Despite certain persistence to treat verbal and nonverbal communication as distinct, separable aspects, research has thoroughly proven this separation as misleading and obsolete (LeBaron, Mandelbaum, and Glenn, 2003). Furthermore, several studies defend that 70% of our communication is nonverbal (Qureshi, Revollo, Collazos, Würth, and el Harrak, 2009), giving these elements an undeniable weight in any kind of face-to-face interaction. Obviously, interpreting processes do not escape this rule, but quite the contrary: bilingual mediated interactions draw a more complex scenario, since the meaning of nonverbal cues changes across cultures (Qureshi, 2009) and the interpreter should thus be the link that decodes their meaning appropriately (Qureshi, 2009). The importance of this task may be even bigger in contexts such as medical settings where people’s health is the issue at stake and, accordingly, a good, efficient communication between patient and provider is essential for a satisfying outcome (Trummer, Mueller, Nowak, Stidl, and Pelikan, 2006; Street, Makoul, Arora, and Epstein, 2009).

Many works have already studied the relevance of nonverbal elements in healthcare communication. In this vein, we can easily find evolving and relevant bibliography approaching these issues in different manners. From groundbreaking studies such as Rosenthal, Hall, DiMatteo, Rogers, and Archer’s (1979) to reference materials for professionals like Silvermans, Kurt, and Draper’s (2005) through papers like de Castro’s and da Silva’s (2001), Preston’s (2005), or D’Agostino’s (2014), several authors have tackled and discussed the relevance of nonverbal cues in healthcare face-to-face interactions. However, the situation is significantly different when it comes to connect these elements to the actual practice of interpreting in medical settings.

Implementing all these elements in a triadic face-to-face interaction is not an easy task: it requires specific abilities and a particular approach to healthcare interpreting. In this regard, researchers like Angelelli, Davidson, and Clifford (as cited in Jacobson, 2009: 54) or the group formed by Miletic, Piu, Minas, Stankovska, Stolk, and Kimidis (2006) advocated the need to include interactional competence in the interpreting process, portraying the inadequacy of word-for- word interpreting when the objective is (or at least should be) rendering the message including all its nuances of meaning.

These and other authors have already created a scarce albeit solid literature connecting interpreting in healthcare settings and nonverbal cues. Besides the abovementioned works, other examples range from overall approaches such as Poyatos’ (1997) almost seminal work to research aimed at specific contexts such as mental health (Bot, 2005). In addition, books like Angelleli’s (2004) or Riggio and Feldman’s (2005) devoted some of their chapters to approach nonverbal communication in healthcare mediated interactions, whereas papers such as Hsieh and Nicodemus’ (2015) focused on how interpreters tackle specific nonverbal cues as, in this particular example, emotions. However, although the aforementioned works have created a sound basis defending the implementation of elements beyond mere words in the interpreter’s task in healthcare settings, the actual amount of research should still be extended in order to cement the importance of nonverbal aspects in interpreter-mediated interactions in these contexts.

Using some of the works cited in previous paragraphs as the main theoretical grounds, I decided to undertake a comparative content analysis of three manuals addressed to healthcare interpreters: Working with Interpreters: Guidelines (Queensland Health, 2007), the Medical Interpreting Standards of Practice (IMIA, 2007), and the National Standard Guide for Community Interpreting Services (Healthcare Interpretation Network, 2007). This analysis is aimed at contributing to widen the bibliography described before and also at achieving the goals described in the following section.

As the following pages will corroborate, healthcare interpreting standards are neither “blind nor deaf” to the importance of nonverbal communication, and they do take into consideration other elements beyond mere words. However, these features should be analyzed in greater depth for a subsequent implementation of increasingly improved suggestions and guidelines (Jacobson, 2009). In this vein, this paper will investigate whether the importance of non-verbal communication in healthcare interpreting is appropriately addressed in a sample of manuals and standards of practice.

For this purpose, the three manuals introduced in the preceding section will be contrasted so as to reach several objectives. The following list presents the two main purposes of this work together with the secondary aims that stem from the first one:

1) To determine how nonverbal communication is reflected in different manuals addressed to healthcare interpreters, to check whether they take interactional competence into consideration or not and, in the latter case, to examine to what extent they do so.

In order to achieve this primary goal, it will be necessary to assess the approach of the manuals to a series of specific nonverbal communication cues in order to explore which ones are properly addressed, which ones are tackled superficially, and which ones are overlooked outright.

