to sort outthe cause of the visit or on admission to the emergencyunit.

If a patient comes in an emergent situation it’s the nursewho meets the patient and then we try with bodylanguage, English, Swedish, Google Translate, relatives, toget information about what the acute need is. Theproblem and the reason why they are here. (R 25,Psychiatric EC)

… check vital parameters … point to where it hurtsand show with facial expressions… (R 5) (Somatic EC)

In urgent situations or in case of severely ill patients orwith lowered consciousness the patient’s status wasassessed by bodily parameters and observations and thusprofessional interpreters were not used.

see that there is something … very serious so maybe youstart to look at all the vital parameters and ECG …before you can … start asking questions … to see if thereis something super-super-fast that needs to be done. (R3, Somatic EC)

The use of a professional interpreter depends on theinterpreter’s linguistic skills, personal qualities, professionalapproach, and organizational aspectsThe professional interpreter’s linguistic competence, positivepersonal qualities, and professional approach facilitateswork when communication is deficientInterpretation was described by the respondents to beof good quality when the professional interpreter hadgood language competence, in Swedish, the native lan-guage, and health care terminology, and paid attentionto cultural expressions, translated word-for-word with aflow, and had good conversation technology, was neu-tral, could keep the code of confidentiality, and controlhim/herself in the emergency situation. Another influ-encing factor was the professional interpreter’s abilityto establish a trustful and empathetic relationship, bestdone with a professional interpreter on the spot, whichalso gave the possibility to observe body language.

… it’s fundamental in the interpreter’s professionthat you know the language really well. BothSwedish and the other language. So that you get a

clear picture and can translate correctly …important that we get what the patient is and notan interpretation of what the patient says. (R 13,Somatic EC)

Sometimes even the patient’s own feelings could be seenas a barrier, e.g. when feeling unwell and being com-pletely silent, or when emotions like fear and anger hin-der the ability to listen.The majority of health care staff in psychiatric and

somatic emergency care have a positive attitude to theuse of professional interpreters at the workplace, butsome do not have any expectations or do not discussthe use of interpreters, particularly in the ambulanceunits where professional interpreters are rarely used.

Professional interpreter perceived as positive and as a toolfacilitating communicationThe professional interpreter is described by many as atool overcoming communication deficiencies and as asolution to the language problem

I think … everyone thinks it’s positive that itexists… There’s no one who thinks it’s troublesome,no. I don’t know, I haven’t heard anything at least.Sure, some might think it’s hard to talk by phone…It’s a bit uncomfortable to talk to someone who isn’tthere for you to see. (R 4, Somatic EC)

Professional interpreter perceived positively or negativelywhen organizational aspects (time, environment, andtechnical equipment and interpreter languages) of the useof interpreters work or notWhen the professional interpreter is available on timeand stays as long as needed, and when the technicalequipment functions well and the interpretation occursin an undisturbed environment, health professionals feltthat these organizational and practical aspects func-tioned and the interpreting situation was good. In thecase of women seeking help for gynecological problems,some found it beneficial to have a female professionalinterpreter.When technical problems occur, or there is lack of

space making it difficult to maintain confidentiality, orwhen the professional interpreter who has been orderedspeaks the wrong language, the interpretation situationdoes not function.

There are all the peripheral factors. That you have tobe sitting in a good place, where there is plenty ofspace, that you have allocated time for theinterpretation, and that you can be undisturbed. (R14, Somatic EC)

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Recommendations to improve the use of interpretingservices in emergency careDeveloping the procedure for prompt access to professionalinterpreters in the workplaceThe healthcare professionals indicate that the use of pro-fessional interpreters would be facilitated and improvedwith fast access to professional interpreters by a hotlinephone round the clock, and many wished for better ac-cess to the most common languages as well as to alllanguages.

… that there was some kind of quick track to theinterpreter service … it goes really fast in many … inmany cases they call them back at once when youhave the phone … for the most common languages theycould guarantee an interpreter in five minutes. (R 8:3,Ambulance care)

Some discussed how better technology and technical so-lutions could improve professional interpreter use andthe organization of interpreting would be facilitated ifthe administrative staff helped to book a professional in-terpreter. For health professionals in ambulance care, itwould help if the SOS alarm staff booked a professionalinterpreter in advance, so that the interpreter was avail-able from the first contact onwards, and all types of pro-fessional interpretation were thought to help to make itbetter for patients and health professionals in ambulancecare

Good instrument when interpreting, either goodtelephones with good sound but also perhaps a videolink … as you talk to someone over the telephone youjust as easily could be able to look the interpreter theface … a face that also sees the patient. (R 3, SomaticEC)

