116
Original Research OPEN ACCESS Integrating Health Navigation and Interpreting Services for Patients with Limited English Proficiency – Views of Pacific Navigators
Jo HILDER, Ben GRAY, Maria STUBBE
ABSTRACT
Introduction: Pacific people and other communities with culturally and linguistically diverse backgrounds (CALD) face barriers to receiving good healthcare. Community health workers and health navigator roles have developed in recent years internationally and in New Zealand to address these barriers. Interpreters are also increasingly used to address language barriers. The interface between navigator and interpreter roles is explored in this study through the experiences and views of Pacific health navigators.
Methods: Qualitative interviews and focus groups were conducted with managers and staff of two health organisations catering for Pacific people: a community-based Pacific Navigation Service and a hospital based Pacific Health Unit. Interviews and focus groups were recorded, transcribed and analysed using a framework approach.
Findings: Participants identified a wide range of barriers to healthcare, and the various skills required in a navigator team. Navigators also perform a wide range of roles, something that can lead to difficulties in managing role boundaries. Overcoming language barriers is a major part of the navigator role, but their approach differs from that of professional interpreters. The concept of an explicitly combined navigator/interpreter role was supported, acknowledging the need for specific training in interpreting for navigators.
Conclusion: Pacific people working in health navigation roles (or similar) support in principle the idea of a combined health navigator/interpreter role, based on providing interpreter training to health navigators. Perceived benefits include greater role clarity if interpreting is an official part of the role, and greater continuity of care with a single person in both roles. A combined health navigator/interpreter role would be likely to lead to better health outcomes for Pacific people, and other cultural groups.
Key words: Communication Barriers, Community Health Workers, Delivery of Health Care; New Zealand
INTRODUCTION
New Zealand’s increasingly diverse population means that many patients come from linguistic and cultural backgrounds that make it more difficult for them to effectively access the New Zealand health system. The clinical risks of inadequate medical communication are well- known.1,2 For limited English proficient (LEP) patients, this can result from both linguistic and cultural reasons including simple lack of knowledge about our health system.
There are many barriers to patients from culturally and linguistically diverse backgrounds (CALD) receiving good health care. These relate both to the design of the health system (for example, complexity, and opening hours and
Corresponding author: Jo Hilder [email protected] Department of Primary Health Care & General Practice University of Otago, Wellington, New Zealand. 6242 Received: 01.10.2018 Published: 30.03.2019 Citation: Hilder J, et al Integrating Health Navigation and Interpreting Services for Patients with Limited English Proficiency – Views of Pacific Navigators. Pacific Health Dialog 2019; 21(3): 116-127. DOI: 10.26635/phd.2019.602 Copyright: © 2019 Hilder J, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
117 locations of facilities) and to characteristics of the
communities (for example, language and cultural features).3-10
Community health workers who are members of the CALD communities they serve have been established in a number of countries and have been effective in helping to overcome barriers to health care.11 Internationally, health navigators are known by a great variety of terms for many similar roles.12 Key attributes of these types of workers are the high levels of trust patients have in them13-15 and the wide range of tasks that they perform. A more detailed literature review may be found in the full report on the current study.12 Another approach to reducing barriers to health care for CALD communities is through professional interpreters. An expanded role for interpreters to include health navigation is starting to be developed in various countries (e.g.
Belgium, Italy, Ireland, Spain, Canada, USA16 and Romania17), with a range of different titles. This expanded role provides professional interpreting as well as help for patients to understand the health system and for health providers to better understand their patients' backgrounds and belief systems.18
In New Zealand, many hospitals and some primary health providers utilise the services of interpreters, in addition to other kinds of support services for Māori and Pacific patients akin to that of health navigators. Our recent research on interpreting in primary care found that patients and their health professionals often wanted help with practical matters that lie outside the narrow bounds of the prescribed professional interpreting role19; this is the kind of assistance that health navigators may provide.20
Patient navigation services in New Zealand (although not necessarily under that name) have historically focussed on Māori and Pacific groups.
More recently, navigation services for the general population have been developed within specific areas of health care such as cancer and mental health. Anecdotally, this ad hoc mode of development has resulted in unclear and inconsistent role definitions (for example, navigators engaging in interpreting without specific training), and limited training (if any) in patient navigation as such.