2) To provide some suggestions and guidelines that may help healthcare interpreters deal with nonverbal elements during their task.

The present project combines different types of analyses that divide the paper into three main stages. During the first one, a comparative content analysis of some of the most relevant manuals related to interpreting in healthcare settings was conducted. In order to do so, different standards of practice and working-with- interpreters’ guidelines within this field were consulted. Given their leading role in healthcare interpreting services, the focus was put on selecting manuals from Australia, the United States, and Canada. After considering different options, the manuals chosen were:

1) IMIA’s (2007) Medical Interpreting Standards of Practice. One of the most renowned manuals worldwide, IMIA’s standards of practice are probably amongst the most thorough approaches to interpreting in healthcare services. It was one of the first manuals to be developed addressing language interpreting in healthcare settings. Nowadays, it remains a reference in United States medical institutions, and its popularity has turned this guide into a landmark used as training bases beyond the US for establishing the competence of interpreters working in this context.

2) Queensland Health’s (2007) Working with Interpreters: Guidelines. A guide including suggestions for an effective coordination between interpreters and providers, aimed at improving the dynamics of interpreter-mediated interactions and the information obtained in this sort of dialogue. Issued in one of Australia’s larger states, the selection of this manual is aimed at including a relevant guide which combines interpreter’s potential performance with the viewpoint of healthcare professionals. This manual complies with the requirements established by the Australian Institute of Interpreters and Translators (AUSIT) regarding conduct, privacy, and confidentiality.

3) National Standard Guide for Community Interpreting Services¹⁾ by the Healthcare Interpretation Network (2007). A national manual which spans the most relevant guidelines used in dialogue-like mediated interactions in Canada. It is built on the opinions and contributions of several professional organizations, and contrary to the Canadian trend of establishing regional standards, it is aimed at being used and distributed nationwide. In addition, it seeks to boost interpreters’ recognition and professionalization while, at the same time, tries to raise awareness among the general public of interpreters’ tasks and duties.

Beyond their relevance, their focus on healthcare interpreting, and the necessary approach to nonverbal communicative features that, to a greater or lesser extent, they all share, selecting these manuals instead of other alternatives serves a further purpose: it allowed me to compare suggestions and guidelines from different countries with strong interpreting networks. In this regard, Australia, Canada and the United States (the regions were these guides were originally edited and published) were, together with the United Kingdom, pioneers in cementing the role of the interpreter within their Public Services system, a long tradition that makes them a reference for latecomer countries (Navaza, Estévez, and Serrano, 2009).

In this vein, the solid training programs for interpreters offered in these countries are another reason to validate the choice. Australia, for example, is one of the most advanced regions in this regard. In Australia, community interpreting (and consequently, healthcare interpreting as well) was established in the mid-1970s to give response to an increasing multicultural society (Hlavac, 2016). This initiative paved the way for Australia’s most distinctive feature: the National Accreditation Authority for Translators and Interpreters (NAATI), created in 1977 (Hlavac, 2016). The creation of this system was later reinforced by the founding of the Australian Institute of Interpreters and Translators (Valero, 2014). In parallel, university programs bloomed during the 80s, faded in the 90s (Valero, 2014), and regained their strength afterwards via institutions as the Middlebury Institute of International Studies at Monterrey or the Western Sydney University. Nowadays, the strongest interpreting courses of tertiary education coexist with private initiatives from different agencies aimed at covering the linguistic needs of citizens in public institutions, including healthcare services (Valero, 2014).

In the United States, interpreting began with sign language interpreters back in the mid-1960s, but it soon expanded to other fields (Mikkelson, 2014). Healthcare interpreting bloomed in the 1990s and solidified in the 21ˢᵗ century with the demographic trends and legal pressure that “forced” the country into implementing linguistic services in every hospital (Roat and Crezee, 2015). To ensure the quality of these services, the National Council on Interpreting in Healthcare established a tough list of standards connected to items such as accuracy, privacy, or cultural awareness (NCIHC, 2005) that every medical interpreter must meet (Mikkelson, 2016). In order to achieve this level, interpreters could be trained at several universities or via different agencies and organizations such as the American Translators Association or the International Medical Interpreters Associations (Mikkelson, 2016). All these elements combined have created a strong healthcare interpreting system in most regions of the country that has Spanish as its most notable second language.

