When collaborating with interpretors, transliterators, or translators, audiologists and speech-language pathologists (SLPs) remain responsible for planning the session, selecting culturally relevant materials, and appropriately administering assessment and treatment. The interpreter or transliterator assists the clinician in gathering the appropriate data and provides language support for services appropriate to the client's disorder.
Appropriate roles and responsibilities of SLPs and audiologists when collaborating with an interpreter, transliterator, or translator include:
- identifying clinical exchanges for which collaborating with an interpreter, transliterator, or translator is necessary;
- identifying the appropriate language(s) of service for clients/patients/families, including identifying the preferred language for meetings, services, and written documentation;
- advocating for access to an interpreter, transliterator, or translator;
- making advance arrangements to ensure appropriate physical accommodations (e.g., space, lighting, noise) necessary for successful collaboration, including placement of phone, computer, and/or video screen to ensure visibility and audibility during remote sessions;
- creating a foundation for successful collaboration, including
- scheduling additional time in sessions to accomplish goals;
- verifying the cultural appropriateness of assessment and treatment materials through collaboration with the interpreter, transliterator, translator and reviewing potential bias;
- reviewing prompts in assessment materials for linguistic influences of a second language and consulting with additional experts and resources to review phonetic information and potential syntactic influences;
- arranging for documents written in unfamiliar languages to be translated, to ensure that they, as clinicians, are aware of the content of the documents;
- understanding that the translation of written material from English to a non-English language may alter the intent and overall readability of the document;
- being aware that each country has its own sign language and that there are dialectal differences in sign languages;
- understanding that not all spoken and manually coded languages, including American Sign Language (ASL), have a written form;
- seeking an interpreter, transliterator, or translator who has knowledge and skills that include
- native or near-native proficiency in the appropriate language(s)/dialect(s)/communication system(s) and the ability to provide accurate interpretations/translations/transliterations;
- understanding of the client's/patient's/family's particular culture and speech community or communicative environment;
- understanding of the basic principles of assessment and/or intervention and the ability to provide context to the client/family to understand clinical objectives and professional terminology;
- understanding of professional ethics, client/patient confidentiality, and the need to limit bias;
- establishing collaborative relationships with interpreters, transliterators, and translators (professional or from the community) to maximize the effectiveness of services;
- maintaining appropriate professional relationships among the clinician, the client/patient, and the interpreter, transliterator, or translator (ASHA, 2010r);
Additional responsibilities specific to service delivery by SLPs include:
- seeking information on the features and developmental characteristics of the language(s)/dialect(s) spoken or signed by the client/patient/family,
- obtaining information on the sociolinguistic features of the client's/patient's/family's significant cultural and linguistic influences when possible,
- understanding the standardization process for assessments and how collaboration with an interpreter, transliterator, translator may influence or possibly invalidate standard scores.
It may be difficult for a clinician unfamiliar with the language to judge the quality of interpreting, transliteration, or translation services. Clinicians must do their best to ensure that services provided are reliable and make every effort to become familiar with their clients' languages. ASHA's Code of Ethics (Principle I, Rules A and B as well as Principle II) provides the baseline for the quality of services that the clinician should provide. Clinicians must provide all services competently, which indicates using the best resources available under the circumstances.
Factors included in the selection of an interpreter, transliterator, or translator include the individual's
- level of proficiency in spoken English and in the language/dialect used by the client/patient/family,
- prior experience,
- educational background and/or professional training,
In the United States, there are limited requirements for training, experience, or licensing for interpreters, transliterators, and translators. However, this is a growing profession. Medical interpreters have professional standards and certification (e.g., through the International Medical Interpreters Association), and there are a growing number of state organizations for trained interpreters. Trained and/or certified professionals have codes of ethics within their professions. See the Registry of Interpreters for the Deaf, America TA, and National Council for Interpreters in Health Care.
Most of the time, the administration and/or the clinician's facility will provide the name of an individual who will serve as interpreter, transliterator, or translator. A clinician may or may not have the opportunity to provide input on the selection for the initial meeting with the client/patient. However, to the extent possible, the same interpreter, transliterator, or translator should be used for multiple assignments, so that the clinician may establish a familiar relationship and provide knowledge of the work process.
