A higher rate of immigration was triggered in the late 1980s by shifts in national ... nish society, as well as immigrants' equality and freedom of choice shall be.
Towards a Collaboration Between Professionals ANNA MÄNTYNEN TUIJA KINNUNEN 1 Introduction It takes two to tango and at least three to interpret. In this article we take a look at intercultural healthcare settings and interpreting practice in Finland. We set out to present user training given by practitioners in the field of community interpreting and to think of ways to make interpreters and their clients play to the same tune. Interpreters are seen as experts in their own field who can contribute to the common good by offering migrants the chance of integrating into society and making use of services provided by it. Interpreters also give the healthcare authorities the opportunity to do a good job in accordance with the law, regardless of the background and language skills of their patients, in the spirit of equal treatment and nondiscrimination. In return, healthcare professionals should open up their system to outsiders, because activity in a field can only be learnt if the insiders are willing to share their knowledge. In our case, sharing information on healthcare and medical activity with interpreters is considered to serve all stakeholders, including healthcare personnel and medical institutions, patients, interpreters and society as a whole.
2 Background on Finland To create a general picture of the ethnic situation in today’s Finland, let us take a look at some figures pertaining to the population of the country. At the end of 2008, there were 5,183,058 Finnish nationals and 143,256 foreign nationals residing in Finland, which makes a foreign national population of 2.7 per cent of the total number of inhabitants – a figure that has been steadily growing and is expected to do so even faster in the coming years. The share of residents speaking as their mother tongue a language other than the official languages of Finland – Finnish, Swedish, and Sámi1 – was 3.6 per cent. The “top five” mother tongues of migrants are Russian, 1
Finnish and Swedish are the national languages of Finland, Sámi holds the position of an official minority language.
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Estonian, English, Somali and Arabic. (Statistics Finland) About half of the migrant population resides in the southern province of Uusimaa, in which Helsinki, the capital, is situated. Interpreting services are available to refugees, asylum seekers, returnees, and EU and EEC nationals based on national and European legislation. Services are provided by community interpreting centres, private enterprises and individuals. The lion’s share of interpreting services used by the authorities is commissioned from community interpreting centres that were founded throughout the country in the 1990s as the size of the foreign population started to grow in Finland. A higher rate of immigration was triggered in the late 1980s by shifts in national refugee and asylum policy, followed by global crisis situations and the collapse of the neighbouring Soviet Union; these reasons made refugees, returnees and other immigrants reach Finland, a country far off in the North. As a response to the sudden demand for interpreting services in a number of “exotic” languages (such as Somali, Arabic, Farsi) that traditionally had neither been spoken nor studied in Finland, a private company was founded, after which municipal community interpreting centres were set up based on the Nordic model during the 1990s. The aim was two-fold: to support the municipalities in receiving refugees and asylum seekers and to enhance their integration by granting them the chance to use the same services as those provided for the original population (Ministry of Labour 2006). Nowadays, eight community interpreting centres operate in Finland, serving a diverse clientele by offering interpreting and translation services mainly for the authorities, especially in socalled immigrant languages. They have both staff interpreters and freelancers on their books to cover various interpreting needs. Most of the interpreting assignments are on-the-spot assignments, but remote interpreting is offered as well, typically in urgent cases and if the clients are far away from the interpreter and/or the interpreting centre. In 2006, community interpreting centres provided a total of around 110,000 interpreting hours2. There are no in-house interpreters working with the authorities, at hospitals, etc., due to the large number of interpreting languages needed and the still relatively small number of immigrants living in the country. Many acts and decrees regulate issues connected to the provision of interpreting services, healthcare issues and migration. Here we touch upon the 2
There is no combined data available for the years 2007 and 2008, but the trend is and has been growing.
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most important ones: the Integration Act, the Administrative Procedure Act, the Language Act, the Act on the Status and Rights of Patients and the Non-Discrimination Act. In addition to these, the Finnish constitution states that the public sector must guarantee adequate social and healthcare services for everyone and must promote public health. The Integration Act of 1999 decrees that immigrants’ integration into Finnish society, as well as immigrants’ equality and freedom of choice shall be promoted through concrete measures, which are to be specified in an integration plan. In the early stages of the integration process, interpreting services are offered by the authorities. Interpreting situations vary depending on, among other factors, the background, needs and aspirations of the immigrant, but they typically include meetings for drafting the integration plan with the immigrant and relevant authorities, physical and psychological examinations, discussions about training and work opportunities to mention but a few. In the case of asylum seekers, it is stated in the Act that they shall also be provided with interpretation services and that all their other basic needs shall be met, which by definition includes medical and health services as well. The Administrative Procedure Act sets out a basic requirement for the authorities to arrange for interpretation and translation in cases initiated by the respective authority. Furthermore, these can be taken care of in other cases too, in order to clarify the matter or to safeguard the rights of the “parties” – the use of the plural shows that interpreting is seen as a right of the authority as well, not just as one of the foreign party. Interpreting does not need to be arranged in the mother tongue of the party concerned; it suffices to offer it in a language that “the party can be deemed to know adequately in view of the nature of the matter”. In the Language Act, more principles are defined for the right to interpretation, primarily in courts of law. Central for healthcare settings are the provisions laid down in the Act on the Status and Rights of Patients. Under the section on the patients’ right to be informed, interpreting is touched upon: a patient shall be informed, among others things, about her/his state of health, treatment options and their effects, as the Act aims at enabling patients to decide on their own treatment. Therefore, healthcare professionals should try to inform patients in an understandable way, and “if the healthcare professional does not know the language used by the patient [...] interpretation should be provided if possible”. The “migrant-friendly” standpoint chosen here is interesting – the Act looks at the language issue through the eyes of the one coming from outside the system. The designations “healthcare profes-
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sional” and “patient” could basically just as well change places and still describe a situation where the parties do not understand each other – but in that case it would appear as if the patient lacked the necessary communication tools, not the authority. With the Non-Discrimination Act of 2004, the principle of nondiscrimination – existent also in the Finnish constitution – was afforded more importance. The act wishes to foster and safeguard the equality and protection by law of persons who have been victims of discrimination. Noone should be discriminated against on any basis whatsoever, including ethnic or national origin, nationality and language; social and welfare services are explicitly mentioned in the scope of the Act. Direct and indirect discrimination, harassment and instructions or orders inciting discrimination are prohibited by law; it also enables a party to apply for compensation in case of discrimination. ”Positive discrimination”, i.e., positive measures aiming at genuine equality, is allowed and even recommended in the Act; treating everyone in an identical way does not lead to a state of true equality, but supporting measures are often in place for people and groups of people with special needs or prone to discrimination – this was the legislator’s starting point. In implementation guidelines (Ministry of Labour 2005), interpreting services, information sessions and material in different languages, as well as taking into account cultural and special issues connected to minorities are mentioned as possible positive measures. Finnish non-discriminatory legislation is in line with the approach of the European Commission: immigrant integration should be mainstreamed in policy making, service delivery and organisational culture in a number of fields, including healthcare. 1) Organisations addressing the needs of society as a whole should ensure equal access to their programmes and services for all members of an increasingly diverse population; 2) Sometimes general measures can be adapted to meet immigrant needs. Sometimes targeted measures are necessary on a temporary or permanent basis. Organisations can learn how to balance these types of measures, ideally in consultation with stakeholders including immigrants. (Handbook on Integration 2007:14; numbers added by authors)
We can see that the necessary legal tools and an up-and-running interpreting service system are in place in today’s Finland; the spirit of the times, in many directions, seems to promote equal treatment for all.