Within Wellington, Pacific navigation services are the only ones targeting whole communities with people who may have limited English proficiency (LEP), although other clinically focussed navigation services may also serve individuals with LEP. Like many New Zealand hospitals, Wellington Hospital has a Pacific Health Unit (established around 2003), which focuses on
both the reduction of DNA (Did Not Attend) outpatient rates and on inpatient services.
Referral to the inpatient service is through patients ticking a box on a form to consent to the service being contacted by hospital staff, or via self-referral.12
A more recent development in primary health care in Wellington is the Pacific Navigation Service (developed around 2012), a community- based service established to provide a clearer referral pathway from the Pacific Health Unit (PHU) of the hospital for patients on discharge.
Clients are referred to this service by general practitioners, non-governmental organisations, hospital services and self-referrals.12
Little research has been conducted on the interface between the roles of health navigators and interpreters for CALD communities.16,21 Few navigation services for CALD communities explicitly include interpreting as part of the job description, with Seattle Children’s Hospital a notable exception.22 This paper explores the experiences of Pacific health navigators in the Wellington region, and how they view their roles and this interface. It draws on a larger study for which a narrative review of the international literature was also conducted.12
METHOD
The study was a qualitative one, comprising interviews with managers and staff of two health organisations catering for Pacific people.
Data collection
We conducted individual or group interviews with 13 participants in total: the two managers and six of the staff of the community-based Pacific Navigation Service (PNS) who were able to attend the meeting, and the manager and three core staff of the Pacific Health Unit (PHU) of Wellington Hospital, and an independent contractor involved in the process to establish the navigation service. Managers and staff from each organisation were interviewed separately to facilitate free and frank discussion, and were interviewed in groups where possible. The staff of both services are referred to as navigators within this paper, although this is not the formal title used in the PHU.
The semi-structured interviews elicited participants’ views and experiences regarding perceived barriers to Pacific patients obtaining quality health care, and the roles of navigators in addressing these barriers, including how these roles intersect with those of other support services for this population including interpreting services. Their views on the current
118 services for LEP patients and how these might be
improved were also sought. (See Appendix for the interview schedule).
Data Analysis
All interviews were transcribed verbatim. We conducted a framework analysis of the interview transcripts, with additional analysis of emergent themes.
Illustrative quotations were checked by participants for accuracy.
RESULTS
Participant characteristics
All but one of the staff interviewed were female.
All but one of the management staff were of Pacific background: Samoan, Tongan or Cook Island Māori. Three participants from the community navigation service and one from the hospital service were registered nurses. One from the hospital service was a social worker. The remainder were community support workers with various health promotion backgrounds with Pacific, new migrants and refugees, or had experience in the police or the court system.
Barriers to healthcare
Participants identified a range of barriers, as shown in Table 1.
Whilst a number of these related to population characteristics, there was quite strong feeling that the major barrier to Pacific people obtaining good health care was to do with the health system.
In my experience, I just have to say about 95% or even 99%, it’s the services that have failed the people. It’s never the patient’s fault. (P5)
Table 1: Barriers to Healthcare for Pacific People HEALTH SYSTEM FACTORS
Structural - complexity of systems, inflexibility, insensitivity (e.g. inconvenient appointment times or opening hours ill-suited to working conditions/hours of Pacific people)
Some of the things, it’s very minute and could be changed just by understanding what the person’s circumstances are. (P3)
Perceived lack of respect by some health professionals
I think it’s the attitude of the workers as well. … it’s how they approach them, it’s how they treat them when they come in for those things as well.