Individuals who serve as interpreters, transliterators, or translators include
- professionals from language banks or other services,
- bilingual assistants,
- bilingual professional staff from a health or education discipline other than communication disorders,
- bilingual staff available within the facility but outside of health or education disciplines.
This list, arranged in approximate order of preference, does not account for the unique variables inherent in clinical interactions. Additional factors to consider include the client's culture, values, beliefs, age, and current ability level and how these factors may influence the client's willingness to disclose information in the presence of an interpreter or transliterator. For example, the client/patient/family may consider it inappropriate to speak with someone of the opposite sex.
Bilingual assistants and professional staff must consider their linguistic proficiency in both languages being used, including their proficiency in the local dialect of the language(s) being used by the client/patient and family and their own knowledge and skills for interpreting/transliterating and translating. Dialectal mismatches—such as a Spanish-speaking individual from Mexico interpreting for a Spanish-speaking client from Spain or Argentina—may result in inaccurate interpretations, translations, and/or cultural misunderstandings (Ostergren, 2014).
Family Members or Friends Serving as Interpreters, Transliterators, Translators
On limited occasions, there may be reasons why a family member or friend serves as an interpreter, transliterator, or translator, either due to client preference or because all other efforts to locate an appropriate interpreter, transliterator, or translator have been exhausted. In addition, a facility may be unable to locate an individual who is able to meet the individual linguistic needs of the client. For example, family members may be the only source of information regarding speech patterns prior to a brain injury in a multilingual individual.
Family or friends acting as interpreters, transliterators, or translators may present potential conflicts (ASHA, 2010r). The reliability of the interpretation, transliteration, and/or translation may be compromised given the potential conflict of interest and likely limited training of the family member/friend. It is important to be mindful of risks in high stakes situations, such as mediation, evaluations, or situations where cognitive capacity might be in question. Children may not possess the emotional maturity and sensitivity necessary to serve in the role to assist family members in the provision of services.
When using family members or friends in this role, the clinician considers the
- intent of the message (e.g., sharing a diagnosis of dementia vs. providing safe swallowing techniques),
- age of the family member providing interpretation, the position and role of that individual within the family structure, and his or her overall linguistic ability.
Collaborating with an interpreter or transliterator may influence a clinician's ability to diagnose, treat, and seek reimbursement for services. Interpreters or transliterators may make mistakes when converting messages into another language and/or reporting client responses, particularly if they are unaware of the purpose of the exercise or assessment. Interpreters and transliterators may also influence client/patient responses or understanding of clinician questions. In some cases, seemingly small errors can change the meaning of a question or response and have drastic effects on outcomes.
Successful collaboration is inherent to successful service delivery and is based on a shared understanding of the goals established by the clinician.
A clinician may need to provide training prior to the session to ensure the best possible outcomes during clinical sessions and should periodically check in to assist in the effective delivery of services.
Prior to the Session
Actions taken prior to the session to ensure a successful collaboration include:
- meeting in advance to allow adequate preparation time;
- reviewing and learning greetings and the appropriate pronunciation of names in the family's primary language;
- providing written information prior to the meeting, including proper names of those at the meeting, technical terms and abbreviations, copies of visual references, and topics to be covered;
- establishing a rapport with the interpreter, transliterator, or translator;
- discussing prompts or cues that the interpreter/transliterator can use in the event the clinician speaks too quickly or too softly or the clinician's speech or meaning is unclear;
- reviewing the goals and procedures of the session or clinical interaction, including discussing
- whether gestures may or may not be used,
- the possible influence of vocal intonation,
- the presence of feedback to the client/patient,
- other cues that may inadvertently influence the session in unanticipated ways;
- reviewing the impact of additional cuing and prompting through repetition of prompts in English by the clinician to target language;
- explaining confidentiality policies pertaining to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations and the ASHA Code of Ethics and documenting that these policies have been explained and accepted;
- reviewing assessment administration procedures or intervention techniques and ensuring that the interpreter or transliterator is aware of (a) the purpose of such procedures/techniques and (b) the need to provide test stimuli—in the client's language—that are as close as possible to the English prompts to elicit the desired type of response;
- providing in advance a copy of assessment prompts to be used to avoid any sight translations;
- discussing the impact that fingerspelling may have on assessment results and reviewing possible differences in the conceptual accuracy of some signs relative to spoken language;
- reviewing procedures for capturing the client's verbal and behavioral responses.