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3 “Cultures Don’t Speak to Each Other, People Do” – Building Blocks of Intercultural Work The growing interculturality of society clearly requires new services and new ways of delivering services in general. Approaches need to be updated on all levels, from the workplace and individuals to organisations and politics (Hammar-Suutari 2006). In the previous chapter, political responses, such as legislative work and the founding of community interpreting centres were discussed. In the following, we will look at intercultural settings from the perspective of the authorities responsible for carrying out the work in practice. In a recent study carried out as a part of the Finnish Labour Policy Research Programme (Hammar-Suutari 2006) and combining methods of action research and ethnography, four dimensions were named as the basis for the intercultural competence needed in the work of the authorities. On the level of attitudes, critical assets are an endeavour to attain equality and equal opportunities, empathy and respect for diversity. The central ingredients in the awareness component are knowing one’s own background and culture, tolerating ambiguity and acknowledging the constantly changing nature of cultural representations. Important skills include the criticallyminded evaluation of interaction and perspective shifting and adapting to change. These factors sum up to action that is visible in encounters with clients, that enhances the chance of meeting the requirements of intercultural work and that, all in all, improves the interaction situation. (ibid.: vii) Social work professional Riitta Järvinen states in her doctoral dissertation (2004) that concrete work with immigrants shows whether and if so, how professionals make use of their awareness of intercultural matters. Relevant questions to ask in intercultural work are: what kind of help or assistance do these people need, who defines this need and how does one respond to it in a professional way. Cultural definitions and relationships are in a constant flux in a dynamic interpersonal interaction, which holds true even in a relationship between an authority and an immigrant. The professional has to commit her-/himself to understanding her-/himself and the client as cultural actors. (ibid.:159p.) The starting point in intercultural work is to admit that cultural knowledge is always limited and that people themselves have the power to work on their cultural identity. By letting immigrants make their voice heard and tell their own personal stories and by asking what these stories mean to them, professionals may improve their intercultural competence. This new knowledge can then be combined with general information and scientific data,
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allowing, for example, a critical approach to the tight standards of immigration policy and a questioning of traditional ways of doing things. (Järvinen 2004:161) In an interpreted conversation, the authorities tend to be willing to offload the responsibility for understanding the culture of their clients onto the interpreters. A representative example of this can be seen in the views of Hammar-Suutari’s (2006) informants: these interviewed authorities say they want “cultural interpreting” instead of “official interpreting”3, and that they sometimes feel uncertain of how interpreters can do their demanding job and make both parties understand each other; understanding being essential for success in their work. It seems as if the authority does not consider itself to have any responsibility in trying to explain the things in an understandable way once an interpreter is present! Another example of this kind of thinking can be found in the case of authorities who find it hard to work with foreigners with the help of an interpreter, because they feel they are not able to read out loud what the Finnish law says about a given situation, but they have to explain it in other words (Mäntynen 2003). Most Finnish-speaking clients would certainly prefer to have an interpreter with them in order to hear some other kind of talk than legal jargon from the authorities. One could say that authorities of this kind lack cultural sensitiveness even in their very own culture, because they cannot see the difficulties Joe Bloggs might have in understanding their field of expertise. It should not be expected that all representatives of a particular “culture” can be treated in the same way. Think of, let us say, different ways of celebrating Easter in different parts of Finland – and in different families in those different parts of the country. Think, too, of the division of household work in different families, or the influence of educational and professional background on one’s ability to understand different subject matters. It seems to be part of the common sense that people belonging to one’s “own” culture have many ways of doing things; but for some reason, this understanding ends at the cultural barrier, if one has not digested a way of thinking described by Järvinen as cited above: let the individual make her/his own voice heard, instead of seeing the person through the cloak of “culture”. Cultures do not speak to each other, people do (Tavassoli 2008), no matter whether an interpreter is present in a situation or not.
3
Official, or authorised interpreters do not exist in Finland, which lacks an authorisation system and protection of the professional title of “interpreter”.
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In an NGO offering psychological support for migrants, mostly in crisis situations, the principle of letting clients make themselves heard has been well digested. “I have the best cultural resource right before my eyes – the client”, in the words of one of their therapists. She does not need an interpreter to explain a culture that is likely to differ from the one of the client, and asks the client directly – mediated by the interpreter, of course – questions like “how was/is this done in your family?” or “what kind of school did you go to? I’m not familiar with the system in your country.” (Bremer 2009) Each and every individual has her/his own cultural background, as aptly put by Tavassoli (2008).