Finally, Canada’s case is slightly different. In this country, accreditation programs are mainly organized at a regional level (Valero, 2014). Thus, regions can establish different criteria according to their needs. Training programs are galvanized and promoted by local entities, but also by universities with interpreting degrees and even translation and interpreting schools such as those at the University of Ottawa and at the University of Vancouver. Healthcare interpreting occupies a prominent place in these programs, since most Canadian hospitals offer language and interpreting services (Valero, 2014) and professional Canadian interpreters should be solidly qualified to cover these needs.

Considering the aforementioned data, it seemed relevant to focus the analysis on a sample of standards of practice coming from three pioneering countries with an overarching approach to interpreters’ training both in general and specific fields like the one at the focal point of this paper.

Once the corpus was delimited to the three manuals described above, the next stage of this undertaking was conducting a comparative content analysis of the selected corpus. In this vein, a qualitative analysis was conducted in several stages. The process started with a close reading of the manuals selected: during this stage, each reference to paralanguage and nonverbal communication was marked on a printout of the manuals. The underlined segments were assessed in order to determine their thoroughness and identify their strengths and weaknesses (if present) afterwards. Subsequently, all references to nonverbal communication included in the manuals (body language, eye contact, spatial arrangements, voice features) were listed.

A review of relevant literature related to nonverbal communication as a whole and to its influence/use in healthcare settings followed these stages. This step helped in identifying some critical elements that were not present in the analyzed texts. Consequently, the discussion crafted after perusing the corpus was divided into two sections: elements included in the manuals and elements missing in the manuals.

The first section aims to describe the manner in which these documents address nonverbal communication in healthcare interpreting in order to determine its appropriateness and highlight its flaws if necessary. The second part of this analysis focuses on nonverbal cues that the three manuals fail to include in spite of their undeniable potential impact on a triadic dialogue. In this vein, further nonverbal elements and their relevance for communication are explained.

The final section of the project takes a normative approach which intends to suggest a list of guidelines with the purpose of improving the current state of affairs and the insufficient emphasis on the importance of nonverbal cues spotted in the three manuals analyzed. In this regard, the problems underscored and itemized during the analytical stage led to a thorough research on academic works that zeroed in on the relationship between nonverbal communication and interpreting. This process seeks to find and put forward several solutions that may give an appropriate response to the difficulties of including definite nonverbal cues in the interpreting process, while they also emphasize the benefits of conveying such aspects during interpreter-mediated interactions occurring in healthcare settings.

Nonverbal communication includes so many different features that it would be impossible to address them all in a few pages. In accordance and given their mere guidance purposes, it is perfectly understandable that healthcare interpreting manuals and standards of practice fail to provide a totally comprehensive repertoire of these items and how to handle them during the communicative process. Therefore, the following description of (some) nonverbal missing elements should not be perceived as a critique, but as a reasoned proposal to assist the interpreters’ task and provide a series of theoretical grounds to at least gauge the convenience of considering and/or including them in the interpreting process when necessary.

Given all the reasons explained in sections 4 and 5, I believe additional suggestions complementing the ones already included in the corpus may lead to more thorough approaches to healthcare interpreting and, therefore, to more successful outcomes. As Poyatos (2002b) claimed, given their recurrent function as emphasizers and/or de- emphasizers of content, and the subsequent implications this fact may have on meaning, interpreters should convey speaker’s message with the appropriate verbal-nonverbal construct.

Following Poyatos’ ideas, I consider interpreting at a pragmatic level would be the best solution to handle nonverbal cues in the type of mediated interactions this paper focuses on. This approach implies understanding literal words, speakers’ intentions, context, potential reactions, and cultural features first in order to provide an appropriate rendering encompassing all the previous aspects later (Hale, 2007). Additionally, this approach should span Leech’s (1983) and Thomas’ (1983) seminal concepts of pragmalinguistic and sociopragmatic elements: whereas the former relate to the differences amongst languages when performing a specific illocutionary act (e.g., an emphasis via silence that may not work in the target language), the latter refers to dissimilarities in action-relevant social features that may have an impact in a communicative process (e.g., the different meaning of body-adaptors depending on the interactants’ culture). Most of the problems presented in previous sections could be solved by raising awareness and enhancing interpreters’ competence in these two fields. On these bases, I hereafter try to gather a series of guidelines aimed at facilitating interpreters’ approach to these issues.

The importance of nonverbal elements advocated throughout this paper implies a directly proportional relevance of seating arrangements. Thus, whenever they are allowed to establish these conditions, interpreters should try to organize the setting so they can equally see the other parties involved. In this respect, Bischoff (2009) claimed that a triangular, equidistant structure may be the most efficient arrangement, since it favors direct communication between patient and provider, reinforces interpreters’ neutrality and allows them to perceive nonverbal cues.

