Volume 3 ~ November 2011

ISSN # 2150-5772 – This article is the intellectual property of the authors and CIT. If you wish to use this article in your teaching or in another format, please credit the authors and the CIT International Journal of Interpreter Education.

Maria R. Moreno [1]

Sutter Health Institute for Research and Education

Regina Otero-Sabogal

Institute for Health and Aging, University of
California San Francisco

Christy Soto

Sutter Health Institute for Research and Education

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According to the 2000 U.S. Census, 47 million residents—nearly one in five—speak a language

other than English at home. During the last few decades, this group has more
than doubled (from 11.0% in 1980 to 17.9% in 2000), whereas the population that
speaks only English has decreased (from 89% in 1980 to 80% in 2007; Shin &
Bruno, 2003; Shin & Kominski, 2010). Similarly, the 2000 U.S. Census
reported that more than 40
U.S. residents do not speak the same language as their health care providers,
and more than 21 million are considered
limited English proficient (LEP), speaking English less than fluently. California has some of the most racially, ethnically, and
linguistically diverse communities in the United States, with 26% of its
residents being foreign born—the highest percentage of any state in the nation
(Grant Makers in Health, 2003).
represents one of the fastest growing LEP populations in the country, with a
growth of 42% between 1990 and 2000. In 2005, 42.3% of Californians 5 years of
age and older were considered LEP, compared with 19.4% of the total U.S.
population (Moreno, Otero-Sabogal, & Newman, 2007).


demographics are not just limited to the United States; global migration to
European countries has increased since 2000 (Herm, 2008). In 2005, migrants
made up 8.5% of the European population. Similar to the United States,
Europe—with an increased proportion of migrants—is facing the formidable challenge
of how to provide high-quality language services to its foreign-born residents.
Language and communication problems among patients with medical providers in
European countries mirror the difficulties seen in the United States. Priebe
and colleagues (2011) conducted a study to identify the experiences of
providing health care to European migrants; participants were 240 health care
professionals in 16 European countries (covering more than 85% of the European
Union [EU] population). These authors found that most participants reported
experiencing language barriers when attempting to communicate with doctors.
Immigrants’ inability to communicate their medical concerns due to language
difficulties put them at risk for being misunderstood and misdiagnosed.
Participants reported that patients undergo extensive physical examinations and
diagnostic tests to compensate for the inability to communicate. With the
changing demographics in the United States and Europe, t
he implications
for language services and trained bilingual health care professionals are


Language barriers in health care may ultimately
result in poorer clinical outcomes (Standing & Chowdury, 2008) and
increased medical errors (Witmer, Seifer, Finocchio, Leslie, & O’Neil,
1995)as a result of patients’ and providers’ inability to
communicate with one another regarding symptoms, diagnosis, and treatment
options. It has been shown that inadequate interpretation services increase the
chances that patients will not be able to follow doctors’ orders, creating an
indirect hidden cost in health services (Woloshin, 2005). From the patient’s
point of view, pervasive language barriers easily discourage them from seeking
timely medical care. Not surprisingly, non-English-speaking patients are reluctant
to seek services from providers who are unable to communicate effectively with
them. For example, a study of the use of two prenatal clinics in the
southwestern United States revealed that Spanish-speaking women would
consciously avoid a clinic whose staff had no bilingual capabilities
(Ngo-Metzger et al., 2007).

Language barriers in health care impede access to
care regardless of the country of origin. The
collapse of the Soviet Union in 1989 substantially increased the numbers of
refugees and immigrants to the United States from that region.
qualitative study to explore the
experiences of various age groups of immigrant women from three former Soviet
Republics (Belarus, Russia, and Ukraine) indicated that because of language
barriers, women had difficulty discussing with physicians the medications that
they were taking (Ivanov & Buck, 2002). Similarly,
in the last
decade, Spain has become one of the countries in the European Union with the
highest number of immigrants. About 64.5% come from Latin America, 22.1% come
from Africa, 9.3% come from Europe, and 4.1% come from Asia. A study from the
Spanish National Health Survey (NHS) in 2006 showed that immigrants reported
that language barriers led to more frequent use of emergency services
(Carrasco-Garrido, Jiménez-García, Hernández Barrera, López de Andrés, &
Gil de Miguel, 2009).


Overcoming language barriers to access health care
is critical for the well-being of millions of patients who do not speak the
same language as their medical provider. The United States and Europe lack
sufficient bilingual providers to meet the overwhelming linguistic needs of
patients. The use of a large contingent of onsite professional medical
interpreters is perceived as too costly for health care institutions of all sizes.
Consequently, medical providers resort to other means of communicating with
their patients—including enlisting family members, friends, and bilingual staff
whose primary job responsibility is not medical language interpretation. Hiring
certified medical interpreters should be the gold standard practice to provide
the best interpretation to patients. However, the use of untrained bilingual
staff who may lack the required education, knowledge of medical terminology,
and familiarity with interpreter protocols is still a common practice in health
care settings in both the United States and Europe. These bilingual staff
members are often referred to as dual-role
staff interpreters
because they were hired in an administrative or
clinical support position (e.g., registered nurse) as their primary role, but
they also use their bilingual skills to serve a secondary role as interpreters.
Often, organizations such as the one in this study employ professional
interpreters for face-to-face interpretation needs, but the demand exceeds the
capacity, and the company then must resort to bilingual staff serving as
interpreters. Although this practice has its limitations, it is critical that
companies provide high-quality training to bilingual staff so that they
effectively serve as dual-role staff interpreters when professional medical
interpreters are not available; such training has the potential to ultimately
enhance patient services through improved patient–provider communication.

