1. COMMUNICATION
Patients travelling down from Labrador for a scheduled appointment or procedure who require an interpreter will have an interpreter travel with them at no cost to the patient, paid by either Health Canada (for Innu Nation) or Nunatsiavut Government (for northern Inuit beneficiaries). According to an EH decision maker, for those who do not have an interpreter with them – such as patients in non planned (emergency) situations – interpretation is provided: the APNs will arrange for an Innu interpreter through First Light (SJNFC), paid for by First Light (SJNFC). For Inuit patients, one of the APNs also acts as interpreter when required
​
➤ Challenge with access to interpretation
We found a great deal of confusion amongst patients about whether interpretation is available to them. This was particularly true for Innu patients; at the time of the interviews, the APNs themselves. were able to fill a gap in interpretation for Inuit patients by providing the interpretation themselves; but this was not so for the Innu patients. The APNs have an Innu interpreter affiliated with First Light (SJNFC) that they call on in emergencies, with the costs borne by First Light (SJNFC).
​
​
​
​
​
​
Innu patient/supporter experiences were also that there is insufficient access to interpretation. This patient supporter, who had often accompanied patients as a paid interpreter, was concerned that the current policy of having interpreters arranged only for specific procedures is insufficient, expressing his concern that there should be someone embedded in the system more readily available to assist when needed:
​
​
​
​
​
​
​
While Inuit patients appear to be better situated with interpretation they, too, occasionally rely on volunteer interpreters outside of the EH and APN system. There is a need for translation services between languages; in addition to improvements to communications more generally.
​
➤ Communication challenges more generally
​
​
​
​
​
​
​
The APNs stress the importance of having not just an interpreter, but an advocate who can act as a cultural broker between patient and clinicians. They clarified that it is often not just language differences, but the culturally-shaped way of communicating that causes communication barriers.
​
​
​
​
​
​
​
​
​
​
​
​
A related challenge with communication is low literacy in general and the barrier this poses, even for fluent English speakers, to fully communicate with clinicians. Furthermore, we have to consider the ways in which low literacy and language barriers interact.
​
​
​
​
​
​
​
​
​
​
​
​
It is important for EH staff and healthcare workers to appreciate that communication styles are culturally shaped, so that even if a patient speaks English, communication can break down in other ways.
​
➤ Role confusion of interpreter and escort
Typically, a patient will arrive with one escort, if required for medical care. That person typically is also the interpreter, but not necessarily. Patients and the APNs reported that occasionally clinicians will assume escorts/supporters are interpreters, or that interpreters are escorts/supporters. For the APNs, one of the major concerns with roles being confused or inappropriately conflated is the potential for misidentification of the legal substitute decision-maker. They recounted, by way of an example, one story told to them by an interpreter who had recognized the inappropriateness of being asked to act as substitute decision-maker and had refused, explaining to the doctor that she was just an interpreter, not a decision-maker, and pointing to a second individual (the escort) whose role was to be the substitute decision-maker.
​
Additionally, there is the challenge of appropriate compensation, whether reimbursement for expenses or pay for interpretation services. The APNs told the story of an individual who assumed she was accompanying a patient to St. John’s as an interpreter. However, the patient was having surgery and required an escort to accompany her back to Nain once discharged; so the interpreter was approved as the escort, rather than as an interpreter. An escort is only required if the patient’s medical condition requires it. As noted above, when an
interpreter is also needed, very often the escort will be the interpreter. However, that individual will only be paid as an interpreter if this has been arranged and authorized in advance – otherwise, the assumption is that the family member or friend who is the escort is doing the interpretation out of the goodness of their heart, as part of their support for the patient.
​
➤ Role confusion of informal vs approved escorts and interpreters
For health care providers, the confusion over who is meant to be on-site as a patient supporter and/or interpreter can be compounded by the use of informal volunteers. These informal volunteers either live in the St. John’s area or are in St. John’s as escorts, interpreters or family members of other patients.