Some staff believe a “joint policy” on (professional)interpreter use could lead to improvement, providedthat the policy does not regulate interpreter use forcertain care situations. (R 30, Psychiatric EC)

Education of health professionals in using a professionalinterpreter, and the professional interpreter’s role in variouscare situationsSome said that the interpretation situation would im-prove if the patient’s perspective was considered moreoften, if a professional interpreter was used more fre-quently used during nursing care situations, if staff weretrained in how to act and use a professional interpreter,and if the professional interpreter is trained to have aprofessional attitude and to adapt to the caring unit’sspecific requirements.

… what one can think about is the patient perspectiveon interpretation, that we’re probably not always sogood at asking for their point of view. (R 30,Psychiatric EC)

If anything would make it easier for me it would be tohave slightly clearer guidelines on how they aretrained, what kind of degree of confidentiality theyhave, can you reach more people without adding yourown values in an interpreter conversation at ourworkplace, it’s more that kind of information I wouldwish. (R 25, Psychiatric EC)

DiscussionThis study explored language interpretation practices inmultilingual emergency healthcare by studying differenthealth professionals describing their actions when organ-izing language interpreting. Thus, comparisons with pre-vious studies will only be partial. The main resultsshowed that language interpretation services in emer-gency care are organized based on the patient’s healthstatus, and the context of emergency care and access tothe interpreter service in the organization determine theuse. Bilingual healthcare staff and family members wereused, but to a limited extent, in somatic emergency care,in contrast to psychiatric emergency care where thenorm was to have professional interpreters present. Inambulance service professional interpreters were seldomused; instead persons available at the moment, such asfamily members, friends etc., were used, along with ob-servation of body language. Booking of a professional in-terpreter was mainly based on informal, collectivelyconstructed guidelines and routines at the workplaceand sometimes on formal guidelines and different na-tional laws, but knowledge of existing laws was limited.The ideal was a professional interpreter with high lin-guistic competence and a professional attitude, andorganizational aspects such as appropriate time andtechnical and social environment. Finally, wishes for thefuture included the development of a better procedurefor prompt access to professional interpreters at theworkplace, regardless of organizational context, and edu-cation of interpreters and their users.In this study, healthcare staff determined the use of

professional interpreters in multicultural emergency carebased on the patient’s health status, the kind of emer-gency care, and access to the interpreter service in theorganization to assess as fast as possible the individual’sneed of care, in contrast to multicultural elderly carewhere the use of professional interpreters was deter-mined by medical consultations with physicians or forindividual care planning activities [13]. Communication

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can be described as a multifaceted phenomenon andthrough communication the person’s identity is madevisible and shows how the other person is perceived onthe individual and the social level [26]. It also makes itpossible for the individual to participate in society. Fur-ther, communication in an institutional context is asym-metrical when patients and healthcare staff do not havethe same aim, knowledge, or resources [17]. This studyfound that communication through interpreters is acomplex process that depends on several factors such aspatients’ health status, context of emergency care, andaccess to interpreting service, but also on informal andformal guidelines governing the workplaces. However, inan emergency situation neither shared decision-makingnor participation in communication might be possibledue to the patient’s health status, e.g. being unconscious,having extreme pain, etc., and the urgency of the situ-ation [16]. Thus, an asymmetrical power relation mightneed to be accepted temporarily to help the individualretain or regain health. Communication is central forcaring, but in such situations it might not be fully pos-sible to provide transcultural care where the individual’sneeds and cultural beliefs are taken into account [16]and person-centered, safe, and equal care can be deliv-ered in accordance with Swedish law [35, 36] and humanrights [26] including the legal and health literacy [28].Health professionals in this study described how they se-lected certain situations for interpreting, in contrast tocare for people who speak the official language of thecountry. This can be explained as caring routines andmight be helpful for a person in a stressful situation [21]but it can contribute to further development of unequalcare [35, 36]. The findings emphasize the need for legaland health literacy and social justice to help reduce in-equalities in accessing healthcare by empowering mi-grant patients to understand and critically engage intheir healthcare [28]. Patients in need of an interpreterreceived less support in dealing with emotions, oftenhad to wait longer, and had more compressed informa-tion and lack of opportunities to ask follow-up questionsthan native-born people, which is similar to findingsfrom a review study concerning emergency healthcarewhich found that patients in need of an interpreter wereless satisfied, received inferior care, had limited diagnosisand treatment, and fewer follow-ups [6]. An interestingfinding in this study is that no one mentioned economicaspects of the booking or use of an interpreter. Thus,care in the studied area is focused on humanism ratherthan bureaucratic values [21].In the present study the use of professional inter-