Ensuring competent medical interpreters for
patients can improve quality of care, patient satisfaction, and follow-up care,
and can reduce unnecessary testing, misdiagnosis, and inappropriate treatment
(Hutchins, Fiscella, Levine, Ompad, & McDonald, 2009). In the United
States, the Office of Civil Rights Title VI Act of 1964 recommends that all
medical interpreters be tested for language competency and trained in
interpreter skills (U.S. Office of Civil Rights, 1964). Specifically, the
California Healthcare Interpreting Association (CHIA) recommends that all
medical interpreter trainings include interpreter skills, interpreter code of
ethics, cultural competence, role of the interpreter, and medical terminology
(California Health Interpreters Association, 2002). Additionally, training
should incorporate an evaluation to measure competency in skills, ethics,
terminology, and roles (Hutchins et al., 2009). Regardless of U.S. legislation,
a formal standard to train medical interpreters does not exist yet, and the
responsibility of fulfilling training recommendations is left to individual
health care facilities  Despite the
mandatory interpreter law in the U.S., the use of professional interpreters remains low as shown by a study conducted in four
emergency departments. However, most patients brought a friend or
family member to serve as the interpreter for the clinical encounter (Ginde et
al, 2010).  In European countries
the movement towards having legislation to formalize interpreter’s
certification and to standardize training is very slow. Spanish legislation is moving toward recognition of sign
languages and the suitability of bilingual education for deaf students at all educational levels (Fernández-Viader & Fuentes, 2004). In
Switzerland, a survey of
attitudes and practices regarding communication with LEP
patients found that there is variation across professions and hospital
departments at the Geneva University Hospitals (Hudelson &Vilpert, 2009).

Health care interpreting standards

Interpretation in a medical context requires very
specific skills. Merely being “bilingual” does not automatically make an
individual an effective interpreter. Quality interpretation requires not only
proficiency in both languages, including specialized medical terminology, but
also “critically important memory skills, the ability to negotiate a three-way
conversation, and basic knowledge of cultural attributes that can influence
health” (Grant Makers in Health, 2003). To date, many countries lack a national
mandate requiring the use of trained interpreters to communicate with foreign
language–speaking patients, and consequently, institutional policies concerning
language assistance vary considerably from nation to nation. The U.S. standards
of practice for interpreters are more developed than those of other countries
(Hudelson & Vilpert, 2009). The U.S. Health and Human Services Office of
Minority Health (OMH) developed Culturally and Linguistically Appropriate
Services (CLAS) (Health and Human Services Office of Minority Health, 2001) as
standards for access to language services and organizational supports for
cultural competence. Following HHSOMH’s lead, CHIA (2002) also developed
standards of practice, which “serve as the basis for the development of
interpreter training curriculum” (p. 10-14) and was used to develop the web-based
training for bilingual dual-role staff interpreters for this study.


Web-based education

In recent decades, there has been a rapid growth in
online learning for health care professionals to fulfill continuing education
requirements (Pullen, 2006). More than 1.6 million students took at least one
online course in 2002 (The Sloan Consortium, 2003). Studies show that students
learn best with a medium that allows for interaction with a teacher and
reflection-in-action which means to reflect critically in day-to-day practices
and life. (Liaw, Pearce, & Keppell, 2002). The advent and convenience of
the World Wide Web allows health care workers to participate in interactive
learning using video vignettes, case studies, and question–response methodology
at times that are convenient for their schedules.

Health care interpreting experts recommend that
training move beyond development of linguistic skills and the discussion of
professional codes of ethics to incorporate specifics of the medical setting
and the interpersonal role of health care (Angelelli, 2004a, b) This requirement calls for the enhancement and
development of specific skills related to the process of interpreting (e.g.,
active listening, note-taking) and expansion of interpersonal areas, such as
the patient advocate role, the interpreter’s responsibilities in the patient’s
continuum of care, and the maintenance of neutrality (Angelelli, 2006). By
incorporating other aspects of the health care interpreting experience in
training, students take a more holistic approach to the task and acquire
specific real-world interpreting skills.