4 “What, Can’t She Manage Without an Interpreter?!” In an ideal world, all professionals would be interested in updating their competence and be willing to serve all clients according to the same principles (or even better: be willing to find solutions with similar effects for different people), as also required by the Non-Discrimination Act. Healthcare personnel need to gather information from patients by asking questions; they need to listen to what patients say in order to understand them, give instructions and explanations about examinations or procedures and ensure that patients understand what kind of treatment is needed and offered (Pauwels 1995:6). These conditions should be met in order for healthcare professionals to be able to treat any patient, regardless of origin or language spoken. Among professionals, there clearly are many different approaches to dealing with migrants as clients and only a few professionals actually see them as “ordinary” people; the choice of an approach and the application of cultural information remains everyone’s own responsibility. Not all professionals are willing to adapt to the requirements posed by social change. According to an integration study by Matkaselkä et al. (2004), the authorities working with migrants can be divided into four groups based on their attitude to intercultural work. Group one treats immigrants as any other clients that are not in need of any special services or guidance. Group two willingly dedicates more time to serving immigrants than the domestic population; group three takes foreigners’ background into account and understands its influence on special needs, but does not grant them any extra time. Group four sees immigrants as difficult clients that cause a lot of extra work and who are not willing to take any responsibility. (ibid.:53p.)
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One example of the last group of professionals is a receptionist at a hospital4: Interpreting was ordered on the occasion of a patient visiting an internist, and on arrival at the hospital, the interpreter asked where to find the right room. The receptionist asked for the name of the patient, repeated it very loudly so that everyone waiting for their turn could hear it and shouted: “what, can’t she manage without an interpreter, then?” The interpreter did not know the client and was therefore unable to judge the Finnish skills of the patient. When she finally found the right place, it turned out that the client had only lived in Finland for about a year and had been taking Finnish classes for four months, starting from scratch. How could one possibly imagine that this person could manage an appointment with an internist without the help of an interpreter? In any encounter between an authority and a client – or a patient –, the authority is the party responsible to a greater degree for leading the conversation and hence takes the role of an initiator. She/he is obliged to try to interpret the needs of the client in detail and to show a willingness to serve the client. In intercultural encounters, demands on professionalism are higher than in “monocultural” ones; readiness in facing new situations and components brought in by representatives of different cultures is a prerequisite. (Hammar-Suutari 2006:8p.) In health services, intercultural competence should be a part of professional basic skills or crossprofessional skills (Arvilommi 2005:29). In practice, equal treatment is obviously not guaranteed in all situations – and even so, the quality of services should not depend on who happens to be sitting behind the desk. On the basis of numerous interviews carried out among professionals in basic healthcare services, the criteria for immigrants’ health services of good quality were set out in a doctoral dissertation (Taavela 1999): the fundamental aspect in arranging the services is to respect the right of self-determination of immigrants, along with fair and equal treatment. Major sources for difficulties and problems seem to be a lack of a common language, shortcomings in cultural knowledge and awareness; for healthcare workers, immigrants also appeared demanding and poorly integrated into the Finnish culture (for instance non-compliance with schedules and instructions given), as proven in other field studies as well (Arvilommi 2005/Voima 2007). The Ministry of Social Affairs and Health has published a handbook for work in Finnish maternity and child welfare clinics (2004). In a chapter concerning immigrant families, a number of recommendations are given on 4
Author’s own experience.
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the provision of interpreting services as well. Clients should be able to use their mother tongue, and enough time should be reserved for their appointments that should preferably take place more often than those with domestic clients. Family members, in particular children, should not be used as “interpreters” It is advisable to turn to a community interpreting centre in order to make use of a professional interpreter – by choice a female interpreter for a female client – to whom rules of confidentiality apply. (ibid.:249) Things turn out to be less rosy in practice. Interpreting services are not always arranged on behalf of the personnel, and clients often have to rely on the help of friends or relatives. Interviews carried out for a bachelor’s thesis (Kauppi 2003) show that while husbands or relatives interpreted for mothers at maternity clinics (and also interpreted the interviews for the thesis); professional interpreters were seldom used in maternity care. The author of the thesis sometimes had serious difficulties in understanding what these “interpreters” said in her interviews and she questions whether healthrelated issues really become clear when interpreted by the same persons. This is a good question and one which should also be asked by healthcare personnel. According to a wide range of interviews reported by Arvilommi (2005), the means of healthcare personnel for supporting clients’ mental wellbeing and for taking up delicate issues are insufficient, especially if interpreting services are not used; it is difficult to prevent mental problems with immigrants or to respond to them at an early stage. Even professionals providing the services have difficulties knowing which departments are responsible for different services in the Finnish welfare system. Therefore, the authorities hope that immigrants are familiar with the system before appearing in their workplace as clients, hence removing from the professionals the burden of having to explain such complicated matters. Arvilommi rightly asks who should be responsible for providing immigrants with the necessary information, if it is not the specialised professionals taking care of them and their matters. One example of an area where guidance is needed in the healthcare sector is the provision of preventive medical services. In many countries, preventive services – such as maternity and child welfare clinics, a cornerstone of the Finnish system – are either non-existent or chargeable. Illiterate women in particular should be informed about these services in their own language through an interpreter. A healthcare worker should also be familiar with the social sector in order to be able to offer holistic advice in situations where a
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migrant family is in need of cross-professional assistance. (Voima 2007:79pp.)