preters was related to the organizational context, withmore frequent use in somatic and psychiatric emergencycare than in the ambulance service, where professionalinterpreters were not used and instead those available at

the time, e.g. relatives and bilingual staff, were used to ahigher extent. This is in contrast to multicultural elderlycare where no dissimilarities were found between differ-ent sectors such as community home elderly care, nurs-ing homes, and nursing homes for dementia patients[13]. This is possibly related to organizational routines[18, 19] and organizational cultural competence [16]. Animportant aspect here is the characteristics of the envir-onment and context in which care is delivered. Ambu-lance service may differ from somatic and psychiatricemergency care particularly due to the limited space, butalso limited timeframes in which care is given and canthus act as barriers to access, availability, and use of in-terpreters. Thus, use of interpreters needs to be adaptedto the environment and context. In the present investi-gation, however, interpreter use was determined by indi-vidual healthcare staff based on collectively constructedinformal guidelines at the workplace and sometimes dis-cussed with workmates; it thus mainly covered only theindividual and interpersonal levels of organizational rou-tines described in the theoretical framework [18, 19].There is a need for development of the three otherlevels: the organization, the institution, and the environ-ment. Unclear routines affect how health professionalsdeliver care, and absence of guidelines and common ob-jectives entails a risk that unconscious behaviors basedon staff ’s own standards and attitudes might negativelyaffect healthcare encounters [22] with migrants. Rou-tines enable coordination, ensure some stability of be-havior, and when tasks are routinized they can beperformed subconsciously, thereby economizing on lim-ited cognitive energy [40]. Improved knowledge and de-velopment of strong routines can shape commonpractice that improves the delivery of service [18] suchas interpreters.As in previous studies [13, 37], it was considered pref-

erable to get an interpreter with high linguistic compe-tence and a professional attitude, and satisfactoryorganizational aspects such as appropriate time andtechnical and social environment. In emergency care theinteraction with an interpreter showing trust, confidenceand empathy is important and fundamental for the qual-ity of the conversation, and the interpreter needs tolearn how to contribute to the alliance in healthcare andthus also learn about the context in which healthcare isdelivered [41]. This needs to be developed in existingguidelines for authorized interpreters in Sweden, whichmainly focus on interpretation technique, translatingcorrectly and neutrally [42] and not on the interpreter’sprofessional attitudes or organizational routines. Know-ledge about existing national laws and policies for usingand booking interpreters in Sweden differed but was ingeneral limited among the respondents, and the use ofinterpreters was seldom on the agenda for managerial

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staff in emergency care. However, no national guidelinesexist with the exception of those mentioned above for-mulated by Kammarkollegiet [42] and the ManagementAct [11], stating the right to get an interpreter in contactwith public authorities, and the Public Procurement Act[34] regulating what companies interpreter service canbe procured from, and so this finding is not surprising.Sweden, like many other European countries, has be-come a multicultural society with a high influx of mi-grants in recent years, with an increasing demand forinterpreters [43], particularly in healthcare, which is un-met due to lack of interpreters [44]. Political interven-tions are needed to solve this. There is an obviousknowledge gap to fill here.

Limitations of the studyIt might be seen as a limitation that a mix of individualinterviews and focus-group interviews was used for datacollection. However, it has been claimed that the sameinformation can be reached by focus-group interviews asby individual interviews, although more time is neededfor the individual interviews [45]. On the other hand, itis a strength to combine different methods for data col-lection, and this strengthens the findings [30]. Not in-cluding patients’ and interpreters’ views in the studycould be seen as a limitation but was impossible due tothe available resources for this investigation; this needsto be further investigated.The focus-group interviews were held without an obser-

ver present, which can be seen as a limitation [31] but as asmall group design [46] was applied, the interviewers hadthe same professional background as the respondents, andwere also familiar with leading and documenting interac-tions in groups, in both research and education, the influ-ence of this is considered negligible [31].The main limitation of a qualitative study is that the

findings cannot be generalized or explain cause-effect re-lationships [30, 31], but the main aim of this study wasto explore reality in order to arrive at a deeper under-standing of the phenomenon, and the findings are trans-ferable to other contexts similar in characteristics andcan contribute new knowledge in developing similarorganizations.