Web-based training (WBT) is often the best medium
for full-time health care employees who need to update their knowledge or
skills, such as dual-role staff interpreters in a medical setting who often are
medical administrative staff and do not possess the expertise of a medical
interpreter. The literature shows that WBT is equivalent to other instructional
methods in terms of gains in, and satisfaction with, learning, as long as the
educational principles are applied (Cook & Dupras, 2004). A study to
improve medical student interviews with LEP patients using WBT curriculum
resulted in short-term improvement in knowledge and attitudes necessary to
interact with LEP patients and interpreters. The interactive format allowed
students to receive immediate formative feedback and be cognizant of the
challenges and effective strategies in language-discordant medical encounters
(Kalet, Gany, & Senter, 2002). Studies comparing multimedia and traditional
educational approaches suggested an improvement in students’ performances using
multimedia (Erwin & Rieppi, 1999).

Online instruction has the advantages of allowing
students to work at their own pace and to participate in interactive learning
with immediate feedback and self-assessment. Additional advantages include
being able to deliver stimulating and current material to large groups
throughout various geographic locations, even when faculty and face time are
limited. Online instruction  is
especially convenient for training students in the medical field, including
physicians and nurses who usually do not have regular schedules that are
convenient for continuing education courses. One recent study compared the
effect of using WBT alone with the effect of using WBT in addition to hands-on
training with pediatric residents to measure knowledge of preventive oral
health and confidence. Both methods resulted in increased knowledge, efficacy,
and practice of preventive oral health (Talib, Onikul, Filardi, Simon, &
Sharma, 2010). Similarly, a separate study compared different strategies for
delivering an e-curriculum to clinicians to assess knowledge, confidence, and
communication about dietary supplements using e-mail, the web and electronic
reminders. All delivery strategies tested comparable levels of improved
knowledge, confidence, and communication scores among the participants (Kemper,
Gardiner, Gobble, Mitra, & Woods, 2006). Another study with Australian
health educators showed that learners who
were enrolled in a WBT acquired the knowledge disseminated through the
educational experience course and used it in their work (Pullen, 2006).
Although educational
applications of the web will continue to grow, well-designed trials are needed
(Gagnon et al., 2009)to
studychallengesof web-based curriculums
including cost, access, educational content, and instructional design (Janicki
& Liegle, 2001).

Few studies thus far have focused on WBT and
interpreters. Of the studies that do exist, most focus on comparing provider
satisfaction with different types of interpretation methods and  describing the interpretation errors of
ad hoc interpreters  compared with
those of professional interpreters (Nápoles et al., 2010). In this study, we
hypothesized that dual-role staff interpreters would improve their
interpretation skills after participating in a WBT and would report higher
knowledge and confidence scores than those who did not participate in the
training. We also explored the association between (a) gender, ethnicity, first
and second language spoken, and level of education and (b) improvement in
knowledge and confidence.


Sutter Health, an integrated health care system

Sutter Health comprises 26 hospitals, five medical
foundations, and more than 3,000 physicians. It serves 23 municipal counties
throughout Northern California, delivering inpatient and ambulatory services to
approximately 18.4% of the State’s patients, representing wide cultural,
ethnic, and linguistic diversity. According to U.S. Census 2010 data, 1.5
million residents within the communities that Sutter Health affiliates serve
can be categorized as LEP and speak languages other than English at home. Of
the total LEP population, 49% speak Spanish, 12% speak Indo-European, and 39% speak
Asian languages at home (U.S. Census Bureau, 2000). Sutter Health is the
largest health care system in Northern California and the ninth largest in the
United States. Its interpreter service needs represent a national trend as U.S.
demographics continue to change. Most Sutter Health hospitals use dual-role
staff interpreters, contract with external vendors for face-to-face
professional interpreting, and provide telephone interpreter services to meet
the language demands of their LEP patient population.



The study sample consisted of 1,112 dual-role staff
interpreters who passed the language competency test at Sutter Health (for a description of this test, see Moreno et
, 2007). The examination tested
accuracy, comprehension, communication, and medical terminology in English and
in the language other than English spoken. Language competence tests were
administered in 16 different languages. The majority of the bilingual staff
tested passed at the medical level (56%), and approximately one third (34%)
passed at the basic level. Staff who passed the examination at the basic level
able to speak both English and the language other than English
fluently and had some knowledge of basic medical terminology. These staff
members are best used for nonclinical interactions such as making appointments
at the front desk. Staff who passed at the medical level had college-level
reading and writing in both English and the language other  than English and were fluent in medical
vocabulary. They were deemed linguistically fit to provide bilingual
communication support at a medical encounter.


This was an action research study (O’Brien, 2001)
in response to a large-hospital-system need to train dual-role staff
interpreters. We used a pre–post training design with a comparison group to
examine the effects of both the web-based Interpreter Skills Training Course
(between-subjects factor: intervention group vs. comparison group) and the
knowledge and confidence improvement scores before and after the intervention
(within-subjects factors: before and after, time effect). To assess the
participants’ pre-existing knowledge, skills, and confidence, all participants
completed a pre-training evaluation and a demographic questionnaire. The course
was designed with five learning modules and a post-test for each module.

