Assessing mediated Assessing mediated interpreting in healthcare interpreting in healthcare

Claudio Claudio Baraldi Baraldi (University of Modena and Reggio Emilia, (University of Modena and Reggio Emilia, ItalyItaly))

claudio.baraldi@unimore.itclaudio.baraldi@unimore.it

This presentation is aboutThis presentation is aboutassessment of interpreterassessment of interpreter--mediated mediated interaction, in healthcare settings, that interaction, in healthcare settings, that is interaction between speakers of is interaction between speakers of different languages talking to each different languages talking to each other with the help of a third party, who other with the help of a third party, who is considered a is considered a mediatormediator in some in some cultural traditions (e.g. Italy) and a cultural traditions (e.g. Italy) and a community interpretercommunity interpreter in in manymany othersothers(e.g. (e.g. SwedenSweden, USA)., USA).

Mediation/interpreting services in Mediation/interpreting services in healthcare systems may be healthcare systems may be assessed for two main aspect:assessed for two main aspect:

1. Organisation (decision1. Organisation (decision--making)making)

2. Practice (interaction)2. Practice (interaction)

Difference between assessment and Difference between assessment and evaluative research evaluative research

1. Different functions: decision vs. analysis 1. Different functions: decision vs. analysis

2. Different actors: decision2. Different actors: decision--makers vs. makers vs. researchersresearchers

3. Different consequences: 3. Different consequences: continuation/transformation/interruption continuation/transformation/interruption vs. advices for improvement vs. advices for improvement

Types of evaluative research on Types of evaluative research on practice:practice:

1. Analysis of customer satisfaction 1. Analysis of customer satisfaction 2. Practitioners2. Practitioners’’ and and mediators/interpretersmediators/interpreters’’ reportsreports3. Analysis of conversations 3. Analysis of conversations 4. Analysis of context 4. Analysis of context

Reasons for choosing evaluative research Reasons for choosing evaluative research (concerning the practice of mediation (concerning the practice of mediation /interpreting):/interpreting):

1. Practice 1. Practice isis communication in communication in interactionsinteractions2. Satisfaction 2. Satisfaction is notis not a cue for good a cue for good practicespractices3. Reports 3. Reports are notare not cues for the cues for the interaction, they are their interaction, they are their ““social social representationsrepresentations””4. Context may be observed 4. Context may be observed onlyonly in in communication practices which communication practices which reproduce itreproduce it

While it is impossible to exclude the While it is impossible to exclude the researcher as (second order) observer researcher as (second order) observer from evaluative research, direct, firstfrom evaluative research, direct, first--hand observation of practices, excluding hand observation of practices, excluding other observers, may be useful other observers, may be useful

Analyses of customer satisfaction and Analyses of customer satisfaction and reports (social representations) may be reports (social representations) may be useful to investigate how the participants useful to investigate how the participants observe the interaction, in order to observe the interaction, in order to enrich the basic and essential firstenrich the basic and essential first--hand hand information about practices derived from information about practices derived from direct analysis. direct analysis.

The clarification of methodological and The clarification of methodological and theoretical assumptions of evaluative theoretical assumptions of evaluative research of mediation/interpreting research of mediation/interpreting practices is the main task of this practices is the main task of this presentation.presentation.

Examples of empirical analysis were Examples of empirical analysis were delivered in the last year presentations delivered in the last year presentations and are available (in English) in and are available (in English) in BaraldiBaraldi--GavioliGavioli 2007, 2008, and in 2007, 2008, and in BaraldiBaraldi--GavioliGavioli forthcoming. forthcoming.

My first assumption is that mediation My first assumption is that mediation /interpreting is a communication system /interpreting is a communication system and more specifically an interaction.and more specifically an interaction.

On the basis of this assumption, I observe On the basis of this assumption, I observe the possible assessment of: the possible assessment of:

1. The specific function of translation as 1. The specific function of translation as mediation in this systemmediation in this system

2. The function of this system in the global 2. The function of this system in the global healthcare system healthcare system

3. The function of this system as facilitation 3. The function of this system as facilitation of intercultural communicationof intercultural communication

Mediation/interpreting is a communication system/interaction in that:

1. Mediation/interpreting exists if and when there is a coordination of action and understanding2. This coordination produces information for the participants 3. Action is visible in turn-taking in the interaction 4. Alternation of turn-taking displays understanding 5. Consequently the sequence of turns (actions) is fundamental to understand the system6. The features of turns in the sequence and of the produced information are cues for the structure and the cultural orientation of the system.