(P10)
Inadequate communication
They reschedule without telling them…..They’re not communicating. (P4)
Communication style - need for more summarising, simple language and visual aids
sometimes I would ask … ‘Can you get some diagrams?’ … because we’re visual. Pacific people are very visual. (P3)
POPULATION-SPECIFIC FACTORS
Health Literacy (including a lack of awareness of the need for healthcare, difficulty understanding complicated health treatments or the New Zealand health system)
They’ve got no idea why they need the healthcare - would be the biggest barrier. (P1)
Language - lack of English proficiency, or of medical terms for those with good English language skills
I think just the interpretation from your lips to my ears … what I think I’m telling you or talking to you or showing or explaining to you isn’t always interpreted the same way in the ears that are hearing it. (P1)
Culture Pride
Our people … have humongous pride. They don't like to go and ask for things. They are very embarrassed to go and ask for help and this is why the majority of them would prefer to just plod along with what they have. (P9)
Attitudes to authority
We receive some calls around people feeling they couldn't ask their bosses for time off because they were scared they’d lose their jobs. (P12)
Collective Decision Making
For example, if a patient needs an operation or surgery and one daughter says “yes Mum’s having it” and the other son says “no she’s not having it because we can get a fa’fo or massage” … that is a real delicate situation to deal with. (P9) Previous Negative Health Experiences
we’re the in-between people to make things right between the doctor and the nurse and say “look this is why the patient doesn’t want the smear any more - it was a bad experience from last time. It may not have been you but you know, this is why and then you understand why the rest of the family are not coming in”. (P5)
Person Specification for the navigator role A wide range of skills was identified as necessary or desirable for this kind of role; these included core skills for individual staff, as well as some which may be distributed across a team.
119 Table 2: Skills or Attributes for a Health
Navigator
Language/Communication Skills - including skills in a range of Pacific languages, as well as general communication skills to deal with sensitive issues and to be able to communicate flexibly.
We talk to the staff [about] being able to say something five different ways and that at least one of those ways is bound to connect. (P8) Cultural Knowledge – including cultural sensitivity
It’s not just about speaking the language. It’s about understanding our fa’a Samoa ways. (P9) At Least Basic Knowledge of Health and Health Care
There should be qualification and understanding, not that we’re going to go nursing, but understanding the different diseases and what it is … understanding that had empowered me to actually face my community, make sure that they understand. (P3)
Personal Networks/Community Experience – both personal and professional
You know them well, you’ve got the links into the community, you’ve got the respect from the community because you’ve been serving them for how many years, that gives you a lead way and [makes it] easier I guess. (P3)
Participants also noted the need for interaction between health knowledge and culturally appropriate communication skills:
You have to have the health knowledge to understand what’s happening and then have the context of that person to understand how to then communicate. (P8)
Personal and professional networks that are based on respect and constructive relationships were identified as important to enable navigators to access a wide range of resources and to operate effectively.
Also noted as important was the need for a range of people in a team in terms of ethnicity, skill-set, gender and age so that clients can receive care from someone similar to them who has the appropriate skills.
The Role of Pacific Health Navigators
A wide range of navigator roles was identified.
There was an emphasis on the holistic and wide- ranging nature of the role which is focussed on the best outcome for clients.
[a navigator] might actually pick up there’s a bigger family need, transport, food, you know that sort of stuff … there’s a bigger picture. (P2)
To help Pacific people get the help they need and have the best outcome for them. (P1) The range of specific roles that this group of navigators performed is shown in Table 3.
Table 3: Specific Roles of Pacific Health Navigators
Literal navigation/support
They’re navigating and holding the hand, more or less, of the person who needs to go through the health service which in itself is really complex and daunting and quite scary for people with English as a second language. (P2)
Helping to overcome language barriers
Here in the unit we only deal with inpatients and their families that have language barriers that … it’s preventing them from better health here in the hospital. (P9)
Education
The good thing about it is you’re educating the person and when they go into consult with the doctor and you’re not there, they know exactly what they want or the problem, if the doctor actually asks ‘you got a problem with you kidneys?’
‘oh yeah I remember that word’. (P3) Advocate
The navigator can … actually act as a voice. (P2) Mediation
And my role is ensure that the family understand where the medical staff is coming from and that the medical staff understand where the family’s coming from. (P9)
Liaison with other services
Part of our role is actually finding out who those people are [other health services involved with patients] and how we would actually do some joined up work together and we can do some joined up work. (P1)
Gatekeeper to the navigation service
Part of the role is actually to explain to them each what the criteria are for services and the reasons why they don’t meet that criteria. Not always an easy conversation to have. (P1)
Table 4 contains several examples of how navigators work that illustrate the type of assistance they provide.
120 Table 4: Mini narratives to illustrate the
work of navigators
Addressing DNA rates with a more informative approach
… they come to me and “we’ve been sending this few letters to this patient and we’re about to discharge from our service and can you..? … Then we have to just go to the patients first … get on the phone and say “oh what’s going on? … the letter’s been sent and you haven’t been to this appointment a few times and they’re about to cut you off from the system”. And then that’s when we found out that … they don’t understand … what’s the importance of coming here to this appointment.