 Interpreter web-based curriculum training

In 2000, Sutter Health started training dual-role
staff interpreters using a traditional group-training approach. The training
content was provided in one session using a PowerPoint presentation, with time
allotted for questions and answers. The training was arranged at each Sutter
Health facility. However, the growing demand for medical interpretation
services at Sutter Health’s 26 affiliated hospitals was beyond capacity and
would not have been cost effective. To meet the training demand and to set a
standard for interpreter skills in a clinical setting, a team of web
consultants, interpreter researchers, and health educators developed a WBT that
was interactive, self paced, and easily accessible and that addressed different
levels of knowledge and skills.Curriculum development took approximately 12 months and followed the Sutter Health Publishing Standards (Sutter Health, 2011), which were created to ensure that all e-learning courses
at the organization were successfully published on the HealthStream Learning
Centre, Sutter Health’s learning management system (LMS). Theoretical framework

This project was an action research study (O’Brien,
2001) that aimed to solve Sutter Health’s concerns about systematically
training dual-role staff interpreters in a more efficient way.. First, we
identified the problem. Second, we planned and tested a potential solution
(i.e., WBT compared with no training). Third, we collected and analyzed data to
learn how successful the WBT was. Fourth, we took best practices and lessons
learned for future improvement of the training curriculum.

We also adapted learning principles from Bandura’s cognitive theory of learning (Bandura, 1986), which explains how people learn and gain confidence through
observing others’ behaviors, attitudes, and outcomes. To facilitate learning by
imitation, we used professional medical interpreters as role models in the
video case studies. The curriculum also used instructional design concepts
(Gagne, Briggs, & Wager, 1988), including clear definition of learning
objectives, variety of presentation styles, multiple exercises,
learner-controlled pace, testing and feedback, clear navigation, and consistent


provide the foundation for the WBT, we adapted a combination of different
learning theories, including constructive, cognitive, and behavioral theories.
In total, 84 images and video segments, adapted from The California Endowment
(2002), were used throughout the training modules to illustrate the main
points. Our training objectives used Bloom’s (1956) classification of
educational objectives. Bloom’s taxonomy provides a structure in which to
categorize instructional
objectives and assessment
. Bloom’s taxonomy enabled us to prepare objectives and, from there, derive
appropriate measures of learned capability and higher order
thinking skills
. The curriculum also incorporated multimedia development principles for a
highly effective e-learning design using Mayer’s research philosophy (Mayer,
2005). Those principles have been validated repeatedly, and researchers have
found that they ensure learning outcomes of proven value. Some of Mayer’s
learning principles view each interpreter as a unique
individual with unique needs and
backgrounds. Thus, the curriculum provides learning opportunities for beginners
and advanced interpreters. The importance of considering the individual
learner’s background and culture was emphasized by providing case studies with
interpreters from diverse backgrounds. The WBT had eight reflection activities
to increase awareness of the participants’ cultural values, beliefs, and
practices. The 14 brief video segments featured three distinct case studies of
interpreter interaction with patients of diverse ethnic and linguistic

Procedures among participants

To implement
CHIA’s linguistic standards at Sutter Health, we assessed dual-role staff
interpreters’ bilingual skills using a validated language evaluation test.
Results showed that one in five dual-role staff interpreters did not have
competent bilingual skills (Moreno et al.
, 2007). A total of 840 dual-role staff interpreters from 26 Sutter Health
hospitals were tested for Spanish (75%), Chinese (12%), and Russian (5%) language
competence in English and the language other than English spoken. Two percent
failed the competency test, and 21% possessed a limited ability to read, write,
and speak both languages. The study uncovered interpretation errors, including
omissions and word confusion, which can negatively affect clinical outcomes and
can potentially lead to miscommunication and medical errors. In this study, we
took the preliminary assessment results one step further, using a WBT to train
dual-role staff interpreters to facilitate communication between LEP patients
and providers.


intervention group was made up of only those dual-role staff interpreters who
passed the aforementioned language competency test at the basic and medical
levels and who were, therefore, qualified to take the WBT. Each participant had
a personal Sutter Health username and password to log into the online WBT
template (HealthStream). The first step of the training was to complete a
demographic questionnaire including age, gender, affiliated medical facility,
education, previous training experience, and spoken languages. Next,
participants answered a 23-question pre-test, enabling us to assess knowledge,
overall interpretation ability, effective communication skills, cultural
competence in interpretation, and interpreter code of ethics (see Appendix).

After the initial assessment, participants had 3
weeks to complete the five modules and individual post-tests at their own pace.
Each participant had three opportunities to fail and retake each module and
post-test. The WBT contained interactive learning tools, including participant
question-and-answer exercises throughout the course and post-tests.
Certificates of completion were given once the participant successfully
completed the 20-question post-test after the last module. HealthStream is set
up to allow each participant to move forward once the previous module is
completed and once the post-test is passed with an 80% success rate. The 10
questions for the first four modules post-tests are randomly drawn from a pool
of questions specific to that particular module; the final post-test consists
of 20 questions covering topics from all five modules.