​
​
​
​
​
​
These volunteers provide additional support by way of includes providing interpretation, patient advocacy, cultural brokering (explaining how the medical system functions and how the city functions to patients; interpreting the cultural and social context of a patient’s needs to health care providers), and running errands, as well as visiting and providing emotional support. These informal volunteers are well known to the APNs (and vice versa). They are an integral part of the care system for patients travelling from other parts of the province to St. John’s. The important role of these volunteers, and the potential role they could play as knowledge holders advocating on behalf of patients, will be returned to in the Recommendations section.
"We had a patient probably two months ago up in the special care unit. She was up there for
probably two months. I had just come in the doors at 7:00 and got the call ten after seven saying they needed me upstairs ASAP. By the time I got upstairs, four family members from
Sheshatshiu were there. She had just passed. The patient had just passed. She was sitting up in bed ... They were shocked that she passed away, and so we needed to get an interpreter. At that time [Innu interpreter with First Light (SJNFC)] was not here, she was away, so I called the liaison worker in Goose Bay to get an interpreter to ask if she could speak to the family. They were all in tears and shocked. I called her [the interpreter] and thankfully she answered, and said she could interpret for them so they did it by phone and explained to them, well she died, like you know, and what happened and whatever."[APN]
"We don’t have somebody [to provide interpretation for the Innu communities]. Sometimes there’s a language barrier. People don’t speak English at all, so there’s a problem that exists when nobody understands English ... You need to have a translator as well in this system, because without that people are lost, or they don’t understand the technical stuff like the words coming from the doctors, so we need translators – that’s what I’m saying." [Indigenous patient 1: Innu man – patient, patient supporter and interpreter]
"APN is a blessing. Doctors and nurses in emerg are degrading to indigenous let alone average people. All health staff that aren't indigenous just don't understand how to care for our population. I.e. our preferred care and our way of communication and community organization. I.e. many people are intimidated by professionals and will not speak up or question anything." [Anonymous response, Indigenous patient survey]
"APN: And [patient] came back and Sol said “How did it go?” and [patient] said “I never
understood a thing he said”. So it’s common for Aboriginal people to just say yes but the doctor is talking to you and asking you questions and you’re just agreeing to agree, just saying yes. They’re not getting the information, they just say yes.
Fern: And so the solution for that is, if you could, to provide training to physicians?
APN: [nodding] “Tell me what I just said to you.” Ask them to relay back what we just shared. Like when we’re there, we help them to better understand because we’re saying “Okay do you understand what’s being said, do you have any questions?”. So they feel a lot more comfortable because we’re there to ease them I guess, to make them feel supported and be their voice.
"My dad is a very low speaker [i.e., not well educated, not very good with communication in English] and when the doctors talk to him, he doesn’t understand, so I have to put it in what you call laymen terms for him. He wouldn’t know what was going on unless I was there, they [doctors] don’t explain themselves. They’re just in a rush: get you in, get you out, like “Here you go, deal with it.” You know what I mean? It’s sad, yeah, they don’t – the quicker they get you in, the quicker they get you out. They’re happy, but like my father looks at me going “What just happened?” ... The biggest misunderstanding is the patients don’t understand their doctors, because they’re talking to them in their [medical] terms. When the person doesn’t understand, and then you have to take five minutes after we’re out of the room, and I’ve got to take at least five or ten minutes to explain to my father, “Well yeah your heart is starting to fail and they need to put this inside of you to make it work”, and he’s looking at me going “He [the doctor] didn’t say that.” I said “Yeah, he did Dad”, like you know. And it’s complicated, it’s really complicated because I mean elders in this day and age, they might have gotten Grade 3 [education]. Some of them didn’t even have that. My father got as far as Grade 3, so I mean, yeah, it’s pretty complicated for them." [Indigenous patient 3: Inuit woman – patient and patient supporter]
"It’s a privilege. It makes me feel good, and it makes the patient feel good too, they just keep saying 'Thank you, thank you' and I’m like 'No you don’t need to thank me.' I just want to say 'Okay, you’re here to get better and that’s all that matters.'"[Indigenous patient 4: Inuit woman – patient, patient supporter, and interpreter]