5 Overcoming the Language Barrier Perhaps the most obvious challenge in intercultural work is the language barrier. Healthcare workers often state that it is challenging to bring about interaction and an atmosphere of confidence without a common language, hindered also by the cultural barrier; this leads to uncertainty and frustration (Arvilommi 2005/Voima 2007). Interaction situations with nonFinnish speaking patients tend to be superficial and only the most essential matters can be dealt with. In maternity and child health clinics, feelings and fears cannot be discussed in a similar way as with domestic clients, and workers are unsure whether the client has understood what has been said. Communication problems may also result in a situation where an immigrant is not offered all of the treatment possibilities that a domestic patient would be, due to problems related to the difficulty of getting the message across. Immigrant patients are not able to participate in the decisionmaking process on their own treatment. A frustrated patient lacking information and influence may choose not to seek healthcare services, thus causing harm to her/his health. (Voima 2007) As we can see, the main causes for success or failure in intercultural work mainly have to do with communication, language, understanding, interaction and not instilling trust in the patients. Ways of taking on the common challenge of communication across the language and cultural barrier vary: some professionals try to get along in Finnish and any possible foreign language as far as it goes; others feel uncomfortable in using languages other than Finnish. Translations of instructions for care in different languages are a practical tool, but the amount of translated texts and the languages they are translated into cannot be exhaustive. (Arvilommi 2005/Voima 2007) Unfortunately, it can neither be guaranteed that the message gets across in writing nor that the target group is able to get hold of it or is even literate in the first place. Despite codes of ethics for healthcare personnel and several acts and decrees urging the use of interpreting services, professional interpreters are not engaged in healthcare settings as much as they should be (Voima 2007/Arvilommi 2005). Many healthcare professionals do not know what interpreting services are about or even how to order an interpreter. Relatives, including children, are used as “interpreters”, in spite of all recommendations, even in matters that clearly are not suitable for children’s ears
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and where they most probably lack the adequate vocabulary. Husbands are used as “interpreters” in discussions about contraception or in gynaecological settings. In many workplaces, professional interpreting is seen solely as a right of a client, not as a responsibility of the authorities to make themselves understood. (ibid.) According to Voima’s master’s thesis (2007) based on a hundred interviews with healthcare workers, professional interpreting is seen as a solution to communication problems. In situations where lay interpreters are used, nurses doubt whether the message is delivered as it should be. The following reasons were stated as justification for not resorting to professional interpreting services: poor availability, time-consuming way of working, interpreting costs, lack of confidence in professionalism of interpreters, schedule problems, risk that a patient might not arrive for her/his appointment (ibid.:66). Sadly enough, some healthcare professionnals seem prepared to jeopardize the success of the treatment because of the time needed for interpreting. In the long run, this attitude may turn out to be the more costly option. Some of Voima’s (2007:68) informants see the ability to work with interpreters as a component of intercultural working skills. There is also a clear need for more information on the use of interpreting services, among other intercultural issues, expressed both implicitly in the insufficient use of interpreting services and explicitly as a wish to learn more about working with interpreters. On the other hand, interpreting services are not always available, as described in a recent study by Wathen (2007), among others. In out-patient units in particular, it is often impossible to arrange for professional interpreting as patients appear at the hospital without a prior appointment. In general, interpreters are not available at all times; female interpreters are even harder to get and telephone interpreting is practically impossible to arrange for acute needs. Interpreters tend to be fully booked for a week or two in advance, and if a suitable time for all parties is found, the patients’ situation either gets worse during the time they have to wait for interpreting, or their symptoms disappear and they do not come to the appointment. Due to these reasons, children are widely used as “interpreters” for lack of a better solution. At the same time, the nurses interviewed were uncertain of whether the message got across when interpreted by relatives, and they were well aware of the fact that children, for example, should not serve for that purpose. Migrants themselves would also welcome a wider use of professional interpreters, especially in healthcare settings (Mustonen 2007). In their experience, nurses and doctors do not arrange proper interpreting,
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which easily leads to misunderstandings about the need for and ways of treatment, even to malpractice. For instance, the son of one informant was circumcised twice, because the informant did not understand any Finnish and interpreting was not available. (ibid.) The interpreters’ knowledge of Finnish medical terminology is criticised by nurses (Wathen 2007:50). It might not only be a problem of the command of the Finnish language, but a more general one – interpreters are probably lacking a knowledge of healthcare and medicine as such and may not be able to express the matters in an eloquent way in their other (non-Finnish) working language either. Even interpreters who have taken the professional exam in community interpreting and are as such trained and proven professionals do not necessarily have much training in medical interpreting. In the Finnish vocational exam for community interpreters, social welfare and healthcare are only one of the four subject areas interpreters have to familiarise themselves with.
6 User Training as Part of Professional Education As stated earlier in this article, intercultural issues are beginning to form a part of the basic professional skills of healthcare personnel in many parts of Finland as well as in other European countries. As a logical consequence, they should be a part of basic professional education in healthcare as well. Let us take a look at the role of interculturality in some education programmes. Nurses with two different professional titles5 are trained at 25 Finnish polytechnics the course lasts 3 ½ to 4 years and is worth 210 to 240 ECTS credits. Many of the training institutions offer voluntary courses in migrant healthcare, but only one has made the topic compulsory for its students – i.e., it believes that everyone active in the profession should know something about intercultural work. A 22 ECTS block of intercultural professional skills is a compulsory part of nurse training at Diaconia University of Applied Sciences in Helsinki: 10 ECTS for theoretical studies and 12 ECTS for an internship at prenatal and child health clinics or at hospitals, mostly in departments for paediatrics and gynaecology. General themes of interculturality and migration are dealt with in the basics, including interpreting: legislation covering interpreting, working with interpreters, good and bad examples of interpreting (or the lack of it) in social and healthcare settings. In this way, students become 5
Terveydenhoitaja and sairaanhoitaja (“public health nurse” and “nurse”)
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aware of intercultural issues, including interpreting services, before embarking on their internship. They are instructed to observe intercultural issues during their internship, for example themes like interaction, equality or the use of means for equal treatment (e.g., interpreting) in their work environment. They also contribute to the development of their community of healthcare professionals in intercultural issues by updating the knowledge of senior workers and by disseminating best practices and present-day knowledge and ideas about intercultural work. (Arvilommi 2009) After their eight-week internship, students report and discuss their experiences and observations through group talks and seminars. In their presentations, interpreting issues arise as a central theme year after year: the use of interpreting services, working with interpreters, children as “interpreters”, etc. According to the experience of the responsible lecturer (Arvilommi 2009), the practice in different work places varies substantially: some clinics or departments have a well functioning system for working with migrant patients and interpreters and some do not resort to interpreting services at all, even though they should. In institutions that have so far paid little attention to interpreting and the equal treatment of all patients, students often are able to change the prevailing practice and highlight the importance of these issues in the work place. Five universities in Finland offer studies in medicine. None of them, so far, include compulsory intercultural studies for future doctors in their curricula. The University of Turku offers two voluntary courses entitled “migrants in healthcare”. The lectures cover themes like regulations concerning migrant healthcare, cultural notions of sickness and health, infections in different parts of the globe, healthcare for refugees and asylum seekers, not forgetting language problems and interpreting. The first of the two courses is theoretical, the second one includes an internship at public primary healthcare centres which treat many migrant patients. At the University of Helsinki, one lecture on interpreting and intercultural communication has been given for years as a part of a brief mandatory ethics course. The adjunct professor giving the ethics course noticed a few years ago that migrants were not dealt with at all in the curriculum in a systematic way, although students had to treat them during their internship at public primary healthcare centres. Now a compulsory two-day course in intercultural patient care is being planned for all medical students; a pilot course took place last autumn. The idea is that when a doctor meets a foreign patient for the first time at work, her/his professional skills will not vanish because of the very unfamiliarity of the situation itself but she/he
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will still be able to perform her/his job and treat the patient. (Louhiala 2009) At both universities, local community interpreting centres take care of presenting interpreting and intercultural communication issues. In the following chapter, we provide a brief and general description of the training activities offered by the three biggest community interpreting centres in Finland.