The comparison group was identified through a pool
of dual-role staff interpreters who had passed the language competency test at
the basic or medical level but had not completed or enrolled in the WBT. The
comparison group was solicited via an e-mail communication, and group
participants self-selected to participate in the study. Comparison group
participants completed the same 23-question pre-test administered to the
intervention group and, 3 weeks later, completed the same 20-question post-test
administered to the intervention group. The 3 weeks between pre- and post-tests
was based on the estimated time allotted for the intervention group to complete
the entire WBT. Unlike the intervention group, the comparison group did not
complete the WBT on HealthStream. This group did not receive a certificate of
completion, but participants were given a $30 gift card for participating.

WBT modules

The five WBT modules are made up of 88 separate web
pages. Table 1 presents an example of WBT learning objectives, activities,
knowledge, and confidence post-test questions.


Learning objective


Knowledge-based post-test question

Confidence-based post-test question

Identify skills that
support the patient–provider relationship.


Describe how to use first-person voice.


First-person voice is defined, followed by first-person voice examples.


The dual-role staff interpreter identifies which statements are in
the first person. When the participant scrolls over the statement, a pop-up
box indicates whether the selection is correct.

During an interpreting session, the interpreter’s positioning can
facilitate or hinder interaction between patient and provider. Which is the
best position for the interpreter?


a) The interpreter is next to and slightly behind the patient.

b) The interpreter is between the provider and the patient.

c) The interpreter is next to the provider.

d) All of the above.


True or False: An interpreter should not accept an assignment in
which she/he is not confident of being able to interpret accurately and



Table 1: Example of
web-based learning objectives, activities, and knowledge-based and
confidence-based post-test questions

Module 1: Introduction to health care interpreting 


Module 1 presents an overview of the training and
reviews the levels of interpreter services at Sutter Health. This module
describes the roles, responsibilities, and protocols of an interpreter in a
clinical setting. Additionally, it details how to conduct an appropriate
interpreter session, describing where to stand during the interaction and the
importance of using first-person speech. At the end of the module, staff were
prompted to take the 10-question post-test. Upon completing the post-test,
staffs receive a score and feedback is provided to further reinforce learning

Module 2: Communication skills in health care  

Module 2 focuses on patient–provider–interpreter
communication, common errors, ways to handle complex interpreting situations,
and tools to support interpreter communication. Visual aids, examples, and case
studies are used to teach the importance of health care interpreter
communication roles and ways to identify those roles. After completing the
second module, staff are prompted to take a 10-question post-test to measure
their communication skills and knowledge.

Module 3: Cultural competence during interpreting

Module 3 reviews organizational management
strategies that interpreters can use to support culturally competent care, CLAS
standards, patient demographics, challenges and solutions to providing
culturally appropriate health care services, and culture-specific issues
typically encountered in medical interpreting. This module provides practical
examples depicting how to create culturally competent interpretation
interactions. The case study in this module highlights cultural influences in a
patient’s experience and the use of staff skills and tools to assist the
patient. Self-assessment tools are used throughout the module to help staff
reflect on their cultural beliefs and experiences. The 10-question post-test
covers content and themes introduced in this module.

Module 4: Code of ethics principles

Module 4 reviews the CHIA Code of Ethics and
introduces staff to California Standards for Health Care Interpreters
(California Health care Interpreting Association, 2002). The 10-question
post-test measures skills and knowledge related to ethics and interpreter

Module 5: Medical vocabulary


Module 5 presents common medical terminology and
clinical tests, concluding with a variety of resources and informational pages
for bilingual staff who want to learn more about health care interpreting or
are interested in pursuing a professional interpreter certificate. After the
fifth module is completed, interpreters are prompted to take a 20-question
post-test,which combines information from
the previous four modules. The 23-question pre-test and the 20-question
post-test contain the same questions, which allowed us to compare the results
and assess improvement of knowledge, skills, and confidence. Table 1 provides
an example of typical module objectives, content, and post-test questions
assessing knowledge and confidence.

Statistical analyses

First, we explored descriptive characteristics of
the sample for both the intervention and comparison groups. Univariate analyses
using chi-square tests allowed us to determine whether the observed proportions
for the dichotomous variables differed from the expected proportions for each
of the demographic characteristics among both groups. Second, we compared
dual-role staff interpreter knowledge means before and after the intervention
by study groups using paired t-test
comparisons. Third, we used a general linear model (GLM) repeated measures
analysis of variance (ANOVA) to examine the effects of both the WBT
(between-subjects factor: intervention group vs. comparison group) and the improvement
knowledge scores before and after the intervention (within-subjects factor:
before and after, time effect). This procedure provides an ANOVA to test the
null hypotheses about the main effect of the online training intervention and
the effect of the knowledge differential pre-post test.. In addition, the GLM
repeated measures ANOVA allowed us to test the effects of covariates and
investigate interaction effects. Finally, this procedure allowed us to use
unbalanced models in which each cell in the model contained a different number
of cases (e.g., different sample size of the intervention and comparison
groups). When making multiple comparisons, we used the Bonferroni correction
(Jost, 2009) to adjust the significance level to account for multiple comparisons.