During the Session
Actions taken during the session to ensure a successful collaboration include
- introducing the clinician and the interpreter or transliterator to the client in the client's native language;
- describing the role of the clinician and the interpreter/translitator/translator and clarifying expectations;
- reviewing and discussing the process for data collection;
- using short, concise sentences and avoiding the use of idiomatic expressions, as these are not conveyed easily between languages;
- pausing frequently to allow the interpreter/transliterator enough time to convey information accurately;
- allowing enough time for the interpreter/transliterator to organize information, recognizing that variations in narrative discourse across languages will influence the amount of information required to accurately convey intent;
- periodically checking with the interpreter/transliterator to see if the clinician's speech is too fast or too slow, too soft, or unclear;
- understanding that words that express feeling, attitude, and qualities may not have the same meaning when directly interpreted or translated;
- talking directly to the client and ensuring comprehension of diagnosis, prognosis, and treatment recommendations, as the clinician would do with all clients;
- being aware of nonverbal body language and gestures that may be offensive to the client's/family's culture;
- observing nonlinguistic measures to supplement the interpreted or translated information;
- avoiding oversimplification of diagnoses, recommendations, and other relevant information;
- providing written materials in the client's/family's preferred written language;
- scheduling extra time for the session and scheduling breaks as appropriate.
After the Session
Actions taken following the session to ensure a successful collaboration include
- reviewing the client's responses, as well as the target responses, and determining if they may have been influenced by cultural and/or linguistic variables;
- discussing any difficulties or concerns.
Working With Translators
Special considerations for effective collaboration with translators include
- providing documentation well in advance,
- being aware that some spoken languages do not have written forms,
- understanding that a client's/family's preferred written language may not be the same as the preferred spoken language,
- allowing time for the translator to consult and ask questions, particularly as it pertains to medical terminology and recommendations.
Dialectal differences may influence translation. To the extent feasible, clinicians should ensure that documents are written in a way that is the most universally understood by speakers of different dialects of a written language.
All vital written documentation provided to the family should be translated into the client's/patient's and/or family's preferred language, and clinicians should allow for sufficient time for the translator to work with the documents.
All legal documents and highly relevant materials should be provided to the translator ahead of time. In a research setting, informed consent is presented to each human subject "in language understandable to the subject" (Protection of Human Subjects, 2001). In most situations, informed consent is documented in writing.
Funding for interpreters may come from a variety of sources. Clients/patients are not expected to pay out of pocket for interpreter/translator services to ensure access to care.
For individuals who are deaf or hard of hearing (D/HOH), the Americans with Disabilities Act of 1990 mandates that all public and private agencies that provide services to the general public, and all employers with 15 or more employees, must be accessible. Therefore, it is the agency, service, or business that is responsible for payment for interpreting services. For students who are deaf and have an Individualized Education Program (IEP), educational interpreting is considered a Related Service under IDEA. As with all IEP supports and services, there is no charge for Related Services. Because educational interpreting/transliterating is a Related Service, an educational interpreter/transliterator is a member of the IEP team for any student who is deaf or hard of hearing receiving this service.
Title VI of the Civil Rights Act of 1964 mandates equal access to services regardless of language used. Executive Order 13166 further stipulates that agencies receiving public funding, such as Medicaid/Medicare or IDEA funding, must make provision and arrangement for that access and are responsible for the funding of an interpreter/transliterator or translator as needed. Consideration is made for smaller agencies with lower annual operating budgets that may influence the agency's ability to provide access. See guidance provided by the U.S. Department of Health and Human Services.
At this time, third-party payers do not pay for the services of an interpreter. However, some third-party payers and insurers may require documentation for how the non-English language or communication system will be addressed prior to sending reimbursement.