Because they’re “oh I feel better and I don't think there’s anything wrong”. Then we explain it to them …“This is something that you need to follow up … so it won’t happen again down the line”. … they need to understand why they need to come and that’s when “oh yeah. I”ll come”. Because … they understand a bit more. (P11) Ensuring understanding of surgery
The other thing that I’m aware of is that going to the hospital … for a person that’s coming up for surgery is that the specialist will just go and say “well, you’re going to have heart surgery because this blah, blah, blah and your heart is not working”. Now the person sitting there, although they can speak English, doesn’t have the faintest idea of all those medical terms, so it’s up to us to actually ensure the person’s understanding. Come to grips with what’s going on with their health and what the next step is. (P3)
Negotiating with health professionals regarding care of elderly
with one of my families where the doctor insisted that this woman goes into a rest care, and the family and woman are insisting that she goes home, I had to talk to the doctor and say “look, it’s all very well from a medical perspective to put her in there, but at the end of the day from a cultural perspective, if you put her in there she’ll die. And when she dies the huge burden … will fall on her children because they haven’t … abided by the wishes of their mum”. So he had to rethink about it. So … my solution was for that is … “can we not write a letter to say them ‘our recommendation is that we want mum to go into the rest home but … you want to go home’”. Then that way … if she goes home and she dies - because they were quite aware, that if she goes home and she gets an infection, she will die. … So from a European perspective, they’re just trying to make sure that this woman is well cared for and that they are not being blamed if things go wrong, the hospital is not being blamed. But from a cultural perspective, they do also want the best care for their mum but to do it at home. … they have to make their decision, and then that’s what the doctor said “Okay, we can write a letter to say that this is our recommendation but … they’ve declined it and want to take mum home and if mum blah, blah, blah”, So the family were happy. And the medical staff were happy with that solution. (P9)
Holistic approach to improving patients’ lives
… this family, he uses the Zimmer frame and he slipped in the house, okay. So I … get to change the house so that they get the one that’s flat. And then I found out the doctors know how he is but nobody has offered him to get him a permit for the car for the disabled. So I got the disabled thing. See those things are just left if we don’t, we have to think about what we can do to make things easy for them. (P4)
Managing role boundaries
Role boundaries were felt to be an issue at both a personal, micro-level for individual navigators and at an organisational level (see Table 5). The holistic nature of the role and the potential intersections with other organisations or professionals means that staff awareness of boundaries is important. For individuals, there was acceptance of the need to sometimes go beyond their role boundaries in their focus to obtain the best client outcomes, as well as of the need for (and difficulty of) managing boundaries.
Staff appeared aware of the issue and had strategies to manage it, such as consulting their colleagues and managers for guidance.
At an organisational level, boundary issues may arise with respect to other organisations offering similar services in an environment where they may be competing for funding and clients. There were also strategies in place to manage this.
Health navigators also reported having to manage the expectations of both health professionals and clients/patients as to what their role entailed.
Table 5: Managing Role Boundaries INDIVIDUAL LEVEL
Acceptance of need to go beyond boundaries It all depends … my priority’s the patient, if something that they need, even if it’s outside of my role and I know that the patient will benefit from it, then I have to step in and try my best to do it … we’re just trying to help really and it’s natural.
(P11)
Difficulty of managing boundaries
there’s a real difficulty in separating your work self from your community self because they all serve their own communities in different ways outside of their job. (P1)
Awareness of and strategies for managing Stepping over … the boundaries and that, it would be something that I will automatically notice, if
121 that’s the case. And it’s just hard because for me, I
always respect… the clinicians and the patients in both ways... And that’s why I always ask questions and always reassure … “Is that alright for me to do this? Is that okay for me to come and explain this to? Is that alright for me to deliver your message to?” (P11)
ORGANISATIONAL LEVEL Multiple similar services
there are lots of services for lots of different ethnic communities. And we’ve always struggled sometimes to know who does what when and how.