Demographic characteristics

Table 2 presents the demographic characteristics of
the study participants. Overall, both the intervention and comparison groups
had similar demographic characteristics, including gender, age, first and second
language spoken, level of education, previous training, and ethnicity. The
majority of participants were women (89.9%), were younger than 40 years of age
(68.7%), spoke English as a first language (68.8%) and Spanish as a second
language (77.6%), had any college level (74.6%), had no formal interpreter
training (64.6%), and were of Mexican, Latin American, or Spanish origin
(76.6%). In addition to these similarities, the two groups also showed
differences: The intervention group had more previous interpreter training than
the comparison group, ?2(1, N = 195)  = 11.37, p < .001; tended to be
older, ?2(1, N = 198) = 5.07, p <
.02, than the comparison group; and learned a second language outside their
home (i.e., learned second language at school or lived abroad), ?2(1, N = 196) = 6.51, p < .01, as opposed to
the comparison group, who did not. Given that respondents had the option to
refuse to answer any of the survey questions, the number of respondents is not
consistent across characteristics for the intervention group.

Knowledge improvements

Table 3 presents the
knowledge score means with
intervention and comparison groups before and after the implementation
of the WBT. For the intervention group, there was a significant increase, t(1) = –20.71, p < .001, in interpreter
knowledge mean scores before (M = 12.74) and after (M = 17.59) the WBT. In contrast, the interpreter knowledge mean scores in the comparison group
remained unchanged, t(48)
= 0.81, p = .41,
before (M = 11.78)
and after (M = 12.18)
the 3-week period between the pre- and post-test. The interpreter knowledge
mean score was 4.84 for the intervention group but was only 0.04 for the comparison group.

Table 4 presents the results in the multivariate
GLM repeated measures ANOVA. Overall, education-relevant variables were more
related to interpreter knowledge improvement scores than were demographics.
Individuals in the intervention group produced higher before–after interpreter
knowledge score differences, F(1,
1) = 107.83, p <
.001, than did the comparison group. In addition, individuals with any amount
of college education, F(1,
1)= 13.3, p < .001, and those with
any type of previous interpreter training, F(1,
1) = 5.90, p = .016,
tended show greater improvement in their interpreter knowledge scores than did
the comparison group. Among the demographic variables, age, F(1, 1)= 3.79, p < .05, was more
associated with interpreter knowledge improvement than was gender, F(1, 1) = 0.011, p = .91, or
race/ethnicity/Hispanic origin, F(1,
1) = 0.19, p = .65.

When testing for within-subjects contrasts,
differences in before-and-after interpreter knowledge emerged. Overall,
interpreter knowledge means were significantly higher in the intervention group
after the WBT than before, F(1,
1) = 10.12, p < .001.
Additionally, two statistically significant interaction effects emerged for the
before-and-after conditions: WBT, F(1,
1) = 79.271, p <
.001, and education, F(1,
1) = 6.39, p <
.01. To better understand these interaction effects, we present profile (interaction)
plots in which each line point indicates the estimated marginal means of the
before-and-after interpretive knowledge score adjusted for covariates (age,
gender, race/ethnicity, education, and previous interpreter training).

Table 2: Demographic characteristics of intervention and comparison groups

Table of Demographic Characteristics

ab = Significant differences at p <
.05; ac = Significant differences at
p < .001.



Table 3: Interpretive knowledge means and levels of significance, before and after training

Interpretive knowledge means and levels of significance, before and after training

Table 4: General linear model (GLM) repeated
measures analyses of variance: Main and interaction effects

Table 4: General linear model (GLM)


Note.  adf = 1.


Figure 1 presents the Before-and-After Condition
(pre-test to post-test) × WBT (intervention and comparison groups)
interaction effects. The estimated before-and-after interpreter knowledge
marginal mean scores increased significantly for the intervention group but
remained the same for the comparison group. The estimated interpreter knowledge
score mean difference between the intervention and comparison group was very
small before the WBT but increased significantly after the intervention,
showing nonparallel lines, or interaction effects.             


Figure 1 presents the Before-and-After Condition

Interpreters’ confidence in their ability to do their jobs 

Participants in both groups expressed a high degree
of confidence in the ability to provide interpreter services, with each group
being equally confident, as shown in the pre-test, ?2(1, N = 171) = 0.001, p = .95. There was no
significant improvement in confidence after the WBT (in the intervention group)
and after the 3 weeks (in the comparison group), as evidenced by the results of
the post-test,  ?2(1, N = 170 ) = 1.55, p = .21.


Our findings
that untrained dual-role staff interpreters can improve their
knowledge of core concepts to a level that will allow them to interpret in a
medical setting after participating in a WBT. Interpreters showed significant improvements in understanding the interpreter’s role as
a member of the patient–provider–interpreter triad as well as the respective
boundaries, responsibilities, protocols and code of ethics. Our findings from
this study support the conclusion that it is possible to train ad hoc
interpreters in a medical setting. Similarly, another recent study showed that
trained ad hoc interpreters were less likely to make errors with patients who
spoke another language and were less likely to make clinical errors than were
ad hoc untrained interpreters (Gany et al., 2010). Our results confirm
conclusions from another study with Australian health care professionals
(Pullen, 2006) showing knowledge
improvement after using web-based continuing health education courses.


