A total of 15 participants (Hospital A (n = 6); Hospital B (n = 9)) were recruited for the study: managers (n = 4, all doctors), doctors (n = 2), nurses (n = 4), and medical secretaries (n = 5). The section below describes how the data align with the COM-B components and the TDF domains. The results are summarised in Fig. 2.
Individual capabilities
Across the sites, participants identified individual capabilities, such as knowledge of interpretation services and the skills to adequately order and use the services, to be important determinants of the use of interpretation services.
Knowledge
The participants reported that they endorsed the rationale of using interpretation services as a means to the efforts of giving all patients safe and high-quality care. The use of interpreters was regarded as a necessity in many situations.
Patient safety is vital and poor communication often leads to poor treatment. To be able to provide the best quality treatment, the different people must understand each other. (Medical secretary 4B)
We would not be able to do what we need to do without interpreters, they are absolutely crucial. (Manager 2B).
Skills
The influences on the ordering and use of interpretation services included the skills to assess the needs to use interpreters.
An interpreter should be used when it is clear that the patient doesn’t understand what is being said. (Doctor 2A).
Further, the participants believed that it was essential to have skills to determine which type of interpretation service they should order: It depends on (…) what kind of interpreter is needed (Doctor 1A). Four different factors were important for assessment: situation urgency, situation complexity, the need for rich communication, and the need to protect the patient’s integrity and confidentiality. For example, the Hospital B participants reported that they preferred in-person to telephonic interpretation in situations that were expected to be complex in terms of their severity or the number of people involved, and further, in situations characterised by the need to address particular concerns of their patients. Telephonic interpretation was used only when there was an emergency or a check-up.
We definitely use personal interpreters the most. It (the choice) relates to how the conversation conveys with the body language - what you read between the lines. (Manager 1B).
Some of the Hospital A participants reported that video interpretation was preferred to in-person interpretation in situations in which clinical staff decided that there was a need for additional protection of the patients’ confidentiality. Video-interpretation provided a wider range of opportunities to use interpretation services that best suited the situation, because the staff could use the option to switch off the screen, thus having only the audio.
If you have a patient that is a victim of violence, then it is better to use the video interpretation because it is more anonymous and has only the (individual’s) voice. (Doctor 1A).
However, sometimes in-person interpretation was favoured because video interpretation was perceived as too detached to the situation.
You lose personal contact. (Nurse 2A).
In sensitive situations (…) a personal interpreter understands the situation and does not ask unnecessary questions. (Doctor 1A).
Other types of skills were also viewed as important to decision-making about the use of interpretation services. For example, technical skills were identified as a determinant of the use of video interpretation services among the Hospital A participants. Some reported that they were less familiar with and capable of using the technology and regarded this lack of skill to be a barrier to its use.
Further, across sites, the participants discussed how a lack of the necessary interpersonal skills to handle difficult situations with unprofessional interpreters or situations in which the patient or the patient’s family was unwilling to use an interpreter influenced the use of one. One participant explained how she and her colleagues used argumentative techniques to persuade the patient and felt that this could be challenging:
There are situations when the patient doesn’t want an interpreter. In order to provide right care, we argue that the doctor needs an interpreter present” (Medical secretary 2B).
Individual motivation
Across the sites, the participants seemed highly motivated to use professional interpretation services due to their beliefs about the favourable consequences of doing so; however, at the same time, they reported other factors (including role conflicts and mistrust in interpreters) that had a negative influence on decisions about interpreter use.
Beliefs about consequences
A range of outcomes was perceived to be gained from using interpretation services, including the avoidance of misunderstandings, reduced costs related to shorter hospital stays and less risk of readmission, all of which further motivated the service use.
The quality of care and treatment gets better (…) because we avoid misunderstandings. The patient gets important information and we can reduce the length of stays (…) Using an interpreter makes our work easier (Nurse 1B).
Professional role and identity
In some situations, the patient or the patient’s family did not want an interpreter present. The participants perceived such situations as a conflict between patient autonomy and professional norms of providing safe and beneficial treatment. The medical staff felt that their role as providers responsible for appropriate treatment was challenged and wanted organisational support to back up their decisions about having an interpreter present. This was a situation that was well known to the managers, who reported that such support was given. One of them said the following:
The doctor can override the patient and say, we have to have an interpreter present. (Manager 2B).