When thinking of nonverbal communication, most people may immediately refer to its most obvious forms, to wit, body gestures, emotions, or facial expressions among others. Interpreters should, however, pay attention to further nonverbal elements. Amongst the most relevant ones in this vein, we should list the interactants’ posture, personal voice features such as tone, (Bischoff, 2009) and other nonverbal tips such as speech tempo and syllabic duration. Including these elements in the interpreting process and/or explaining their meaning when necessary may improve communication in two different ways. On the one hand, it provides a more accurate transmission of the real meaning of the message that may be helpful for diagnosis and other clinical considerations; on the other, it makes interpreting a more dynamic process, thus avoiding a monotonous rendering that may have a negative effect on interactants’ perception of other interpreting aspects (Collados, 2002). To name but a single case, monotonous interpretation could result in the loss of meaning nuances, with the parties involved feeling slighted or assuming that some of their intentions are not being appropriately transmitted (Jacobson, 2009).

Silence and stillness are recurrent elements in every conversation, but their meaning may vary ostensibly, and it may be complicated to grasp oftentimes. For this reason, besides explaining their many functions in different communicative situations, Poyatos (2002a) also explored the potential implications of silence and stillness roles during interpreter-mediated interactions and suggested possible guidelines for interpreters to manage them properly (Poyatos, 2002b). For instance, if these elements signify in themselves without a reference to anything else, interpreters may have to explain them verbally, especially when they entail a substantial cultural difference; when working as “zero signs” and no sound or movement is perceived, interpreters should decide whether to fill or maintain this vacuum; finally, when they act as emphasizers of meaning, it is advisable for interpreters to respect silence and stillness as not to alter the connotations underlying the message: if appropriate, they may disclose their implicit meanings when rendering it or explain their effect on discourse if they think it may have a positive outcome on the information exchange.

The previous practice can also be extrapolated to the field of hesitations. However, in this particular case, it is worth stressing a crucial aspect: given the implications of filled pauses listed in section 5.1, it is important for interpreters to avoid the overuse of their own fillers (Ng as cited in Kurz, 2001: 399) in order to prevent possible misunderstandings derived from “mixing” their voice with others’. As with personal voice features, including these elements when rendering other people’s discourse may be beneficial to the communicative process, since it increases meaning accuracy while curbing monotony and its possible negative repercussions (Collados, 2002; Jacobson, 2009).

Finally, body adaptors are another aspect worth expanding on in interpreting manuals and interpreters’ training. As explained in section 5.3, these elements may provide us with important information about different aspects representing patients’ past and present, attitude, and mood. Thus, analyzing and understanding the potential meaning of body adaptors may give interpreters a more accurate perspective on the patient’s situation, thus enabling him/her to decide the most appropriate approach for a specific interaction.

Furthermore, it should be underlined that there may be several transcultural changes of meaning when dealing with such features. For instance, purple clothes are associated with death in some Latin countries whereas red attire is associated with the same tragic situation in some African regions and with blasphemy in others (Ricks as cited in Newsom, 2007: 50). Therefore, when the possibility of holding the desirable pre/post-interview with practitioners (see manuals 1, 2 and 3) exists, interpreters should explain not only attitudes and physical behaviors, but also those personal sensible body related components (Poyatos, 2002a; Poyatos, 2002b) that may be or might have been relevant. Such variety also implies, in my view, that specific guidelines and standards of practice should probably be locally addressed, focusing on the body adaptors related to those communities with more weight on the demography of the country at hand.

It is also important to note that not only the last one but most of the reflections listed hitherto, reinforce the potential benefits of holding previous and succeeding interviews with healthcare providers in order to discuss nonverbal cues carrying different kinds of information. These meetings may lead to a more precise construction of patients’ image together with a more accurate clinical approach and treatment. This line of work fits in with the approach suggested by experts and researchers such as Messent (2003) or Tribe and Sanders (2003), and it is another example of how cooperative work may be a good instrument to bridge cultural and linguistic gaps in healthcare contexts.

According to the arguments presented throughout this section, a digest of specific guidelines connecting healthcare interpreting and nonverbal cues could be established. This summary could be used as the basis for honing certain practices and expanding on several points healthcare interpreting manuals (sometimes) do not address comprehensively.