To avoid disagreements, practitioners who provide contract services with institutions should clarify the party (e.g., the facility or the contracting clinician) responsible for payment of interpreter/transliterator/translator services. For example, it may be determined that it is the responsibility of the facility to provide appropriate accommodations for those services, or it may be decided that interpretation services should be listed as a line item in the services the clinician provides.
A client's equal access to services encompasses the continuum from making an appointment for services, to completing paperwork and case history forms, to participating in face-to-face meetings, to receiving written reports, as well as interaction during assessment and intervention. The client/patient/family should be consulted to determine the mode of communication or accommodation that is preferred and best suited to each clinical interaction. This choice may vary depending on the type of clinical encounter (i.e., meeting, counseling, assessment, intervention) and the needs of the setting.
During service provision, clinical encounters with the client and family may necessitate different types of interpreting, transliteration, and translation services.
Simultaneous Interpreting (SI)—the interpreter converts a speaker's or signer's message into another language while the speaker or signer continues to speak or sign. This approach may be used to keep meetings flowing without interruption in a clinical setting or when most persons at the table speak English. Simultaneous interpreting may be more commonly used with manually coded languages than with spoken languages due to the auditory interference that may be present in spoken language interpretations, if the interpreter is speaking at the same time as the clinician or the client/patient (Langdon, 2002).
Consecutive Interpreting—the interpreter transmits the message after a section of the source language is produced and during a pause. The interpreted message is divided into segments of appropriate length to be conveyed to the target language and be well-understood. Compared with SI, consecutive interpreting may be more commonly used during assessment and intervention of spoken language. Additionally, interpreters of both spoken and manually coded languages may utilize consecutive interpretation when the client provides a great deal of information at once in order to fully comprehend the information and then accurately convey the meaning. Consecutive interpreting may also be preferred for clients/families with compromised cognitive abilities (Langdon, 2002).
Effective interpreting may alternate between consecutive and simultaneous depending on the needs of the clinical interaction and communicative intent.
Oral Transliteration—the transliterator mouths words clearly, so that people who are D/HOH and skilled in speechreading can understand what is being said by watching the transliterator's face, gestures, body language, and lips. Oral transliterators may choose to rephrase a message with words that are more visible on the lips when possible. They may also "voice" for individuals who are D/HOH (Registry of Interpreters for the Deaf, 2000).
Cued Speech Transliteration—the transliterator uses handshapes and movements in different locations near the mouth to depict sounds used in spoken language. Cued speech is generally used to support speechreading by providing a visual representation for the sounds in a language. However, it is not a form of sign language (National Cued Speech Association, 2006).
Sign Transliteration—the transliterator uses signs in the word order of the target spoken language (e.g., signed English) to convey the spoken message for people who are D/HOH who do not use a formal sign language (e.g., ASL).
Prepared Translation—the translator prepares the written version of a document, such as a letter or report, in advance. Enough time must be allowed based on the complexity of the task. A reminder-of-next-appointment letter will not take long. However, even a short assessment piece could take much longer, depending on the focus of the assessment. The clinician should be available to answer the translator's questions about the materials. Prepared translation may be the most common form of translation in clinical settings.
Prepared translation can be used to prepare instructions, assessment, treatment, and education materials in advance. Additionally, prepared translation may be important when the clinician is providing written reports or documentation of assessments and progress, such as IEPs or discharge reports.
Sight Translation—the translator provides a spoken or signed translation while reading a written document in a clinical encounter reserved for more immediate and spontaneous needs. This approach is not a reasonable option for informed consent or other legal documents or for formal assessment measures. Sight translation may be used when the clinician decides materials may be more appropriate to use in a clinical encounter than those which had been previously prepared. (Langdon, 2002)
Not all spoken and manually coded languages, including ASL, have a written form.
Technology offers opportunities for individuals to access interpretation, transliteration, and translation services.
- Telephone or video interpreting services offer access to off-site interpreters or transliterators. Clinicians ensure that equipment will facilitate clear connections throughout the session and optimize communication.