Emotions
Some participants at both sites voiced concerns about the quality of in-person interpreters. They spoke about experiences with “unprofessional” interpreters who were believed to lack language skills, did not arrive on time and interfered in the conversation. For example, some participants said that they felt uncomfortable because they did not trust the interpreters to be adequately knowledgeable regarding medicine and medical terminology. They also talked about situations in which the interpreter discussed topics that were irrelevant to the medical situation or did not seem to interpret all that was said, which again resulted in a lack of trust. In this way, the perceived lack of interpreter capabilities influenced participants’ motivation to use their services.
Not all interpreters are certified in the specific medical terminology that is needed. I cannot be sure what is being said and I don’t know the quality of the interpretation (…) You don’t know the interpreter’s intention, you have to trust that they will be professional and will want to help. (Doctor 1A).
However, compared to Hospital B, the motivation to use interpretation services seemed greater among Hospital A participants and seemed to evoke more positive emotions. The introduction of video interpretation was perceived as motivating.
Now the system is working well. It is good always to have the opportunity to use the video interpretation. We are very satisfied. (Nurse 3A).
Organisational and social opportunities
A range of organisational and social opportunities was perceived as important determinants of the use of interpretation services, including interpreter availability, time, money, and the preferences of the patient and the patient’s family.
Organisational resources
While monetary costs did not generate substantial discussions among the participants, they were clearly well aware of budgetary constraints. The costs per appointment were perceived as “high”, and the participants reported that the service should be used efficiently.
We assess the situation and only order an interpreter if we really have to. (Medical secretary 1B).
The video interpretation is charged per 15 min, thus being well prepared and organised is essential. (Doctor 1A).
However, the participants seemed to consider budget constraints as being “soft”.
Managers are concerned about the costs (…) but they also want the patient and the doctor to understand each other. (Nurse 1B).
If we need it (the interpretation service), we use it. (Nurse 3A).
The managers, in contrast, reported that the costs of interpretation services should be assessed relative to the risk of longer hospital stays and readmissions:
It is an expensive service, but if you risk the patient having to come in again, it also costs money. I will not say, No. Let us skip the interpreter because it’ s so expensive”. (Manager 2B).
Across the sites, the participants had undergone experiences with personal interpreters who had not always been available because of the limited opening hours of the services, long travel distances, and delays. Further, there was sometimes a need for the interpretation of less-used languages, and it was difficult to find someone to interpret these. In addition, some interpreters were difficult to reach:
The interpreters do not always pick up the phone or (they) cannot come in. (Nurse 3A).
Some participants said that ordering interpretation services was sometimes time-consuming, and creating extra work. Further, some participants found that it could be difficult to plan the need for interpretation services.
It can be quite an effort to get an interpreter (…) We usually need the interpreter right away, but the appointment needs to be scheduled in advance. (Nurse 1B).
Across the sites, the participants reported that they were reluctant to order professional interpreters for routine clinical interactions and instead tried to “get by” or “manage” without an interpreter or with the help of family, friends or bilingual staff. They further reported that although they knew that family members should not be used as interpreters, this was found to be the only alternative in emergency situations.
Often, the adults don’t know Norwegian, but their children do and then, the children help to explain. (Medical secretary 3B).
Yes, especially in the emergency room, it’s important that family or a friend is with the patient and can help interpret. (Nurse 3A).
However, the use of ad hoc interpreters was commonly described as “something that should not happen”. Several reasons were cited, including considerations of patient confidentiality, emotional ties, and lack of knowledge of medical terminology, as well as the negative consequences of these. One participants stated,
When a family member interprets information, it’s often lost because the relative only interpret parts of the information. (Manager 2B).
The availability of professional interpreters was however, perceived to have improved at Hospital A when video interpretation was introduced. The video interpretation service was accessible at all hours, both male and female interpreters were available, and the service offered a wide range of languages. The use of video interpretation was considered to lessen the practical work of ordering a personal interpreter. Further, the nurses considered it less “emotionally draining” to order a video interpreter because they were less dependent on one person’s availability and goodwill:
It is a lot easier because we do not have to find somebody, call them and beg them to come in and help us. (Nurse 3A).
Social influences
Furthermore, social opportunities were identified across sites as a factor affecting the ordering and use of interpretation services. According to the participants, in some cases, the patient’s and/or the patient’s family preferences constrained the opportunity to use interpreters. This was a factor in terms of preferences for privacy and confidentiality.
Some patients do not want an interpreter present; because they are afraid, it might be someone from their own community. (Manager 2B).