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research-article2014 Drolet et al.

QHRXXX10.1177/1049732314523503Drolet et al.Qualitative Health ResearchQualitative Health ResearchDrolet et al.

Article

Health Services for Linguistic Minorities in a Bilingual Setting: Challenges for Bilingual Professionals

Qualitative Health Research 2014, Vol. 24(3) 295­–305 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049732314523503 qhr.sagepub.com

Marie Drolet1, Jacinthe Savard1, Josée Benoît1, Isabelle Arcand1, Sébastien Savard1, Josée Lagacé1, Sylvie Lauzon1, and Claire-Jehanne Dubouloz1

Abstract We explore in this qualitative research the challenges faced by bilingual health and social services professionals in a Canadian bilingual setting, as well as the strategies used to overcome them. Eight focus groups were conducted with a total of 43 bilingual Francophone professionals who offered services in French in 21 health and social service organizations in eastern Ontario, Canada. We highlight linguistic issues affecting a minority Francophone clientele, the shortage of services in French, and organizational issues within these agencies. The solutions that the professionals adopt for better serving the clients and overcoming these challenges focus on adapting services from linguistic angles. In the long term, such an enhanced approach can affect staff well-being. Ensuring access to services for linguistic minority populations and the active offer of same should not rest solely on the shoulders of such professionals, but rather on organizational strategies. Keywords focus groups; health care professionals; health care, access to; language / linguistics Speaking a minority language is increasingly recognized as a determining factor in the fields of health and social services given that verbal communication serves as the foundation of intervention (Snowden, Masland, Peng, Wei-Mein Lou, & Wallace, 2011). People from minoritylanguage communities face major barriers to adequate levels of such services if they have difficulty in understanding the majority language, or when services offered in their mother tongue are not available (Baker, HasnainWynia, Kandula, Thompson, & Brown, 2007; Flores, 2005; Jacobs, Chen, Karlinar, Agger-Gupta, & Mutha, 2006). In this context, the United States adopted National Standards on Culturally and Linguistically Appropriate Services (CLAS) in 2001. These standards seek to improve health and social services offered to minority communities by focusing on (a) culturally adapted health care and interventions, (b) access to services in language spoken by clients, and (c) organizational support (Office of Minority Health, U.S. Department of Health and Human Services, 2001). Little attention has been paid to the purely linguistic dimension of such adjustments and the particular issues faced by health and social services professionals working in bilingual settings (Castano, Biever, Gonzalez, & Anderson, 2007). Although language can be a channel toward understanding a social

group’s norms and a clients’ expectations (Castano et al., 2007), it represents a factor of discrimination and social exclusion (Harrison, 2009; Lo Bianco, 2010; Piller & Takahashi, 2011). In a similar manner, Wales—which recognizes both Welsh and English as official languages—passed a law in 2003 that supports access to health and social services in Welsh. It did so by mandating cultural awareness training for all students and new employees in the two fields. Indeed, minority language use and the provision of services in that language are influenced by (a) individual factors such as the linguistic competence of case workers and their attitude toward the minority language and (b) organizational factors, including the consideration accorded to minority-language clients, use of a system for noting their language of choice, and the shortage of professionals who can offer services in the minority language (Irvine et al., 2006; Roberts et al., 2007; Roberts, Irvine, Tranter, & Spencer 2010). 1

University of Ottawa, Ottawa, Ontario, Canada

Corresponding Author: Marie Drolet, University of Ottawa, School of Social Work, 120 Université, Room 12022, Ottawa, Ontario, K1N 6N5, Canada. Email: [email protected]