7 Training Provided by Community Interpreting Centres6 All community interpreting centres in Finland offer training and guidance in interpreting issues for groups of different professionals. A typical starting point is that a stakeholder contacts the interpreting centre and asks whether someone could come and speak about interpreting issues in further training measures. In the areas of Helsinki, Tampere and Turku, the three community interpreting centres offer a total of some 40 to 50 information sessions per year; a rough estimate is that half of the training activity takes place in healthcare settings, for and with healthcare professionals. Interpreting is often one topic among others in a seminar dealing with intercultural issues or migrants, but specific, tailor-made training on working with interpreters in a particular subject area is offered as well – for instance on how to carry out neuropsychological tests with the help of an interpreter. As a foundation, basic communication and interaction rules, including construction, visibility and significance of cultural differences are usually introduced along with “actual” interpreting issues. Encountering otherness always comes with uncertainty, which in its turn comes with anxiety. Therefore, the primary goal in intercultural interaction is to reduce uncertainty, which can be done by getting to know the unknown, i.e., gathering information about the other. Professional interpreting services are presented as a means to the end of getting to know the other, not as a magic cure that will take all responsibility for communication off the authorities’ chest. Along with the main legal framework, the most important points of the Finnish code of conduct for community interpreters are presented: interpreters are bound to professional secrecy; they will not accept assignments they would not be capable of handling or that would compromise their impartiality and position as an 6
Based on information received from representatives of the community interpreting centres of the regions around Helsinki (interview with Mohsen Tavassoli [2009] and presentation for a seminar [2008]), Tampere (telephone interview with Janne Salo), and Turku (e-mails exchanged with Marjatta Nieminen).
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outsider; interpreters strive for an extensive reproduction of what is said, they will not leave anything out nor will they make things up. Essential advice is given on how to behave and work in interpreter-mediated talks: divide your speech into sections that are easy to understand in order to get your message across; let the interpreter finish interpreting before you move on; address the client, not the interpreter. Anecdotes and examples from real-life situations function as effective tools in getting the message across: they give the audience the possibility of laughing at other people’s experiences or mistakes – allowing them, at the same time, to laugh at themselves, their prejudices and conceptions. If the thought “the same could have happened to me” hits the participants, they are bound to learn something and be better prepared to be confronted by similar situations at work. Participants in a training mostly wish to share their own experiences in intercultural situations and interpreting and ask questions about culture and cultural habits, which often produces a fruitful exchange of views and gives them the opportunity of addressing the specific issues of the domain in question. Participants often report that they have learned the hard way how important proper interpreting can be – for instance, they have experienced cases in which a child has “interpreted” for its parents and no-one has been able to understand anything, which has meant a complete waste of the precious time for doctors, or when lack of interpreting has led to a worsening of a patient’s condition. It is however not only the users of interpreting services who can learn from interpreters and interpreting; it is a two-way street in which the trainers have to keep their eyes and ears open and be open for feedback and suggestions given by their clients. Examples of recent target groups of training sessions in the area of healthcare are healthcare students at different stages of their training, healthcare personnel who work with the aged, administrative workers in hospitals, or specialists like neonatologists and clinical physiologists.
8 “I’m not Interested in Hearing About Your Stomach Problems” – Taking Professionals by the Hand An effective way of spreading best practices as an interpreter is to intervene in situations and actions which do not correspond to the principle of equal and human treatment. Every interpreting assignment may be used as a chance to take professionals in other domains by the hand and point out important aspects of intercultural communication or interpreting, Professional community interpreters are expected to be able to inform their clients
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about issues related to the organisation of interpreting situations. In the examination requirements of the Finnish vocational exam for community interpreters (Asioimistulkin ammattitutkinnon perusteet 2006), for instance, it is stated that the candidates must demonstrate an ability to counsel their clients on working with an interpreter. This includes clarifying the role of the interpreter before the beginning of the discussion and explaining what the role covers – interpreters do not, for example, serve as hospital guides, make telephone calls for their clients and so forth. In the exam, it is also required that interpreters know how to arrange adequate working conditions for themselves, including agreeing on the procedures in the interpreting situation (such as modes of interpreting like chuchotage or consecutive; rendition of the speech in first person; asking questions to clarify matters; interrupting the clients). The Finnish code of conduct for community interpreters aptly points out that each party included in an interpreting situation plays a role in making the interpreting work. The code also recommends that the roles of all participants should be clarified beforehand. An interpreter is working at a doctor’s practice. The patient says what is bothering him, the interpreter translates for the doctor into Finnish: “I’ve been having stomach ache and diarrhoea…” The doctor – who has certainly worked with interpreters before – interrupts him, saying in Finnish: “I don’t want to hear about your problems, just tell me what’s wrong with the patient.” Instead of pointing out to the doctor that those were the words of the patient, the clever interpreter translates the doctor’s utterance for the patient – who obviously gets confused and wonders whose problems the doctor is interested in, if not his. This is interpreted for the doctor, who then notices his mistake.7 The above example demonstrates that letting a client figure out an idea by her-/himself instead of preaching about it can be an effective way of getting the message through, provided this is done nicely and does not result in the client losing face. A typical case is where a doctor or a nurse addresses the interpreter as if the patient was an outsider: “Does she have hypertension?”, or: “What medication is he on?” For interpreters, the basic role issues, such as using the “Iform” when interpreting and speaking about oneself in the third person (“the interpreter would like to suggest taking a break”) seem perfectly logical and crystal clear – as does any practice in a given branch for insiders of the profession in question. 7
Example given by Tavassoli (2009).
