3.1.1. Communicating on Unequal Terms

Though a few positive aspects of interpreter-mediated communication were highlighted among nurses and doctors, such as being provided more reflection time between speaking turns (Group 5, MD2) and being forced to keep communication more concise (Group 2, MD2), nurses and doctors seemed to share the experience of incomplete, broken communication. As a doctor puts it: “Communication is one of our tools, but it gets completely disrupted when it goes through an interpreter, so it’s very difficult to have a communication that you’re happy with” (Group 2, MD1).

As demonstrated, compared to the communication with Danish-speaking patients, nurses describe interpreter-mediated communication as not only becoming more simplified but almost mechanical, like a robot. In contrast, interpreters describe it as “optimal (…) when the clinician speaks in shorter (completed) units” (PI1) and that a (linguistic) “symbiosis” can even develop between the clinician and interpreter. When both parties are trained in interpreter-mediated conversations, it can almost come to resemble “simultaneous interpreting” (PI1); a potential also indicated by a doctor, who recalled a collaboration with a blind patient and a sign-language interpreter where the conversation flowed more naturally, similar to language-concordant communication.

In addition to constantly running behind because “appointments are never on time” as described by a nurse (Group 3, RN4), all three professional groups described a shared experience of communicating within a context characterized by a lack of knowledge. This is illustrated in Table 2.

As the first two examples show, doctors and nurses described feeling uncertain when having no idea what is communicated between patients and interpreters, and in more cases, the terms of communication were even juxtaposed to those of patients with physical disabilities, including hearing or visual impairments. As one of the doctors in Example 1 puts it, she expects some kind of collaborative “game” but describes how the (nonverbal) knowledge she normally senses during a conversation gets lost in the process of interpretation. In continuation of this, decoding patients’ body language, including facial expressions, was described as particularly difficult, and in more cases, this was partly ascribed to different cultural norms being at play.

Whereas both nurses and doctors emphasized the need for more cultural knowledge, body language was assigned a pivotal role, particularly when communicating with patients in the absence of interpreters. As exemplified in Example 2, more nurses described how being unable to communicate verbally with patients during treatment sessions makes other senses “come into play” (the visual). Notably, however, as highlighted in the example, such difficult terms of communication can lead to feelings of being completely “left out” (of the game). The interpreters described a similar experience of groping in the dark during communication, however, as a consequence of not being briefed about patients beforehand. This is illustrated in Example 3 where the terms of communication are directly compared to being blind.

In fact, across all three professional groups, having prior knowledge about the patient was emphasized as highly significant. Thus, the consequences of racing against time were underscored when the discussion turned to the use of family members as interpreters. While it was noted that, in principle, family members ought not to interpret, it was described how involving them is sometimes considered more effective, as they already know the patient’s history (Group 5, MD3). Along the same lines of not having to spend time on briefing a professional interpreter, another nurse described how not utilizing the full interpreting time allotted can sometimes be the easier choice. As she said: “Then you can just win an extra 15 min there” (Group 4, RN1).

3.1.2. Lack of Agreed Roles and Shared Rules

While all three professional groups agreed that organizational frameworks challenge an already fundamentally difficult communication process, several participants emphasized that successful communication also relies on each other’s collaborative communication skills. When discussions specifically focused on video interpreting, however, differing views on the roles of interpreters appeared as an additional challenge.

While some doctors and nurses described an increased sense of distance with video interpreting, making it even harder to decode body language, others preferred the format for its efficiency. Interpreters themselves also described video interpreting as effective but, more importantly, emphasized that the physical distance from patients becomes crucial when conveying life-changing messages:

As the quote underlines, the interpreters describe themselves as both communicative channels and individuals with feelings, and the description highlights the often contrasting and emotional nature of interpreters’ tasks. However, as Table 3 below reveals, there is disagreement about this role. Specifically, the interviews reveal a debate over whether interpreters should act as robotic translators or engage as human beings.

As Example 1 shows, the interpreters perceive their role as encompassing not only language translation but also cultural mediation and providing patients’ safety. At the same time, they are aware that doctors and nurses may not always agree with this. This is illustrated by the recall of encounters with healthcare professionals who, “in order to reach their goals,” expect interpreters to perform robotic translations without interfering. Important in this context, the interpreters both emphasized and acknowledged the responsibility of nurses and doctors to “control the conversation and set the framework” (PI2). Yet, at the same time, the interpreters described how they sometimes find themselves needing to “moderate the tone” when, for instance, doctors show visible signs of “being pressed for time” (PI1) or having to interfere to ensure accurate understanding. Importantly, interfering can be perceived as running a risk: “If I feel that these two people are talking completely past each other […] then I ask very politely, of course, to interfere a little bit […]. The most important thing is that everything ends well, even if I might get a knock on the head” (PI1). Nonetheless, this willingness to interfere seemed driven by the interpreters’ goal of ensuring that “the patient receives the best possible quality of care” (PI1).

While some doctors described the interpreter as a “tool” or “machine” that should not interfere, this view was not shared by all doctors as also reflected in the dialog between two doctors in Example 2. Similarly, more doctors acknowledged the complexity of interpreters’ tasks. Nevertheless, Example 2 demonstrates how not only time pressure but also differing perceptions of interpreters’ roles directly impact on whether or not interpreters are briefed before a conversation. In fact, differing perceptions prove to have a decisive impact on whether an interpreter is present at all as underscored by a nurse who recounted a discussion with a doctor during a patient consultation: “The doctor said, ‘We don’t need an interpreter when she’s just coming in for treatment; it only takes 15 min’” (Group 3, RN1).