(P1)
Competitive environment
…because a client, for providers is money, at one level…if you see someone’s got asthma and you’ve facilitated their visits and things like that then you talk to them about smoking cessation but somebody else has the smoking cessation contract... (P8)
Strategies for managing
I meet with Work & Income every month … with … Budget Advice and Housing New Zealand and then we meet with any issues that we had come across with our patients or people that we’ve dealt with. (P9)
The navigator’s role is to weave through the traffic. (P8)
MANAGING EXPECTATIONS From health professionals
We had one last week you know “Could your Pacific navigator do this?” … something to go and do … give someone some medication or something in the weekend and I said “No, no, no, no, no. We do Monday to Friday, just like you”. (P1)
I would suggest that the other professionals are quite happy to offload work to the navigator. (P8) From patients/clients
So there is expectation in the community because of the relationships, and so they’re put under a bit of pressure I think at times from their own communities as to what they can do for them.
(P1)
Providing Language Assistance
Participants noted that there was a high need for language assistance in newer immigrant communities, but that, although many Pacific people do speak English, this is also a need among all those who just feel more comfortable in their own language, especially older people. The use of professional interpreters was felt to be
‘haphazard’, despite stated policy, and it was noted that family members were still often used
by clinicians out of convenience. The factors that underlie this were acknowledged, as in the following:
It’s time consuming because you have to book it, you have to make sure the patient turns up on time, your doctor’s got to be on time to be able to do that appointment, so there’s quite a bit of coordination around that and the simplest option would be “Oh actually they’re coming with”, and that’s why family members are used all the time.
(P1)
Language assistance, in various forms, is a key part of the role of health navigators, whether in English (to explain something more fully or clearly, e.g. medication) or in a Pacific language, both in direct conversations with clients and as interpreter. This kind of assistance is not formal interpreting, however. It was felt that health professionals do not always distinguish between professional interpreters and health navigators:
When you go in as a navigator, [staff] still expect you to interpret and to understand so their perception of a navigator and interpreter is the same with them. They can’t tell the difference. (P3)
A lack of clarity was evident among the navigators themselves in the variety of comments regarding whether or not navigators should or should not be interpreting for patients when professional interpreters are available.
Those employed within the hospital were more likely to be used as an interpreter. Patients may expect health navigators to interpret for them and this represented another difficulty with role boundaries:
Pacific staff are taken for granted because, you know, because you can understand a language, then therefore we expect you to use that language and … we can’t say ‘no’ to a patient, you know, “Sorry can’t come and interpret it for you because it’s not in my job description”. (P10)
Some of the community health navigators, on the other hand, felt frustrated that they were prevented from interpreting when accompanying patients into hospital:
They just make me feel down and not wanted, you know? Like I offered that I can translate. I’m a nurse. (P7)
Navigators expressed awareness of and desire for some formal training in interpreting but there was frustration with the lack of a course tailored to their needs. Their desired course was one that was more than the one-day training session that
122 some have received but less than the full
programme that a professional interpreter requires.
Health navigators expressed a number of reservations about the services provided by professional interpreters, as shown in Table 6.
Table 6: Perceived Shortcomings of Professional Interpreters
Lack of health experience, knowledge or vocabulary
One day I went in and the interpreter’s there and
… he turned around and asked me “What’s the word for such and such”. (P4)
I think that if they chose to do interpretation and translation in a health setting, they would need a health qualification as well or some health experience. I really do believe that. (P12)
Lack of established relationship with patient A navigator gets to be part of a patient’s life because of the health things. …They know the issue, they know the plans and they are more than that visit. (P8)
Limited working hours/lack of commitment to patients
They come in and then five o’clock, whatever time they finish work, they go and the consult’s still going. (P5)
Limited role of professional interpreters The worrying point for me in being called an interpreter itself is because it’s got limitations. … Because we work holistically for our people. … What is an interpreter? Just interpret according to what’s been said. You cannot do anything like support the person to the extent. (P3)
I’ve attended family meetings where they’ve gotten a Samoan interpreter, and then I just listen to see whether, and he actually does a good interpreting, but I can still see that the family are not quite understanding what they’re saying, so I intervene and put it in a way that makes our family fully understand what it is that the doctors are trying to say. (P9)
Perceived lack of confidentiality
if I was just a lay person and then you have an interpreter just coming in … I couldn’t talk about everything. … like if I see this person again somewhere … at the shop or the church … they’ve got the very sensitive information and it’s only just interpretation. So that’s really scary. (P5) Discomfort of Pacific people with telephone interpreting
But with our people, face to face is a lot better … than telephone. We don’t do telephones. You get
very little information from people because they don't know who they’re talking to. (P9)
Interviewees described what they saw as shortcomings in the professional interpreters they had seen in action, and saw the strictly confined role of professional interpreters as an impediment to providing the help needed to get the best outcome for patients.