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Interpreters are trained to think that they “merely” enable interaction; in a way, they have to “forget” about themselves, because they do not – and cannot – have their own axe to grind in any assignment. They adopt an idea that in an interpreted discussion, the participants pursue an interaction between themselves as if the third party, the interpreter, were not even present in the situation. Obviously, the interpreter is there; it is thus natural that the parties coming from outside the depicted interpreting standard take the interpreter into account, address her/him and concretely speak to the other conversation partner(s) through her/him – the interpreter being the only person in the room capable of understanding all parties. According to Leinonen (forthcoming), the use of first/third person in interpreted conversations is a supremely interesting research subject. There is an abundance of research on roles of participants in monolingual settings, but these roles are constructed in a slightly different way to those in interpreted bilingual settings. Based on the research done so far, it can be said that a speaker usually directs her/his speech and eye contact to the person with whom she/he shares a common language, because anything else would be fruitless. When a doctor addresses a patient in the third person and in a way asks an interpreter how the patient is doing, she/he acts according to the principles of monolingual interaction and seeks interaction where it is available, i.e., where it can be expected that understanding is at hand. Doctors, as well as patients and other clients of interpreters, may – at least subconsciously – think that there is no point in addressing someone that is not going to get it anyway. Therefore, clients may resort to third person speech through the interpreter; they probably do not think that they are posing a question to the interpreter but simply wish that it would be interpreted for the conversation partner. It is important that interpreting professionals have understanding and patience for outsiders’ unawareness and ideas that for insiders might seem inconsiderate or even unthinkable. Bearing this in mind, interpreters should, prior to the beginning of each conversation, willingly and over and over again, double-check that their clients are aware of the general framework of interpreted interaction, such as addressing the conversation companion, not the interpreter, and interpreting in the I-form. Interpreting can also be interrupted to clarify functional matters of this kind, if deemed necessary or useful for the interaction. However, interpreters are there for the clients and not to make a fuss about themselves; therefore, any intervention by an interpreter should be carefully considered and serve the interests of the clients.
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9 “I Thought You’d Just Do Some Translating” Interpreters contribute to the work carried out in multi-professional healthcare settings, presenting a new professional perspective that cannot be overlooked. Their training provides them with an understanding of interaction in multilingual settings. A prerequisite for the success of interpretermediated multilingual work in healthcare settings is that a part of the knowledge is distributed to interpreters outside the healthcare organization. Without the professional agency of an interpreter, patient contribution remains rather low, and the patient is hardly able to participate in her/his own treatment. Without the expertise provided by patients in their own matters, healthcare practitioners do not have a reliable basis for their work. This is even more important when patients are treated by a team of many professionals and the information provided by a foreign-language patient (i.e., through an interpreter) is delivered and distributed to many other groups of professionals, who later take part in the treatment of the patient concerned. The multi-professional environment of healthcare settings consists of doctors and nurses, as well as secretaries, laboratory assistants, physical therapists, etc. Much of their work is based on information provided by patients. If the interaction between the healthcare practitioners themselves and patients (or their guardians) does not function properly, treatment resources and time are wasted, which translates into a waste of money. Thus, it is essential that professional interpreters be engaged in the process of interaction, in their position as intercultural communication experts within the multiprofessional healthcare team (Leinonen, forthcoming) Engeström (2004:44pp.) has investigated the work of Finnish public primary healthcare centres, for instance concentrating especially on work with patients whose treatment requires the contribution of many different professionals. Engeström has developed a model which aims at enhancing collaboration between various healthcare professionals and patients. In his model, one objective is to share knowledge about and from a particular patient with all practitioners involved in the treatment of the patient. While developing interpreter education and methods for informing users of interpreting services in healthcare settings, we should also bear in mind the complexity of the future working environment of interpreters. Taking into consideration treatment processes that may last a very long time, it might be useful to investigate the feasibility of establishing a system enabling the use of “personal” interpreters; i.e., the same interpreter would always interpret for the same patient. In a system like the Finnish one, where interpreters also work in settings other than healthcare, this would at least allow
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the interpreter to have the opportunity of increasing his or her working knowledge in the case. In mental health settings in particular, the same interpreter should be available throughout the whole therapy process. In this case the client has to be able to rely on the stability of the setting and build a trusting relationship with the therapist, which, in case of foreign-language clients, is built up through an interpreter. Therefore, changing the interpreter would mean starting the therapy all over again. Language is the central tool and method in therapy work; therefore, the therapist has to be able to concentrate on her/his own work and to count on the interpreter without having to question the trustworthiness of the messages delivered through her/him at every turn. (Bremer 2009) In educational research it has been emphasized that a person willing to become an efficient participant in his or her future work has to learn the basics of collaboration during the training itself in order to learn to act as a professional. This is guaranteed by ensuring participation at work, since participation gives the opportunity to learn. Newcomers turn into professionals by taking part in everyday practice. (Lave and Wenger 1991) If we look at the processes taking place in primary healthcare centres, we can understand the fusion of these processes to one activity system (Engeström 1999), where different practitioners interact in order to achieve a common goal, i.e., the treatment of patients. Interpreters come from outside this activity system but can be considered essential participants in the process of reaching the common goal. They can be seen as beginners among healthcare professionals as long as they are not trained members of the activity system. Interpreters must be socialised into the working processes and daily routines in order to understand the objectives of the activity and their own role in it. This learning process could and should be launched in theoretical studies; valid literature on doctor–patient interaction is available in many languages. This material would be helpful in informing the students of the progress of a typical doctor’s appointment, of the roles taken and speech patterns used by different parties and the function of the different phases of the event. Furthermore, it is of utmost importance that the other members of the activity understand the role of interpreters in achieving the common goals. The use of interpreting services must become a part of the daily routine, instead of a source of stress in the process. Therefore, taking on the role of an apprentice in the system – realised in the form of an internship as a part of the education – would help interpreters to prepare themselves for their future work. In this way, interpreters could see what kind of activities take place