In continuation of this, Example 3 in Table 3 illustrates how many nurses acknowledge interpreters’ often contrasting and emotional tasks, ranging from discussing a foot wart to delivering a terminal diagnosis. Put differently, the example shows recognition of interpreters as both human beings and crucial communicative and relational links between patients and health professionals. Additionally, the example underlines the differing views on this role, highlighted when the nurse recalls a doctor who insisted that interpreters should be considered “machines.” Meanwhile, the recollection of a patient and interpreter nearly spending the first quarter of an hour getting to know each other not only indicates a debate about whether interpreters should build relationships with patients before medical conversations but also highlights a complex relationship between time constraints and the need to prioritize.

To further illustrate the contrasting perspectives, the following question posed by a nurse in another group revealed an underlying understanding of direct translation being integral to the interpreter’s professional responsibilities: “The interpreter – what should she lean on? culture or her professional duties? I think that must be quite difficult, actually” (Group 4, RN4). In other words, while the nurse acknowledges interpreters’ often complex tasks, the quote clearly contrasts with how interpreters view their own role as outlined in the first example in Table 3; a role based on the belief that language and culture “cannot be separated.”

Aside from revealing a lack of agreement on the roles of interpreters, the interviews also revealed a lack of fundamental shared rules as a basis for communication. To illustrate, a nurse from one team described a culture where “there is an interpreter for everything” (Group 4, RN2), while a nurse from another team wondered how a culture had developed where “it should only be when it’s necessary” (Group 1, RN1). In accordance with this, some doctors did not consider time or cost when using interpreters, while another doctor wished it were “more legitimate to spend the time on interpreting” (Group 2, MD1), indicating more underlying disagreements. Consequently, both doctors and nurses explicitly requested clearer rules, while nurses across all three groups agreed that they could be “better at making agendas with doctors” (Group 1, RN2). To achieve what appeared to be the nurses’ goal of “getting all the way around the patient” (Group 1, RN2), a nurse suggested that they should “put all cards on the table” at the start of interpreter-mediated conversations (Group 1, RN4). According to nurses, this approach would facilitate better collaboration based on aligned expectations, ensuring that everyone has the opportunity to communicate effectively and that all parties’ communicative needs are met, including the patient’s.

The interpreters similarly formulated a suggestion for improving communication within the context of playing a game when they extended a direct invitation to consider interpreters as colleagues rather than competitors: “You’re not an opponent; you’re not a competitor. You’re a colleague” (PI1), subject to the same confidentiality obligation.

3.1.3. Missing Opportunities as an Invisible Consequence

While interpreters highlighted the importance of adaptability in communication to meet various situations and needs, their discussions also revealed differing opportunities for interprofessional collaboration. While one interpreter (PI2) described good options for extending interpreting time when needed, another interpreter described a contrasting experience, explaining that this often depends on the linguistic demand for the interpreting language, frequently leaving interpreters unable to extend: “In my situation (interpreting in a language with fewer available interpreters), we’re quite vulnerable when it comes to time. If I have another appointment right after, there’s not really much to be done […]. So yes, there is an opportunity for extensions if someone is available” (PI3).

Furthermore, when discussing shared decision-making, the first example in Table 4 below reveals an expectation of cultural norms potentially being at play again but, more importantly, the example demonstrates how language barriers literally make choices disappear during decision-making processes.

As the final part of Example 1 demonstrates, the discussion between two doctors reaches a shared understanding that what health professionals consider “need-to-know” information may not always align with patients’ needs, potentially resulting in missing opportunities from the patient’s perspective. In continuation of this, language barriers not only make treatment options disappear. According to both doctors and nurses, language barriers make care disappear. While a doctor formulated how, “there is simply a lack of care being translated” (Group 2, MD3), a nurse bluntly concluded “They don’t get the same quality as the others [Danish-speaking patients]. They get their treatment” (Group 1, RN2).

Among nurses, being able to provide care was emphasized as highly significant, articulated by one nurse as follows: “Seeing the patient first is almost engraved in our DNA, and maybe that’s why it feels so incomplete when you have a foreign patient that you can’t communicate with properly, either due to time or other circumstances” (Group 4, RN2). As exemplified in Example 2 in Table 4, the nurses’ descriptions revealed a particular experience of having “no time for care” and no opportunity to prevent the disease from entering the hospital first, as described by one of the nurses. Example 2 particularly demonstrates how nurses refrain from asking certain questions because they feel unable to “pick up” the patients afterward.

Notably, as the example also demonstrates, nurses can be left with the feeling that they could have “done better.” However, in many cases, it seems that nurses are left without any actual opportunity to provide proper care—not due to strict time constraints, but because of no verbal communication being enabled at all. To exemplify, a nurse from another group described how being the one “who takes over in the treatment room” is not only “difficult” but also “horrible” when no interpreter follows (Group 3, RN5). The nurse describes how she consequently shuts down emotionally: “You’re the one who has to hand out tablets, and you’re the one who has to be sure they can react to side effects, and you’re the one who has to pick them up if they actually have something on their mind… and I just shut down because it’s too difficult” (Group 3, RN5). Thus, nurses’ experiences of responsibility, combined with a lack of real ability to act, ultimately affect how they interact with patients. Accordingly, a nurse not only highlighted the tangible consequences of feeling powerless, but how communication inequality can lead to both prejudiced thoughts like, “Why the hell can’t you just speak Danish” and burnout: “You actually get a bit burnt out” (Group 4, RN3).

In continuation of this, the interviews revealed that language barriers not only make choices—and care—disappear. They also make nurses literally disappear. As one nurse puts it: “When the interpreter signs off, that’s it. And then you do that thing where you sort of disappear” (Group 3, RN1). Another nurse nuanced this perspective when she elaborated on what happens when communication becomes so difficult that the only choice, she feels she has left, is not to be there. In other words, the choice is not to participate in the game at all.