Potential combined navigator/interpreter role
The concept of an explicitly combined navigator/interpreter role was supported, partly because this is what is happening to some extent in practice already. The perceived benefits of such a proposal are shown in Table 7.
Table 7: Benefits of a combined interpreter/health navigator
Greater continuity of care for patients
At least with the navigator, they are there. So when they are there and they need to, then I think they should be the interpreter because you don't have to wait for somebody else and … reschedule and they are part of the patient’s journey. (P8) Greater clarity of role
It would really clarify what it is I’m interpreting when I’m doing it. You know what I mean? It would be actually “That is my role as an interpreter.” (P1)
DISCUSSION
Navigators in the Pacific services studied here have a challenging and complex role. It is evident that they are fulfilling a genuine need in their community. The many barriers to good health care identified here and the varied roles performed by navigators to overcome these barriers mirror those described in the literature.3-10,23-25 Navigators need a broad range of skills and attributes, the core of which are strong community networks, sound health knowledge, and well-developed cultural and communication skills. These cannot be expected to be present in any one individual but can be distributed across a team, especially language skills.
Our research found a significant overlap between the roles of navigators and interpreters, with navigators routinely interpreting for patients, especially in the hospital. Overcoming the language barrier was felt to be a major part of the
123 navigator role, but their approach differs from
that of professional interpreters.
Pacific navigators believe that interpreting that is executed strictly according to professional interpreter guidelines26,27 is not sufficient for their clientele. The language assistance navigators provide was felt to be qualitatively different to that of a professional interpreter.
Their focus is on more than just interpreting the words of the health professional, often extending to explaining more fully in ways that their community will understand. Navigators felt health professionals could ideally communicate more clearly using simpler language and visual aids, but reported using their own skills to compensate for this where necessary. Their ability to facilitate effective communication rested on some degree of health knowledge, plus the greater depth of relationship and trust afforded by the ongoing contact that a navigator often has with a patient. They acknowledged the need for specific training in interpreting for navigators but felt that such training needed to be tailored to the requirements of their role. The need for professional interpreters for critical conversations (such as informed consent) was acknowledged, possibly in addition to a navigator.
Pacific navigators expressed concerns about the confidentiality of interpreters which probably reflects the perception in their communities. The length of time that navigators spend with patients is greater than interpreters are able to, and the personal relationships they can then develop also encourages the development of trust. This is a key reason that Pacific patients may prefer to be assisted by a navigator (or indeed a family member) rather than a professional interpreter.
The anecdotal evidence in this study of unnecessary duplication or complexity caused by multiple staff interactions suggests that LEP patients may be better assisted by a single person or team who can get to know them and their circumstances and can assist with overcoming a range of barriers, including language. This needs to be officially recognised in policies and training.
Our findings suggest that when multiple roles are performed by a single person clear communication about roles is essential. There needs to be explicit discussion of role at a local level with patients, their families and clinicians to ensure that all understand what to expect and what the relevant boundaries are. It is important that there be clear definitions of when a task is beyond the navigators’ scope of practice and should be referred on to an appropriate
professional such as a professional interpreter or social worker.
Using a focus on barriers to healthcare could be an effective way to tailor navigation services to individuals by identifying which barrier(s) are most important in each case. Such an approach requires a comprehensive service with well- trained staff with a range of skills, training and experience, given the many potential barriers to care. The need for such diverse teams is an argument for developing more overlap or integration between community and hospital based services as this would create an even larger pool of skills to draw from. A more integrated service would also enable greater continuity of care across the settings which would further capitalise on the benefits of stronger individual relationships.
Also worthy of reconsideration may be the current focus on individual clients. Although not specifically addressed in this research, a household focus could be more useful and cost- effective and may be more culturally appropriate, given the family structure of many Pacific households (and probably other CALD communities).20
The Pacific community is the only set of ethnic communities with LEP patients in the Wellington area that has a formal navigation service. Other CALD/LEP communities beyond the Pacific community may also benefit from such a service, in combination with interpreting services.