Questions about mediation/interpreting as a communication system/interaction:

1. What are the features of function of translation, function in the healthcare system and function for intercultural communication?

2. In which conditions and with which range of variability?

3.With which frequency?

The following suggestions are based on provisional results of a research which is in progress and must be considered as a source for discussion and confrontation.

The specific function of The specific function of translation as:translation as:

mediation in interpretermediation in interpreter--mediated mediated communication systemscommunication systems

TTranslation is a ranslation is a reaction to translatable turns reaction to translatable turns which projects different opportunities for which projects different opportunities for interlocutorsinterlocutors’’ active participation in the active participation in the interactioninteraction

TTranslation:ranslation:

(a) assures common understanding (a) assures common understanding

(b) facilitates a direct communication (b) facilitates a direct communication between the parties between the parties

The very activity of translating is an activity of The very activity of translating is an activity of mediatingmediating

Mediation/translation is the result of the Mediation/translation is the result of the coordination coordination of the mediatorof the mediator’’s and the s and the other participantsother participants’’ (doctor and patient) (doctor and patient) actions.actions.

The interplay among these three The interplay among these three participantsparticipants’’ actions permits the actions permits the construction of interpreterconstruction of interpreter--mediated mediated interaction.interaction.

Variables for assessment. Translation as mediation:Variables for assessment. Translation as mediation:

1. After turn translation1. After turn translation

1.1 Trivial machine/non person (?)1.1 Trivial machine/non person (?)1.2 Types of rendition (zero, non, reduced, expanded)1.2 Types of rendition (zero, non, reduced, expanded)

2.2. Suspension Suspension (dyadic sequences)(dyadic sequences)

2.1 Instructions 2.1 Instructions 2.2 Questions 2.2 Questions 2.3 Direct answers2.3 Direct answers2.4 Requests for clarifications 2.4 Requests for clarifications 2.5 Acknowledgment tokens 2.5 Acknowledgment tokens 2.6 Continuers2.6 Continuers2.7 Echoes2.7 Echoes

3. Formulation (after sequence translation) 3. Formulation (after sequence translation)

3.1 3.1 ““Summarized renditionsSummarized renditions””

4. Negotiation of translation relevance 4. Negotiation of translation relevance

4.1 Dislike for translation of a turn or a series4.1 Dislike for translation of a turn or a series--ofof--turns, signalled through turns, signalled through direct reply or request of confirmation of correct understandindirect reply or request of confirmation of correct understanding.g.

Formulation Formulation

Heritage defines formulation as Heritage defines formulation as ““summarising, glossing, or summarising, glossing, or developing the gist of an informantdeveloping the gist of an informant’’s earlier statements earlier statement”” (1985: (1985: 100).100).

Formulation projects a Formulation projects a direction for subsequent turnsdirection for subsequent turns by inviting by inviting responses. responses.

TwoTwo dimensionsdimensions of after of after sequencesequence translational formulationstranslational formulations: :

1. 1. LinguisticLinguistic functions functions summarisingsummarisingdevelopingdevelopingglossingglossingInferencingInferencingmakingmaking somethingsomething explicitexplicit

2. 2. FormulatedFormulated expectationsexpectations concerning concerning the the gistgist of of earlier earlier statementsstatementsAffectiveAffectiveCognitiveCognitiveNormativeNormative

InterpretersInterpreters’’ relevant actions in relevant actions in connecting dyadic suspensions and connecting dyadic suspensions and afterafter--sequencesequence translationaltranslationalformulationsformulations

1. 1. Provision of feedback to allow Provision of feedback to allow patient/doctor expression patient/doctor expression

2. Stimulation of participants2. Stimulation of participants’’ expressions expressions by asking for more, encouraging to go on, by asking for more, encouraging to go on, providing feedbackproviding feedback

3. Formulation of their understanding of 3. Formulation of their understanding of dyadic interaction, distinguishing their dyadic interaction, distinguishing their contribution from the doctorcontribution from the doctor’’ss

Negotiation of translation relevanceNegotiation of translation relevance

1. D1. Doctorsoctors’’ attempts to speak and display attempts to speak and display understanding of the patientunderstanding of the patient’’s language.s language.

2. P2. Patientsatients’’ opportunities to speak and display opportunities to speak and display understanding of the native language understanding of the native language

3. 3. Mediators/interpretersMediators/interpreters’’ opportunities to opportunities to encourage and help the doctor to speak the encourage and help the doctor to speak the patientpatient’’s language and promote direct contact s language and promote direct contact between doctor and patient.between doctor and patient.