- Communication Access Realtime Translation (CART; or Computer Assisted Realtime) transcribes and instantaneously captions spoken language to relay messages; CART provides access to services for individuals who are D/HOH.
- Apps and online translation allow for immediate translation. However, translation is more than merely word-for-word substitutions. Caution should be used, as translation programs have not been proven to be a reliable source for quality translation.
Technology may be used to facilitate carryover and recall of strategies and techniques. Smartphones provide an opportunity to record spoken language and video signed languages to allow clients, families, and caregivers to revisit clinical recommendations.
Refusal of Services
At times, clients/patients and caregivers may refuse the assistance of an interpreter/transliterator. Clinicians consult with clients and families on the value of working with the assistance of the interpreter/transliterator in order to obtain the most accurate data. A signed release statement should be collected, in cases where such services are declined.
All vital written documentation should be translated into the client's/patient's and/or family's preferred language, and clinicians should allow sufficient time for the translator to work with documents. Not all spoken or signed languages have written forms of communication.
There may be times when the interpreter or transliterator is asked to also provide translation services. However, translation requires different skills from interpreting and transliterating. Unless the interpreter is also a translator, the clinician should not expect this. Some qualified professional interpreters do not feel comfortable doing sight translation or written translation.
Software programs frequently look for verbatim substitutions and do not offer professional, reliable results. Interpreting and translating is not word-for-word substitution and may require more or fewer words to communicate an intended message as well as complete syntactic restructuring of sentences or even full paragraphs to maintain cohesion and coherence.
The basis of an appropriate diagnosis of a communication disorder is a reliable, valid, and culturally and linguistically appropriate assessment. When conducting an assessment while collaborating with an interpreter, translator, or transliteratorm, clinicians:
- ensure that the interpreter or transliterator comprehends the importance of not cuing, prompting, or modifiying prompts in an assessment situation;
- recognize that in many cases words cannot merely be translated from English to the client's language (i.e., assessment lists for audiologic evaluations utilizing speech reception testing [SRT] are based on frequently occurring sounds in English).
Selection of appropriate assessment tools is based on the needs of the client/patient and the presenting concerns. Currently, only a limited number of tests have been translated, and an even smaller number of those assessments have been standardized for administration with the collaboration of an interpreter. If the clinician believes that assessment results are a valid and accurate representation of what the client can do, it may be appropriate to report standard scores, if the test developers provide documentation that doing so is acceptable.
Prepared or on-site translation of formal assessments that have been standardized on English-speaking populations may provide the opportunity to gather information in a structured manner. However, the clinician must critically evaluate the validity of the translated materials. For example, speech sound elicitation materials may not elicit the same sounds, and allophonic variation will differ across languages; subject omission is acceptable in Spanish but not English, so in a sentence repetition task, one should be careful how data are used. Written permission is to be obtained from the test publisher before test materials can be translated for either a clinician's individual use or for dissemination of the translated version of the test for use on a wider scale (i.e., clinical program, district, or research group). In these circumstances, it is not appropriate to report standard scores.
The intervention process and subsequent ongoing consultation allow for more prompting and feedback than assessment. Effective intervention also takes the cultural significance and relevance of goals into account. Therefore, it becomes critical for the clinician to share the overall goals of intervention sessions with the interpreter to optimize service delivery. When working with an interpreter or transliterator, the clinician
- considers the client's experience during the assessment process and collaborates with the same interpreter or transliterator from assessment through intervention as appropriate;
- explains to the interpreter/transliterator why and how various activities and exercises assist the client;
- keeps in mind that word-for-word substitution in interpretation is not always culturally relevant—for example, in familiar word pairings used in a conceptual activity, the term "peanut butter and jelly" may not be culturally relevant to the client.
Engagement of family members may facilitate a carryover of clinical objectives and strategies to a functional environment that is beneficial to the client's progress. Intervention plans may include components on how to engage the family members and how the family will support the client in the home. The clinician considers communication preferences and interpretation/transliteration/translation needs for family members and caregivers as well.