However, while Pacific navigators firmly believe that it is best for navigators to add interpreting skills to their training, rather than trying to train interpreters as navigators, this may not be the case in other CALD communities. Further consultation within such communities or those working with them (interpreters and health professionals) will be required to determine the best design for such services. The views of the participants in this study suggest that meaningful health knowledge in those taking on such roles is likely to be a key element.
Overall, we believe the strengths of the current services should be built on and lessons learned from their experiences are likely to be useful when considering similar services to assist other Pacific and other CALD communities. Further research into the views of other stakeholders in this area would be very desirable.
Limitations of the study
The study only investigated the issue from the point of view of those involved in health navigation and in a single area of New Zealand (Wellington). The views of interpreters, health
124 professionals and service users were not
investigated as this was beyond the scope of the funded research.
CONCLUSION
Pacific people working in health navigation roles (or similar) support in principle the idea of a combined health navigator/interpreter role, based on providing interpreter training to health navigators. Such a role would enable greater role clarity with interpreting being an official part of the role, as well as greater continuity of care through the involvement of a single person for both roles. Health navigators/interpreters may enable better communication through their closer relationships and more extensive health background, combined with an approach to interpreting that focuses more on communicating the ideas effectively using their own experience and expertise (cultural and otherwise) rather than only interpreting the talk of health professionals and patients. A combined health navigator/interpreter role would be likely to lead to better health outcomes for Pacific people, and for other cultural groups.
Implications for Practice
The scopes of practice for the various types of navigators (depending on training and experience in other professions such as nursing and social work) need to be clearly defined and clear guidelines about when to refer on and to whom should continue to be developed.
Navigators need to be fully aware of the wide range of roles they perform and to have a clear idea of their individual scope of practice. With each individual client, navigators need to be aware of what role(s) they are taking and this should be discussed with patients and health professionals to ensure clarity. They also need to be able to clearly assess situations that are out of their scope of practice and to bring in additional help when appropriate, such as a professional interpreter for more complex or ‘high stakes’
discussions.
Systems for training and accrediting navigators as interpreters need to be investigated to enable interpreting to be explicitly incorporated into the navigator role. Ways of providing navigation in tandem with interpreting should be explored for both Pacific and other CALD communities, with consideration given to appropriate training, recruitment and funding.
Further work also needs to be done with other professional groups. Health professionals can be supported to improve their communication skills, including the use of visual aids, writing notes and
rephrasing; professional interpreters need to be made aware of the existence of health navigation services and the range of roles and expertise that navigators can offer, and trained in when to call them in.
Author contributions: JH contributed to the design of the research, conducted the field research and initial thematic analysis and drafted the manuscript. BG and MS contributed to the design of the research and to the analysis and writing of the manuscript.
Funding: The research was funded by a grant from the University of Otago. The project was approved by the University of Otago Human Ethics Committee through the Department of Primary Health Care and General Practice, University of Otago Wellington, Reference Number: D14/411 (19 December 2014).
Acknowledgements: The research team wishes to thank all the study participants, both management and staff from the Pacific
Navigation Service
(CCDHB/Compass/WellHealth PHOs) and the Pacific Health Unit of Wellington Hospital.
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Appendix 1: Interview Schedules 1. Interviews with Pacific Navigators A: General
1. How would you describe what you do as a health/pacific navigator?
What are the kinds of tasks you are expected to do day to day?
2. (If relevant) What is the difference between a Community Clinical Nurse and a Community Support Worker?
3. How are clients usually referred to your service?
By clinicians or self-referral?
Whose decision should it be that a patient receives this service?
4. How closely are you matched to the culture/origin of the patient?
How important do you think that is?
5. How much do you follow your own sense of what needs to be done, and how much do you follow direction from the organization?
How closely do you follow the parameters of the job outlined in the JD?
6. How do you personally assess whether you’ve been successful in your work?
7. What kind of experience or training did you have before starting in this role?
(e.g. what previous roles have you held?) 8. What makes a good health navigator?
B: LEP patients General
1. What do you think are the main barriers to patients with LEP obtaining quality health care?
2. What is your view on support services generally for LEP patients (not just Pacific ones)?
Are there enough? Of the right sort?