4. 4. LevelsLevels and and formsforms of of linguistic coordination linguistic coordination between mediators/interpreters and doctorsbetween mediators/interpreters and doctors (in (in turnturn--takingtaking and and usedused languagelanguage). ). ClaimsClaims and and competitioncompetition

DoctorDoctor’’s relevant actions of s relevant actions of negotiation of translation relevancenegotiation of translation relevance

1. Attempts to 1. Attempts to understand, even if the understand, even if the language is not theirslanguage is not theirs

2. Interruptions of long dyadic sequences 2. Interruptions of long dyadic sequences involving the mediator and the patientinvolving the mediator and the patient

3. Direct questions about patients3. Direct questions about patients’’ feelings feelings and worries and worries

4. Encouragements to patients and 4. Encouragements to patients and interpreters to express in their own terms interpreters to express in their own terms

The function of interpreterThe function of interpreter--mediated interaction: mediated interaction:

in the healthcare system in the healthcare system

Interaction is basedInteraction is based onon cultural cultural presuppositionspresuppositions ((GumperzGumperz 1992: 1992: 230): 230): presuppositions the participants presuppositions the participants ““must rely on to maintain must rely on to maintain conversational involvement and assess conversational involvement and assess what is intendedwhat is intended””

Cultural presuppositions may be Cultural presuppositions may be conceived as conceived as generalised expectations in the encapsulating social systems (Luhmann 1984), eg. healthcare system

In In healthcare systemshealthcare systems, cultural , cultural presuppositions of interaction are presuppositions of interaction are expectations about: expectations about:

1. Value of patients1. Value of patients’’ illness and health illness and health

2. Roles of doctors and patients 2. Roles of doctors and patients

3. Recovering as interrelation of 3. Recovering as interrelation of medical expertise and patientsmedical expertise and patients’’adaptationadaptation

Variables for assessment. InterpreterVariables for assessment. Interpreter--mediated mediated interactions may favour: interactions may favour:

1. Doctor1. Doctor--centred communication:centred communication:

1.1. Patients adapt to medical expertise1.1. Patients adapt to medical expertise1.2 1.2 PatientsPatients respond to doctorsrespond to doctors’’ questions and questions and uncritically accept doctoruncritically accept doctor’’s recommendations s recommendations 1.3 1.3 DisplayedDisplayed expectations concernexpectations concern patientspatients’’adaptation, doctorsadaptation, doctors’’ performance and hierarchical performance and hierarchical relationships based on difference in competencerelationships based on difference in competence

2. Patient2. Patient--centred communication:centred communication:

2.12.1 Doctors support patientsDoctors support patients’’ emotional display emotional display (concerns, worries doubts) (concerns, worries doubts) 2.2. Patients are treated as competent interlocutors 2.2. Patients are treated as competent interlocutors and are encouraged to express their problems and and are encouraged to express their problems and needs in the interaction needs in the interaction 2.3 Displayed expectations concern patients2.3 Displayed expectations concern patients’’expressions and doctorsexpressions and doctors’’ display of sensitivity display of sensitivity

Different cultural presuppositions (and forms Different cultural presuppositions (and forms of doctorof doctor--patient communication) may be patient communication) may be observed in the interaction through specificobserved in the interaction through specificcontextualizationcontextualization cuescues, which, which are: are:

linguistic cues which linguistic cues which highlight, foreground or highlight, foreground or make cultural presuppositions salient in make cultural presuppositions salient in communication (communication (GumperzGumperz 1992).1992).

The function of interpreterThe function of interpreter--mediated system as: mediated system as:

facilitation of intercultural facilitation of intercultural communicationcommunication

Intercultural communicationIntercultural communication is a type of is a type of communication in which cultural diversity is communication in which cultural diversity is observed and treated as a meaningful observed and treated as a meaningful phenomenonphenomenon

InterpreterInterpreter--mediated interactions may mediated interactions may facilitate either: facilitate either:

1. Reproduction of specific cultural 1. Reproduction of specific cultural presuppositions (cultural coordination)presuppositions (cultural coordination)

or or

2. Cross2. Cross--cultural adaptationcultural adaptation between different between different presuppositions (intercultural coordination)presuppositions (intercultural coordination)

Variables for assessment. Mediation may Variables for assessment. Mediation may mean: mean:

1. Separation of the parties 1. Separation of the parties 2.1 Non renditions of prescriptions2.1 Non renditions of prescriptions2.2 Parties and their cultural identities substituted 2.2 Parties and their cultural identities substituted through mediators/interpretersthrough mediators/interpreters’’ initiatives.initiatives.