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in primary healthcare centres as a matter of example. This would allow interpreters to gain access to the necessary information and to understand the processes taking place there. In many cases, this would bring about a different kind of support from inside the institution; healthcare professionals might thus begin to see interpreters trained in this way as their equal collaboration partners. This did not hold true on one occasion8 where an interpreter was called to work at an appointment with a special nurse; she knew the reason for the appointment beforehand, namely the patient’s sleep apnoea, and had prepared for the interpreting assignment accordingly. At the end of the appointment, the nurse thanked the interpreter for the job well done and wondered how it was possible that she was familiar with the special terminology used by the nurse. The interpreter explained that as she knew what the reason for the appointment was, she had studied the essential vocabulary and familiarized herself with the condition in question to be able to perform her job. Truly impressed, the nurse answered: “Oh my – I thought you’d just pop in and do some translating!” As Lave and Wenger (1991:95) put it, apprentices could little by little “assemble a general idea of what constitutes the practices of the community”. Interpreting is not just about mastering healthcare terminology and interpreting techniques, it is much more about understanding the activity framing the communication. As newcomers they could observe the interaction of patients with the healthcare institutions, mediated by other interpreters, other newcomers or “old-timers”. However, one must remember here that not all old-timers are masters, as they probably neither have been properly educated nor have (had) the opportunity to reflect on their work with professionals in the field. The problem with this kind of apprenticeship in today’s Finnish system can be found in this field: there are only a few true masters to follow, and most interpreters work on a freelance basis. However, an apprenticeship should be seen as a chance to understand the common activity system and to develop one’s own identity as an interpreter in healthcare institutions. Apprentices would thus have an opportunity to bring their own perspective with them to the work of the healthcare institution. Lave and Wenger (117) point out that “inexperience is an asset to be exploited”, because it is good to have someone new to comment on existing processes. This can only work if there are experienced participants willing to interact with newcomers who bring in their new ideas. 8
Author’s own experience.
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On the other hand, interpreters have to protect their sensitivity towards their clients, representing the voice of clients who also come from the outside. Interpreters are the ones able to take a position on both parts of the interaction: firstly, he or she can understand the position of healthcare practitioners and their working goals; secondly, he or she can understand the position of a newcomer (i.e., patient) in the system.
10 Conclusion From the point of view of interpreting in Finnish healthcare, legislation offers a good basis for the functioning treatment of foreign-language patients. Still, much remains to be done in order to turn equal treatment into an everyday reality. Interpreters need a better education for interpreting in healthcare settings, a deeper understanding of how the system works and they have to come up with solutions in order to offer their services in a more flexible and extensive way than hitherto. Interpreters and their organisations must steamroller the legislator into protecting the occupational title of “interpreter”. With the respective qualifications, control and sanction mechanisms included, this would unquestionably be a positive step: unprofessional practitioners that sully the reputation of the whole profession would be shackled, and users of interpretation services could rely on the professionalism of the person performing the service. Healthcare institutions seem to be aware of the interpreting needs and their patients’ right to interpreting; this knowledge should now be transferred to the level of action. Healthcare professionals must begin to require that interpreting services be available and that they are carried out in a professional way. Nowadays, everything comes with a price tag; therefore their awareness of the cost factors of non-interpreting should be promoted. Together with interpreting service providers, educators and policy makers, healthcare institutions should search for ways of opening up their own system: offering internship possibilities and information of their ways of working, giving feedback on interpreting services delivered at their workplace, requiring quality in interpreting as in any other service they pay for. As nurse and social worker educator Arvilommi (2009) puts it, things are changing for the better, but the changes are taking place at a surprisingly slow pace. She estimates that nowadays out of the some 150 students who every year participate in the “intercultural internship” at clinics and hospitals treating migrants, one third refers to the state of interpreting provision
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as miserable; ten years ago every second student had to gasp for breath because of the inadequate treatment of migrants and handling of interpreting. The common goal of all stakeholders should be to improve the level of professionalism, knowledge and awareness of interpreters and healthcare personnel, as well as finally to start implementing the regulations in force about equality and interpreting as one way of working towards equal treatment. Only interpreters and healthcare workers working side by side as professionals in their own right can enable a true interaction between the relevant parties in an intercultural healthcare setting – the patient and the healthcare professional. It may be needless to say that specialized education for medical interpreting, combined with an opening-up of the healthcare sector to support the participants of such education would be a great step in the right direction. The fact being that money talks, information campaigns on the costs of non-interpreting would perhaps make decision-makers in healthcare listen up and implement new ideas. References9 Asioimistulkin ammattitutkinnon perusteet (2006) (“Examination Requirements of Vocational Exam for Community Interpreters”). Opetushallitus. Arvilommi, Nicola (2005): Monikulttuurisuus sosiaali- ja terveysalan ammatillisena haasteena. Hyvinvoinnin rakentajat -osahankkeen työraportti. (“Interculturality as a professional challenge in social welfare and healthcare. Report on the project ‘Builders of welfare’”). Arvilommi, Nicola (2009): Telephone interview. February 24, 2009. Bremer, Lena. (2009) Lecture at education seminar for interpreters arranged by the Finnish Association for Translators and Interpreters (SKTL). Helsinki, March 20, 2009. Engeström, Yrjö (1999): ”Activity Theory and Individual and Social Transformation”. In: Engeström, Yrjö/Miettinen, Reijo/Punamäki, Raija-Leena (eds.): Perspectives on Activity Theory. Cambridge: Cambridge University Press, 19-38. Engeström, Yrjö (2004): Ekspansiivinen oppiminen ja yhteiskehittely työssä (”Expansive Learning and Co-Configuration at Work”). Tampere: Vastapaino. Hallintolaki 434/2003/ Administrative Procedure Act, unofficial English translation available at http://www.finlex.fi/en/laki/kaannokset/2003/en20030434.pdf Hammar-Suutari, Sari (2006): Kulttuurien välinen viranomaistyö. Työn valmiuksien ja yhdenvertaisen asiakaspalvelun kehittäminen. (“Intercultural Work of Authorities. Developing Competencies and Equal Customer Service”). (Työpoliittinen tutkimus 300/2006). European Commission, DG JUST. (22007) (ed.): Handbook on Integration for Policymakers and Practitioners.