Own experience
3. How many of your clients need help with English/have limited English proficiency?
4. How often do you use your own Pacific language skills when talking to a client?
How often is that required due to limited English rather than patient preference/rapport etc?
5. Do you ever act as an interpreter for a client? (i.e. use your own Pacific language skills to help a patient communicate with someone else)
If so, how frequently?
How do you feel about doing that?
6. Do you ever bring in a professional interpreter to communicate with a patient or to enable a patient to communicate with another professional?
How often?
7. Do clients’ family or friends ever act as an interpreter for you or for a health professional in your presence?
8. Do you have any training in interpreting?
How much? Who trained you? Do you feel it was sufficient?
C: Roles
1. How would you define the role of the health/pacific navigator?
2. Do you think that patients/health professionals have a clear idea of your role as per your job description?
3. How do patients and their families see your role?
Do you have any difficulty with expectations that differ from your official role?
Do you get asked to do things that lie outside your role?
4. How do health professionals see your role?
Do you have any difficulty with expectations that differ from your official role?
Do you get asked to do things that lie outside your role?
5. How do you think your role intersects with other support services for LEP patients? e.g.
a. Interpreters (Do interpreters sometimes navigate/navigators sometimes interpret?) b. Social workers
c. Others?
How do they intersect? What are the intersections?
Are overlaps or intersections beneficial or problematic?
6. Have you experienced any difficulties with role boundaries in your work?
7. Are there any questions you think we should be asking health professionals or patients about your service/role (in future research)?
D: Service Improvements
1. How do you think the navigation service could be improved?
2. How do you think the navigation service could be improved for LEP patients?
3. How do you think relationships with other support services for LEP patients could be improved?
127 4. If not already mentioned:
a. What do you think about a combined interpreter/navigator role?
b. Would you like to have more training in interpreting?
c. Do you think some interpreters should be trained as health navigators as well?
2. Interviews with Managers of Pacific Navigator services A: General
1. How many staff do you employ?
2. What are their official roles? (request written job description) 3. What kinds of tasks do they do day to day?
4. How closely do staff follow the parameters of the job outlined in the JD?
5. What kind of experience or training do you require for staff?
6. I understand that clients usually self-refer to your service. Could you comment on the referral process, how well it works and what you think the ideal would be?
7. How closely are staff matched to the culture/origin of the patient?
How important do you think that is?
B: LEP patients
1. How many clients need help with English/have limited English proficiency?
2. What do you think are the main barriers to patients with LEP obtaining quality health care?
3. How often do staff use their own Pacific language skills when talking to clients?
What is the main reason:
• limited English of the patients (i.e. it’s necessary)
• for other reasons: social/cultural/rapport related etc (i.e. it’s beneficial but not essential) 4. Do staff ever act as an interpreter for a client?
• If so, how frequently?
• How do they feel about doing that?
• Are there times when you think that is not appropriate?
5. Do staff ever bring in a professional interpreter to communicate with a patient or to enable a patient to communicate with another professional?
How often?
6. Do clients’ family or friends ever act as an interpreter for your staff or for a health professional in their presence? How often?
7. Do your staff have any training in interpreting?
• How much?
• Who from?
• Do you feel it was sufficient?
C: Roles
1. Do you think that patients and health professionals have a clear idea of the role of your service as per the job descriptions?
a. How do patients and their families see the role?
What difficulties do staff encounter with expectations that differ from their official role?
b. How do health professionals see the role?
What difficulties do staff encounter with expectations that differ from their official role?
2. Do you think the role intersects with other support services for LEP patients? e.g.
a. Interpreters (Do interpreters sometimes navigate/navigators sometimes interpret?) b. Social workers
c. Others?
How do they intersect?
Are overlaps or intersections beneficial or problematic?
3. Are there any other difficulties with role boundaries that staff experience in their work?
4. Are there any questions you think we should be asking health professionals or patients about your service/role (in future research)?
D: Service Improvements
1. How do you think the service for Pacific patients could be improved?
2. Do you think the service could be improved for patients whose English is limited?
3. How do you think relationships with other support services for LEP patients could be improved?
4. If not already mentioned:
a. What do you think about a combined interpreter/navigator role? How would this best be set up (e.g.
in terms of training, location in the system etc)
b. Should pacific navigators/pacific health unit staff have more training in interpreting?
c. Do you think some interpreters should be trained as health navigators as well?