Collaboration with an interpreter, transliterator, or translator and any observations regarding the impact of this collaboration on assessment and intervention findings should be documented in reports and submissions for insurance claims. Use of translated materials should also be indicated. This documentation provides an accurate record of clinical interaction and a legal record of the effort to uphold the civil rights of the client/patient. It also provides evidence of ethical conduct, consistent with Principle of Ethics I, Rules B and C (ASHA, 2010r).
Ethical and legal considerations are foundational to appropriate services. There may be times when services meet legal requirements; however, ethical obligations may not be met. Codes of ethics/conduct are intended to provide direction and guidance, in addition to legal requirements, and cannot be substituted for legal requirements. It is critical that clinicians have a working knowledge of both the legal and ethical standards, as they pertain to working with interpreter, transliterators, and translators, to ensure appropriate clinical interactions. Relevant ethical and legal requirements focus on anti-discrimination in the provision of services and on ensuring patient privacy.
State and Federal Legislation
State and federal regulations, along with industry standards, mandate equal access to services regardless of language used. A number of state and federal regulations have implications for audiologists and SLPs collaborating with interpreters/transliterators and translators.
Rights to linguistic access to services may come from multiple pieces of legislation. "In 2008, all 50 states had at least two laws in place on language services in healthcare settings …" (Au, Taylor, & Gold, 2009, p. 2). Differences in state regulations may be reflected in a number of requirements. See ASHA's state-by-state page for a summary of state requirements
Executive Order 13166
Executive Order 13166 was signed in 1990 to provide guidance to federal agencies on the enforcement of Title VI of the Civil Rights Act of 1964 as it pertains to language spoken. It reminds agencies receiving federal funding that "health care organizations must offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner, during all hours of operation" (Youdelman, 2008, para. 6). The guidance provided applies to any health care provider or entity that receives federal funding, including
- Medicare Part A,
- federally funded clinical trials,
- Children's Health Insurance Program (CHIP),
Failure to ensure equal access may result in loss of funding.
Americans with Disabilities Act
The Americans with Disabilities Act of 1990 prohibits discrimination and ensures equal opportunity for persons with disabilities in the areas of employment, state and local government services, public accommodations, commercial facilities, and transportation. Congress has mandated the need for auxiliary aids and services, such as interpreters, transliterators, and translators, to ensure equal opportunity for individuals with disabilities (Americans with Disabilities Act, 1990). A language difference alone is not a disability. To confirm compliance, consult ADA's Checklist for General Effective Communication.
Equal Educational Opportunities Act of 1974
The Equal Educational Opportunities Act of 1974 states, "All children enrolled in public schools are entitled to equal educational opportunity without regard to race, color, sex, or national origin." No state can deny students the right to equal education by "failure by an educational agency to take 'appropriate action' to overcome language barriers that impede equal participation by its students in its instructional programs" (Equal Educational Opportunities Act, 1974).
Individuals with Disabilities Education Act (IDEA)
For school-age children, the Individuals with Disabilities Education Act (IDEA) was enacted to ensure that all children with disabilities have available to them a free and appropriate public education (FAPE) that emphasizes special education and related services designed to meet their unique needs and prepare them for further education, employment, and independent living.
IDEA states that, in the development, review, and revision of an IEP, the team must consider several factors with regards to interpreters:
"(iv) Consider the communication needs of the child, and in the case of the child who is D/HOH, consider the language and communication needs, opportunities for direct communication with peers and professionals in the child's language and communication mode, academic level, and full range of needs including opportunities for direct instruction in the child's language and communication mode, and (v) Consider whether the child requires assistive communication devices and services." IDEA Sec. 1414(d)(3)(B)
Parents and IEP teams assign or hire an educational interpreter, based on the child's mode of communication. Specifically:
"Interpreting services, as used with respect to children who are deaf or hard of hearing, includes oral transliteration services, cued language transliteration services, and sign language interpreting services." IDEA Sec. 300.34(b)(4).
Services for children who are learning English as a second language must take the language(s) of the home into consideration for both assessment and intervention. For children who receive services with an IEP under Part B (age 3–21), "When evaluating English language learner (ELL) students, it is important for speech-language pathologists (SLPs) to carefully review the child's language history to determine the language of assessment. If it is determined that the child should be evaluated in a language other than English, the SLP must use all available resources, including interpreters when necessary, to appropriately evaluate the child" (ASHA, n.d.).