2. A2. Assessmentssessment ofof WeWe--IdentitiesIdentities1.1. Normative expectations expanded beyond 1.1. Normative expectations expanded beyond medical culture medical culture 1.2 Over1.2 Over--adaptation of patientsadaptation of patients’’ actions to medical actions to medical cultureculture

3. Promotion of different narratives 3. Promotion of different narratives 3.1 Affective expectations expanded beyond technical 3.1 Affective expectations expanded beyond technical treatment treatment 3.2 Cross3.2 Cross--cultural adaptation of patientscultural adaptation of patients’’ and doctorsand doctors’’actionsactions

AAssessing Wessessing We--IdentitiesIdentities

1. Mediators1. Mediators’’ initiatives create shared initiatives create shared normative or cognitive expectations with normative or cognitive expectations with one party one party

2. Mediators2. Mediators’’ translations project translations project confirmationsconfirmations and enforcementsand enforcements of these of these expectations in the interaction with the expectations in the interaction with the other partyother party

3. 3. SharedShared cognitive and normative cognitive and normative expectationsexpectations withwith one party areone party areconfirmed and enforcedconfirmed and enforced in the interaction in the interaction with the other party with the other party

PromotingPromoting narratives narratives

1. C1. Creating the conditions for the reating the conditions for the growth of alternative stories growth of alternative stories

2. Building these stories as incompatible 2. Building these stories as incompatible with hierarchical forms of relationships with hierarchical forms of relationships

3. Opening space for shifts in 3. Opening space for shifts in participantsparticipants’’ discursive positioning discursive positioning (towards (towards ““positivepositive”” positioning)positioning)

4. T4. Thickening alternative storieshickening alternative stories

Assessment of translationAssessment of translation’’s consequences s consequences for intercultural communicationfor intercultural communication

1.1. ContextualisationContextualisation ((GumperzGumperz 1992): projection 1992): projection of interpretersof interpreters’’ actions by the cultural actions by the cultural presuppositions of healthcare system (forms of presuppositions of healthcare system (forms of doctordoctor--patient communication). patient communication).

2. Re2. Re--contextualisationcontextualisation (Baker 2006): change of (Baker 2006): change of cultural presuppositions, promoting the cultural presuppositions, promoting the participantsparticipants’’ understanding and responsibility for understanding and responsibility for their actions. their actions.

3. 3. ContextualizationContextualization and reand re--contextualizationcontextualization are are made evident through particular linguistic cuesmade evident through particular linguistic cues

An example. Interplay of formulation (translation) An example. Interplay of formulation (translation) and narrative (mediation)and narrative (mediation)

1. T1. The mediator encourages the patient to express he mediator encourages the patient to express her/his worries which are eventually translated to the her/his worries which are eventually translated to the doctor through a formulationdoctor through a formulation

2. By formulating the patient2. By formulating the patient’’s worries to the doctor, s worries to the doctor, the mediator promotes the patientthe mediator promotes the patient’’s need to be s need to be reassured by the doctor and the doctorreassured by the doctor and the doctor’’s care of the s care of the relationship with the patientrelationship with the patient

3. 3. MediationMediation as formulation can promote crossas formulation can promote cross--cultural cultural adaptation in medical settingsadaptation in medical settings

4. This means promoting both4. This means promoting both patientspatients’’ expression and expression and doctorsdoctors’’ involvement in the interaction involvement in the interaction

5. That is: promoting a patient5. That is: promoting a patient--centred approach in centred approach in medical culture, which coincides with a culturemedical culture, which coincides with a culture--centred centred approach. approach.

The three examined functions concerning The three examined functions concerning systems of interpretersystems of interpreter--mediated interactions mediated interactions (function of translation, function in healthcare (function of translation, function in healthcare system, function for intercultural system, function for intercultural communication) are clearly intertwined.communication) are clearly intertwined.

However, their analytical distinction is useful However, their analytical distinction is useful because it permits the evaluative analysis of because it permits the evaluative analysis of differentiated components of the system. differentiated components of the system.

This enhances the opportunities both to This enhances the opportunities both to observe different aspects of the system and to observe different aspects of the system and to assess separately these different aspectsassess separately these different aspects

The reconnection of these aspects permits The reconnection of these aspects permits analysis and assessment of mediation in its analysis and assessment of mediation in its complexity complexity