    Our study suggests that the type of learning experience provided in our WBT curriculum is
effective in improving knowledge of core interpreting concepts. The
multiple strategies and presentation styles
used in the
HealthStream curriculum include advancing the interpreter through five
self-paced modules highlighting fundamental
concepts for interpreting
in a medical encounter, tailoring the content to dual-role staff interpreters
at a basic level as well as at a medical level, and addressing the cultural and
language needs of the diverse LEP patient population served. In addition, the
training reinforces interpreters’ learning through each module by asking them
to address case studies, using audio and video aids, and providing individual
feedback throughout the training. Although
combination of learning strategies successfully improves dual-role staff
interpreters’ knowledge, we do not know what strategy—or combination of strategies—played
a critical role in our results. Further studies should address this question.
Although our curriculum asked the interpreter to learn actively by engaging in
real-life scenarios, it is limited in its coverage of the key interpreter
skills suggested by Angelelli (2006), including cognitive processing,
interpersonal, linguistics, professional, setting-specific, and
sociocultural-related skills.


Results also indicate that there was no improvement
in the intervention group’s confidence when compared with pre-test scores and
when compared with the confidence differential of the comparison group. A
potential explanation for this finding is that the WBT mostly addresses
knowledge and subject-matter content but not confidence-building activities. Another
possible explanation for the lack of improvement in confidence scores is that
the self-ratings of confidence can be influenced by social desirability bias.
Additionally, awareness of skill level improves as interpreters become more
skilled; however, at the same time, interpreters become more conscious of their
lack of knowledge in certain areas as their skills improve (i.e., they begin to
know how much they don’t know), and affecting self-ratings. These issues could
have affected the confidence questions in the study.Future research that refines the confidence
measure would provide helpful insights. Our findings also illustrate that there
are many dual-role interpreters who have a poor knowledge base and low
awareness of their lack of skills but who may feel confident to serve as
interpreters. Caution should be used with health service organizations that
currently employ unskilled staff to serve as dual-role staff interpreters.


Focus groups that were conducted with Sutter Health
dual-role staff interpreters after they participated in the training suggest
that they would like to continue seeking training to improve their knowledge
and their confidence in managing difficult situations during a medical
encounter. Examples of learning objectives to be incorporated in future
trainings may include keeping up to date with the latest guidelines, improving
knowledge of medical terminology, using techniques to pace interpretation, and
managing the triadic patient–provider–interpreter communication. Confidence-related
skills to be taught include how to deal with role conflicts when interpreting
in a medical encounter, managing the requests of a patient’s relatives, working
with rushed and anxious physicians, and being assertive with providers when
attempting to clarify roles. Given the limitations of addressing the
aforementioned complex issues in a WBT, future WBT programs could use
interactive learning strategies such as clinical simulation and group training
to enhance complex behaviors. A more appropriate method of evaluating complex
interpreter skills is to conduct observations of professional interpreters’
encounters with doctors and patients. One observational study (Laws, Heckscher,
Mayo, Li & Wilson, 2004) evaluated the quality of medical interpretation in
a pediatric outpatient setting and explored the patterns and correlates of
errors and failures in interpretation. The authors found that 66.1% of segments
were interpreted with substantial errors or omissions, or were not interpreted
at all.

As expected, individuals with any level of college
education and those with any previous interpreter training tended to improve
their interpreter knowledge scores, as compared with their counterparts, who
did not improve at all. A study conducted by Refki, Avery, and Dalton (2008)
indicated that individual characteristics can impact the interpreter’s belief
about whether a certain knowledge or skill should be considered a core
competency. These characteristics include length of training, trainees’
experience with previous training or having gained knowledge from taking
relevant courses, and the number of interpreting encounters performed (Refki,
Avery, & Dalton, 2008).


This study
has some limitations. The use of nonrandomized small samples limits the
generalizability of our results. Given Sutter Health’s policy for study
participation, random selection of interpreters was not possible. In addition,
participants’ self-selection to the study may have biased our findings. It is
possible that the most motivated interpreters were the ones interested in
participating. There is still potential for improving our measures of knowledge
and confidence in interpretation and in assessing other key interpreter skills.
Particularly, the validity of the question that we use to assess confidence
(i.e., “How confident do you feel in your ability to interpret?”) may need
further study. Despite the design of the instructional modules, the WBT was
intended to address the most critical interpreter skills. It used proven
strategies to facilitate critical thinking, exploration, and integration.
Blended strategies, in which face-to-face and online methods for learning are
combined, would produce the best of both learning modes (Bourne, Harris, &
Mayadas, 2005) to improve interpretation of complex skills such as cultural
communication styles, values, beliefs, and attitudes and, in turn, would
improve interpreters’ confidence. Interpreting is a profession requiring a
complex set of skills that cannot be adequately taught in a single short course.
Our approach is appealing, convenient, and effective in responding to
real-world training needs in large health care organizations. However, this
type of training has shortcomings for interpreters. WBT gives the interpreter
less of the one-on-one attention that is often necessary for the improvement of
communication skills. Future research is needed in which the authors combine a
mixture of face-to-face and virtual interactions among a group of interpreters
led by one or more coaches over an extended period. Studies show that combining
online and face-to-face instruction has a greater advantage than courses that
are offered exclusively online or exclusively face to face (Means, Toyama,
Murphy, Bakia, & Jones, 2009). In addition, allowing the participants and
instructors opportunities to communicate with one another asynchronously,
through either a “chat room” or e-mail, could improve the learning of complex
skills (Pullen, 2006).
Efficient WBT combined with other interpreter
training strategies needs to be explored and evaluated in further studies as we
attempt to improve the skills of untrained bilingual staff (Ramirez, Engel,
& Tang, 2008) in their role as dual-role staff interpreters.