For children who receive services with an Individualized Family Service Plan (IFSP) under Part C, (birth–2):
"All contact with families referred to Early Intervention must be in the family's language and mode of communication. Interpreter services may be needed for a service coordinator to communicate with parents for IFSP meetings, as well as to conduct evaluations and provide direct services. Evaluations should be conducted in the language normally used by the child. Clinicians assess the developmental appropriateness of language(s) used across different speaking environments to consider the child's total language system, in particular for a child who uses more than one language. When interpreter services for the deaf are linked directly to a specific child, these services can be authorized as part of that child's IFSP. Services are also to be relevant and culturally competent."
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides national standards to protect the privacy of personal health information. Some regulations include provisions related to service providers working with interpreters/transliterators and translators.
HIPAA allows covered health care providers to share a patient's health information with an interpreter without the patient's written authorization under the following circumstances.
- A health care provider may share information with an interpreter (e.g., a bilingual employee, a contract interpreter on staff, or a volunteer) who works for the provider.
- A health care provider may share information with an interpreter who is acting on its behalf (but is not a member of the provider's workforce), if the health care provider has a written contract or other agreement with the interpreter that meets HIPAA's business associate contract requirements.
- A health care provider may share information with an interpreter who is the patient's family member, friend, or other person identified by the patient as his or her interpreter, if the patient agrees, or does not object, or the health care provider determines, using his or her professional judgment, that the patient does not object.
Health Care and Organization Standards
The Joint Commission accredits and certifies health care organizations and programs in the United States. Patient-centered communication standards for hospitals are published in the Comprehensive Accreditation Manual for Hospitals (CAMH). The standards address issues such as qualifications for language interpreters and translators, identifying and addressing patient communication needs, collecting patient race and ethnicity data, patient access to a support individual, and nondiscrimination in care.
National CLAS Standards
The National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care (2000; the National CLAS Standards) are intended to advance health equity, improve quality, and help eliminate health care disparities by providing a blueprint for individuals and health care organizations to implement culturally and linguistically appropriate services. Although these guidelines are not federal law, they are recommended by the U.S. Department of Health and Human Services, Office of Minority Health. With regards to communications and language assistance, the CLAS standards seek to
- offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services;
- clearly inform all individuals of the availability of language assistance services in their preferred language, verbally and in writing;
- ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided;
- provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area.
ASHA's Code of Ethics provides the fundamentals of ethical conduct. Principles and Rules of ethics are specific statements of minimally acceptable professional conduct or of prohibitions and are applicable to all individuals (ASHA, 2010r). "When a professional is not proficient in the language used by the client and family, a suitable interpreter should be used. The use of interpreters and others who are proficient in the language of the persons served does not negate the ultimate responsibility of the professional in diagnosing and/or treating the individual" (ASHA, 2013, Discussion section, para. 4).
Several provisions within the Code apply to working with individuals who use a language other than spoken English, including:
Principle of Ethics I, Rules A, B, C, and E
Principle of Ethics II, Rule D
Periodically, the Board of Ethics develops Issues in Ethics Statements when further clarification and guidance are needed to assist in ethical service delivery. The Cultural and Linguistic Competence Issues in Ethics Statement specifically addresses the use of interpreters for the provision of services.
Case studies may serve to illustrate the complex decision-making process, as clinicians strive to provide the most appropriate services to individuals who do not use spoken English in the home.
Case Study 1:
Rosita is 3 years, 8 months old. She came to the United States from Mexico 6 months ago with her parents and 1-year-old brother. Spanish is the language used at home. Five months ago, she enrolled in a Head Start preschool where only a few staff members speak Spanish. Many of the students also are native Spanish speakers. Three months after Rosita began preschool, her teacher referred her for a speech and language assessment. This is the first year that the SLP, who speaks only English, is providing services at this preschool. The SLP recently completed her clinical fellowship at a neighborhood school, and her mentor has moved out of state. The preschool director, also a monolingual English speaker, spent most of his long career at an elementary school where most students spoke only English. The SLP knows that she should not proceed without an interpreter. The school uses the teaching assistant, whose son attends the preschool, to assist with as-needed interpreting. The assistant is not a trained interpreter and is not comfortable with her own English skills. The SLP has taken her concerns to the director who, although sympathetic to the situation, is insistent that the SLP complete the evaluation.