9
English names in quotation marks after Finnish titles are authors’ translations to provide an idea of what the reference is about.
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Järvinen, Riitta (2004): Ammatillisen maahanmuuttotyön kulttuuri: erilaisuus sosiaalija terveydenhuollon jäsennyksissä. (“Culture of Professional Immigration Work: Dissimilarity in Social Welfare and Healthcare Analysis”) Tampere: Tampere University Press. Kauppi, Kaisa (2003): Somaliäitien kokemuksia neuvolapalveluista ja saamastaan sosiaalisesta tuesta (”Somali Mothers’ Experiences on Prenatal and Child Health Clinics and Social Support”). Bachelor’s thesis. Helsinki: Diaconia University of Applied Sciences. Kielilaki 423/2003/ Language Act, unofficial English translation available at http://www.finlex.fi/en/laki/kaannokset/2003/en20030423.pdf [25/03/09].. Laki maahanmuuttajien kotouttamisesta ja turvapaikanhakijoiden vastaanottamisesta 493/1999/ Act on the Integration of Immigrants and Reception of Asylum Seekers, unofficial English translation available at http://www.finlex.fi/en/laki/kaannokset/1999/en19990493.pdf [25/03/09].. Laki potilaan asemasta ja oikeuksista 785/1992/ Act on the Status and Rights of Patients, unofficial English translation available at http://www.finlex.fi/en/laki/kaannokset/1992/en19920785.pdf. [25/03/09]. Leinonen, Satu (forthcoming): The Norms of Interpreting in the Light of Interactional Regularities (working title). Louhiala, Pekka (2009): Telephone interview. February 26, 2009. Matkaselkä, Pirkko/Memni, Pauliina/Mikkonen, Kirsi (2004): Kotoutujan ja kotouttajan polut kohtaavat kunnan peruspalveluissa. Selvitys maahanmuuttajien ja palvelujen kohtaamisesta Myyrmäen palvelualueella. (“The Integration Paths of Immigrants and Authorities Cross in the Basic Services of a Municipality. Report From a Service Area.”) The Association of Finnish Local and Regional Authorities & City of Vantaa. Mäntynen, Anna (2003): Tulkin muotokuva (“Interpreter’s Portrait”). Master’s thesis. Tampere: University of Tampere. Ministry for Social Affairs and Health (2004) (ed.): Lastenneuvola lapsiperheiden tukena. Opas työntekijöille (“Child Health Clinic in Support of Families With Children. A Guide for Staff”). Ministry of Labour (2005) (ed.): Yleiset suositukset yhdenvertaisuussuunnitelmien sisällöiksi (“General Recommendations on Contents of Equality Plans”). Ministry of Labour (2006) (ed.): Kunnallisten tulkkikeskusten laatukäsikirja (“Quality Handbook for Communal Interpreting Centres”). Mustonen, Päivi (2007): Pompottelua ja osallisuuden kaipuuta. Maahanmuuttajien kokemuksia asiakaslähtöisyydestä ja sen toteutumisesta sosiaalityössä ja muissa julkisissa hyvinvointipalveluissa (”Migrants’ Experiences of Customer-Based Approach in Social Welfare and Other Public Services”). Master’s thesis. Tampere: University of Tampere. Nieminen, Marjatta (2009) Director of the community interpreting centre of Turku. Email on interpreting training. February 24, 2009. Salo, Janne (2009) Then director of the community interpreting centre of Pirkanmaa region (Tampere). Telephone interview. February 27, 2009. Statistics Finland (2008) (ed.): The population of Finland 2008. In: http://www.tilastokeskus.fi/til/vaerak/2008/vaerak_2008_2009-0327_tie_001_en.html [25/03/09].
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Taavela, Raija (1999): Maahanmuuttajien palveluiden laatu Suomen terveydenhuollossa (“Quality of Immigrant Services in Finnish Healthcare”). (Publications of the University of Kuopio, Series E, Social Sciences 72). Tavassoli, Mohsen (2008): Education material on interpreting services at a seminar for healthcare professionals. Helsinki, December 8, 2008. Tavassoli, Mohsen (2009): Interview. January 13, 2009. Ulkomaalaislaki 310/2004/ Aliens Act, unofficial English translation available at http://www.finlex.fi/en/laki/kaannokset/2004/en20040301.pdf. Wathen, Marja (2007): Maahanmuuttajien potilasohjaus sairaanhoitajien kokemana (”Counselling of Migrant Patients as Experienced by Nurses”). Master’s thesis. Tampere: University of Tampere. Voima, Kyösti (2007): Sithän sä oot se poppamies. Terveysalan työntekijöiden kokemuksia monikulttuurisesta hoitotyöstä. (“You Must be the Medicine Man! Experiences of Health Personnel on Transcultural Nursing”). Master’s thesis. Kuopio: University of Kuopio. Yhdenvertaisuuslaki 21/2004/ Non-discrimination Act, unofficial English translation available at http://www.finlex.fi/en/laki/kaannokset/2004/en20040021.pdf [25/03/09].
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