WBT can be used as a promising option for large
health care organizations with high language-services demands. However, strict
organizational and government regulations should be established to limit
interpretation only by competent bilingual staff who are properly and
consistently trained. In addition, hospitals can help with the appropriate
allocation of resources by setting and enforcing standards for using certified
interpreters and for motivating trained dual-role staff interpreters to become
certified interpreters.Unfortunately,given the high demand for
interpreters, many providers find it convenient to use untrained dual-role
staff interpreters with insufficient bilingual skills. In addition, providers
often “get by” in providing interpreting services for the patient, only to have
negative consequences later. In a recent study (Schenker, Pérez-Stable,
Nickleach, & Karliner, 2011), few patients (19% at admission, 12% since
admission) reported that physicians spoke their language well, and even fewer
(6%) reported that nurses spoke their language well. Patients reported that
they “got by” without an interpreter or were barely spoken to at all by nurses
(38%) and by physicians (14%) at admission.

This study provides insight into an e-learning
curriculum that could be used across large, diverse health care organizations.
Future studies using larger random samples are needed; such studies will enable
generalizations to be made about the use of WBT for all dual-role and
professional interpreters and will allow researchers to examine factors that
may influence the effectiveness of a WBT intervention, including the type of
technology, potential users, and practice settings (Gagnon et al., 2011) as
well as the cost-effectiveness of training modalities across different clinical

Although Sutter Health employs professional
interpreters for face-to-face interpretation needs, the interpreter demand is
at such a high level that Sutter Health providers also use tested and trained
bilingual staff (i.e., dual-role staff interpreters) to interpret when
certified interpreters are not available. To respond to this high demand, we
are currently pilot-testing a video remote interpreter service that has a cadre
of professional interpreters in many languages connecting (via computer) with
providers and patients to provide real-time interpretation. We plan to report
on the results of this study in the near future. Many organizations face the
challenge of ensuring that sufficient resources are in place in order to
provide the highest quality interpreting services, and it is likely that the ability
to meet this challenge will continue to be influenced by other competing
priorities. The training of interpreters absorbs resources and needs firm
support from organizational leadership, the availability of effective training
programs, and the interest of the staff to be trained. As the interpreting
field continues to advance, more evidence is required for how best to design,
use, and disseminate WBT curricula for interpreters.


5. Acknowledgments

This research was
generously supported by a grant from The California Endowment. The authors
greatly appreciate Susan Maunders’ contribution to the development of the
HealthStream curriculum.



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of Questions on Sutter Health Online Interpreter Skills Training Demographics


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Question 1

What is your

Question 2

What is your
primary language?

Question 3

Where did you
learn the second language that you speak?

Question 4

What is your

Question 5

How confident do
you feel in your ability to interpret?


and Post-Training Evaluation Questions


Question 1

During an
interpreting session, there is a three-way partnership among patient,
provider, and interpreter. Which role is most important?


Provider—who  brings medical expertise


brings knowledge about symptoms, personal health beliefs, and practices


brings linguistic and interpreting skills


All of the above

Question 2

True or false: If
a patient talks for a very long time or gives information that does not seem
relevant, it is the responsibility of the interpreter to redirect the conversation.





Question 3

True or false: If
a patient asks for medical advice, a staff interpreter who is also an RN can
assume the duties of RN as well as the duties of interpreter and respond to
the patient’s request.





Question 4

True or false:
The interpreter’s beliefs toward folk remedies have little influence on the
interpreted encounter.





Question 5

True or false: An
interpreter should not accept an assignment in which she/he is not confident
of being able to interpret accurately and completely.





Question 6

True or false: If
the patient is rude or swears, this does not need to be interpreted because
you may offend the provider.





Question 7

True or false: In
California, the law mandates the disclosure of information to health care
providers by interpreters when there is evidence of abuse or when a person is
threatening harm to him- or herself or others.







Correspondence to:


note: IJIE and the Conference of Interpreter Trainers does not endorse the use
of unqualified interpreters in any context but recognizes the value in
providing training to those people who are employed in hospitals and who may be
called upon to interpret.