The administrators of Head Start programs are legally responsible for ensuring the appropriate provision of services per Title VI of the Civil Rights Act of 1964. Given that the SLP is monolingual, adherence to the law would call for working with the assistance of an interpreter. The law does not specify the training and/or qualifications of the interpreter. ASHA's Principle of Ethics I, Rule B. states that "individuals shall use every resource, including referral when appropriate, to ensure that high-quality service is provided." In order to ensure that the SLP is meeting this requirement, the SLP may do two things: seek out a trained interpreter or provide training to the bilingual assistant to ensure high-quality services.
(as adapted from Chabon, Brown, Gildersleeve-Neumann, 2010)
Case Study 2
A clinician's supervisor asks him to evaluate a Cantonese-speaking 7-year-old. Her family came from China. No Cantonese-speaking SLP is available in the district, so the clinician evaluates her through an interpreter. This interpreter knows the dialect spoken by the child and understands the purpose of a speech-language evaluation and her role in the evaluation. The clinician knows of no standardized speech-language tests in Cantonese, and he knows it is inappropriate to report scores on translated tests. He has kept up to date on all related research, and his evaluation is consistent with current preferred practice guidelines for the assessment of bilingual/bicultural children.
A few days after the clinician submits his evaluation, he receives a phone call. His district has rejected his evaluation, because test scores have not been not reported. He explains that translated tests are invalid, because they do not take into account differences between the two languages. He also explains that the assessment procedures he followed provide an appropriate assessment of the child's communication skills.
His district supervisor, however, reminds him that up until this point he and every other SLP in the district provided test scores. These scores, she explains, were an easy way to see a child's level of performance to determine eligibility for services. So, he must go back, retest the child using a translated test, and report those test scores.
The ethical dilemma: Does the clinician go back with his interpreter, have her translate the tests, and then determine eligibility based upon the child's scores?
According to IDEA, there is a need to demonstrate academic impact and the absence or presence of a disability. A number of different measures may be used. There are no legal requirements that standard scores must be used to qualify an individual to receive services.
Principle of Ethics II indicates that Individuals shall honor their responsibility to achieve and maintain the highest level of professional competence and performance. It would not be honoring this responsibility to knowingly use standard scores from a translated version of an assessment that has not been validated on a population representative of the individual tested (as adapted from Crowley, 2004).
Case Study 3
An audiologist who works in a hospital is working with an individual who utilizes cued speech to communicate. The audiologist knows that cued speech is the preferred communication system used by the client, but does not have any information about how the individual best understands or uses written language. The audiologist does have some written reports to provide to the patient about the assessment results. The audiologist provides the patient with a written copy of the report without any additional support, because cued speech is not a language in itself and is based on spoken English.
Legally, all materials must be presented to the patient in the preferred language. In addition to legal requirements, the Joint Commission requires that patient intake forms request preferred language. Signed languages and manual communication systems do not have a written language component. English is often the presumed form of preferred written language; however, it may not be. It may be necessary to supplement written documentation with visual translations in order to ensure comprehension. To ensure the best mode of communication, the preferred written language should be requested.
Case Study 4
A child who speaks Russian in the home exclusively is referred to an SLP. An interpreter was provided for the assessment, and it was determined that the child has a language disorder. The school administration and teachers want the SLP to provide intervention services in English only, as that is the language of the school. The SLP has concerns that this will not be sufficient to address the child's needs. What is the least unethical thing to do moving forward?
IDEA states that the language of intervention should be the language most likely to yield the best results. Although English is the langauge of the school in most cases, the language disorders of children who do not speak English can best be remediated in a language that they are familiar with. Executive Order 13166 stipulates that agencies receiving public funding provide equal access to services regardless of language spoken. It is important that the SLP advocates for the most appropriate resources to work with that child.