ConclusionsIn conclusion, the data seem to show that health profes-sionals act as gatekeepers for migrants’ access to inter-preters and fail to apply Swedish laws. The use ofprofessional interpreters in multicultural emergency carewas determined by health professionals based on thepatient’s actual health status, and they did whatever waspossible to deliver fast and individualized care as neededand based on humanistic values. However, there areshortcomings in the institutions’ organizational routines

that need to be rectified concerning organizational, insti-tutional, and environmental factors and the importance oftranscultural awareness to achieve the aim of person-centered and equal health care. The main task is to de-velop clear formal guidelines for the use of interpreters atthe workplaces, including the procedure for the use de-pending on the patient’s desire, health status and type ofemergency healthcare, but also to fulfill the health profes-sionals’ wishes for future development of prompt accessto interpreters, education of interpreters and of users ofinterpreters as regards how to perform interpretation.

AcknowledgementsWe are grateful to Dr. Alan Crozier, professional translator, for review of thelanguage. The authors also thank Dr. Anna Bredström and Dr. Sabine Gruberat the Institute of Research on Etrhnicity, Migration and Society (REMESO),Department of Social and Welfare Studies, at Linköping University for thecollaboration that led to this study. This study was supported by grants fromVetenskapsrådet (The Swedish Research Council), Sweden, reference number:521-2013-2533.

FundingThis study was supported by grants from Vetenskapsrådet (The SwedishResearch Council), Sweden, reference number: 521–2013-2533.

Availability of data and materialsData sharing is not applicable to this article as no datasets were generatedor analyzed during the current study.

Author’s contributionsStudy design: CL, EH and KH; Data collection: CL and EH; Data analysis: CLunder supervision of EH and KH. Drafting the manuscript: CL undersupervision of EH and KH who also made critical revisions to the paper forimportant intellectual content. Obtaining funding: KH, CL and EH. All authorsread and approved the final version of the manuscript.

Author informationEmina Hadziabdic is a Senior Lecturer and postdoctoral fellowship. Herresearch focuses on Migration and Health, especially on communicationthrough interpreters investigated from different perspectives: the individuals,healthcare staff and families, using different qualitative and quantitative datacollection methods: individual and focus group interviews, reviews of officialdocuments, qualitative systematic reviews and self-administered question-naires. Further, she uses different qualitative and quantitative methods fordata analysis in her research.Katarina Hjelm, is a professor in Nursing Science. She is a diabetes specialistnurse and nurse tutor with a PhD in Community Medicine. Her dissertationconcerned migration, health and diabetes and led to two main areas ofresearch: 1) Migration and health and 2) Chronic disease management,particularly diabetes mellitus and chronic leg ulcers, but also COPD, strokeand IBD. International comparative studies have been implemented and thusinternational health is a third area of research. She has a particular interest instudying the influence on health-related behavior of beliefs about healthand 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 centralarea of research.Christina Lundin is a lecturer in Nursing Science. She is a nurse, midwife andnurse tutor with a degree of Master in Medical Science in Reproductive andPerinatal Health Care. Her Master’s degree was about Swedish urbanwomen’s symptoms and management of mastitis. She has a degree inProviding Professional Guidance in Health Care for healthcare staff and isinterested in professional development and problem-based learning. She hasparticular interest in studying the influence of communication in health careorganizations, e.g. use of interpreters.

Ethics approval and consent to participateThis study has been conducted in accordance with Swedish law [47] andethical considerations according to the Declaration of Helsinki [48]. Written

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informed consent was obtained from the participants before the interviewsstarted. There was no dependent relationship between the informants andthe researcher. Participation was voluntary and participants could withdrawfrom the study at any time without explanation. The confidentiality of theparticipants’ data was ensured by having the tapes and transcriptsanonymized and coded by number. The analysis and presentation of thedata were done in a way that concealed the participants’ identity. All datawere stored in a locked space to which only the authors (CHL, EH) hadaccess [48]. According to Swedish regulations on ethical guidelines [47],approval by an official research ethics committee was not required as theinvestigation posed no physical or mental risk to the informants and did nottreat informants’ personal data.

Competing interestsThe authors declare that they have no competing interests.

Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims in publishedmaps and institutional affiliations.

Author details1Department of Social and Welfare Studies, University of Linköping, CampusNorrköping, S- 601 74 Norrköping, Sweden. 2Department of Health andCaring Sciences, Faculty of Health and Life Sciences, Linnaeus University,Växjö, Sweden. 3Department of Public Health and Caring Sciences, Uppsalauniversity, Uppsala, Sweden.

Received: 30 July 2017 Accepted: 30 April 2018

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