Firstly, issues related to the position of the three parties should be tackled thoroughly in order to encompass the different situations that may occur within a medical practice. As for the case of seated conversations, a triangular structure with practitioner and patient facing each other and the interpreter as a vertex aside may be the most appropriate choice.

Secondly, manuals should approach voice features in depth, listing the importance (or irrelevance) of several elements and not focusing only on the notion of “tone”, normally used as an umbrella concept that encompasses many other voice features. In this vein, interpreters following a pragmatic approach should try to render a message that maintains the connotations the different uses of these elements may entail. In addition, manuals could also discourage monotonous rendering in order to avoid potential negative outcomes as those described a few paragraphs above.

As for silence and stillness, it would be necessary that reference materials discuss the different connotations they may carry so that interpreters become aware of their potential implications on the message, especially when they have culture-specific meanings attached. Appropriate information on these cues can contribute to build further knowledge on them as it helps interpreters determine those meanings that might be necessarily disclosed and those instances in which it is not necessary for them to step in. In like vein, manuals following a pragmatic approach to interpreting could advise to identify their significance on the original message and convey their meaning in those cases in which no intervention may result in a cultural clash or misunderstanding. Similarly, additional explanations could be given if appropriate as long as they are explained to both parties. The same rules could be applied to hesitations, keeping in mind the importance of avoiding the use of our own fillers.

In addition to the abovementioned, this paper supports the importance of meetings before and after the interaction, where elements as nonverbal cues could be properly explained to healthcare professionals. But besides that, it also advocates in favor of empowering the interpreter when elements like body adaptors can have a strong impact on a mediated interaction. In this vein, a useful practice could be similar to the one suggested in the previous paragraph: briefing the patient about the intention of disclosing a specific chunk of information, provide the explanation to the practitioner, and interpret his/her response back to the patient.

In the same vein, it seems necessary that healthcare interpreting manuals include at least the most significant meanings attached to common body adaptors used by them. This measure should not be seen as a means to consolidate clichés, since it only provides chunks of information that interpreters will/can use when applicable. In my opinion, implementing measures like the ones listed before could benefit the three parties involved in this triangle: interpreters would render a more accurate message and practitioners may have a more comprehensive understanding of the patient’s situation, thus enhancing the prospects of providing the most appropriate treatment.

In my viewpoint, the arguments presented hitherto meet the main purposes posited at the beginning of the article to a reasonable extent. On the one hand, the rationale built throughout this paper supports the importance of nonverbal communication in healthcare settings while, on the other, demonstrates the improvable approach taken by the manuals analyzed here. The comparative analysis conducted on the three documents has helped underscore their strengths and weaknesses, showing that even if they do address relevant factors like spatial arrangements, visual contact, or voice features, information and guidelines tend to be scarce and significant aspects related to nonverbal communication are neglected or vaguely discussed. These findings have paved the way for suggesting several guidelines that could help provide further and meaningful information regarding nonverbal cues and assist interpreters when tackling certain issues that may arise from their presence during a triadic conversation. Essentially, the project as a whole advocates for an increasing importance of this field of communication in current and upcoming standards of practice.

The main fact supporting this point is the intrinsic relationship existing between verbal and nonverbal communication. Accordingly, the latter should be exhaustively addressed for a total communicative approach to interpreting in its multifarious modalities (Poyatos, 2002b) and settings, thus including healthcare. Despite current interpreting standards and guidelines evincing a growing and stronger focus on these elements of communication, a deeper approach briefing the importance of traditionally overshadowed elements may still be necessary on a path headed for an increasingly refined interpreting process. Likewise, emphasis on nonverbal elements in overall interpreting training programs may be a basic tool to raise awareness on the importance of these elements in interpreter-mediated interactions occurring in medical settings.

In this regard, the present paper intends to be another step towards foregrounding nonverbal elements in healthcare interpreting; but as any other project, it has its obvious limitations of time, scope, length, and resources. Thus, I would like to conclude by encouraging further research on this area which may lead to complementary or extension studies (encompassing for example, the analysis of other manuals) and additional suggestions that could boost and hone interpreting practice – in healthcare settings and other contexts– while preventing the negative effects derived from neglecting nonverbal cues. As Jacobson (2009) stated, serious miscommunications may occur if these elements are not accessible or understood during interpreter-mediated interactions. Furthermore, consequences when such cues are not taken into consideration may be devastating for members of minority groups (Schiffrin as cited in Jacobson, 2009: 56); and that is an outcome all professionals should try to avoid.