296 In Canada, the federal government proclaimed the Official Languages Act in 1969 (Official Languages Act, R.S.C., 1985) to confirm the official status of both English and French (Allaire, 2007). It inserted a section into the Canadian Charter of Rights and Freedoms in 1982 (Constitution Act, 1982) that protects the rights of these two linguistic communities where they form the minority, that is, the 14% of Québec residents whose primary language is English (Statistics Canada, 2012) and the Francophone minorities residing throughout the rest of the country. To improve access to health and social services for these Canadians in their mother tongue, Health Canada focused on establishing service networks as well as the training and retention of minority-language professionals (Traisnel & Forgues, 2009). In Ontario, where 95% of the population is either Anglophone or Allophone (a person whose mother tongue is neither English nor French), the French Language Services Act of 1986 (French Language Services Act, R.S.O., 1990) guarantees the provision of health and social services in the minority language; 85% of the province’s Francophones (approximately 600,000) live in 25 regions designated by this law (Office of Francophone Affairs, 2013). From this contextualization, the following research question emerges: What are the challenges faced by bilingual health and social services professionals employed in a bilingual work setting? More precisely, what are the major issues related to the access to, and the offer of, health and social services for minority-language clients? What can be done to facilitate the provision of services in the minority language (French)? To respond to these questions, we present a summary of the current literature on language issues related to the delivery of health and social services. The points of view of 43 bilingual minority Francophone professionals working in a bilingual context in eastern Ontario will cast light on several issues relating to service access and the factors that enable service provision to official language minority communities. We conclude by outlining the avenues that might lead to a more effective minority-language service delivery process—an active offer of services, in essence, a made-inCanada solution.

The Importance of Language in the Provision of Health and Social Services When health and social services are offered in a client’s language, the impacts are a sense of comfort for the client and the establishment of a trusting relationship between the client and the professional. This helps to establish an approach to service delivery appropriately centered on responding to client needs (Irvine et al., 2006). People who are considered bilingual generally demonstrate

Qualitative Health Research 24(3) greater ease in one language than the other (Boudreau & Dubois, 2008). One cannot assume that a person conversant in a second language would necessarily be able to express him- or herself at the same level of competence as someone for whom that language is the mother tongue. This reality becomes more evident when a client is in distress, trying to explain emotions, or analyzing/interpreting life events (Castano et al., 2007). In this respect, many scholars have outlined the consequences that arise when clients cannot receive services in their language of choice, whether in terms of access, comprehension of an intervention or treatment plan and adherence thereto, the quality of treatment, or client satisfaction. With regard to access to health services in particular, Jacobs et al. (2006) mentioned that minority-language patients are less inclined to encounter professionals who can offer regular follow-up, to undergo primary care examinations, and to benefit from preventive treatments; such patients do not fully understand the treatments they receive. Moreover, compared to majority-language patients, they are less inclined to follow the recommendations of health or social services professionals and to seek medical followup. Given this context, minority-language patients are at a higher risk for admission to hospital (Drouin & Rivet, 2003) and usually remain there longer (Jacobs et al.). As for the quality of care, these patients have a greater chance of being misdiagnosed and suffering repercussions in terms of treatment (Drouin & Rivet; Ferguson & Candib, 2002; Flores et al., 2003; Irvine et al., 2006). For example, they might react negatively to medication if they did not completely understand instructions, given the complexity of medical language (Drouin & Rivet). Whenever conversation becomes difficult because of language barriers, the confidence that the client feels toward the health care professional or caseworker might well diminish (Anderson et al., 2003) and result in a low level of satisfaction with services offered (Anderson et al.; Ferguson & Candib, 2002; Irvine et al., 2006; Mead & Roland, 2009). Madoc-Jones (2004) contributed that in the case of Wales, people whose mother tongue is Welsh and who are less conversant in English believe they are compromising their cultural identity when obliged to communicate in English to receive services; their very self-confidence can unravel. Emphasis on the need for linguistic rapport between client and professional becomes all the more evident when it comes to vulnerable groups such as children (Flores et al., 2003), senior citizens (Irvine et al., 2006), and people with mental health problems (Madoc-Jones, 2004). Linguistic-minority parents believe that overcoming linguistic barriers is a major factor in ensuring their children have access to health and social services (Flores, 2005). Children who grow up in a bilingual milieu are

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Drolet et al. traditionally more comfortable conversing in their mother tongue. Moreover, a number of them will not yet have acquired the ability to express themselves easily in their second language, especially when it comes to complex concepts (Madoc-Jones). As for senior citizens, secondlanguage skills often deteriorate because of such conditions as hearing loss or neurological disorders such as stroke, Alzheimer’s disease, and related dementias (Crystal, 2002, as cited in Madoc-Jones). In terms of social or mental health services, wherein communication is a key component of intervention and reintegration into society, conversing or analyzing in a language that is not one’s mother tongue can be particularly difficult because the expression of emotions or ideas does not flow readily. Furthermore, communication skills might weaken because of problematic psychosocial conditions. Being forced to express oneself in a second language thereby amplifies feelings of stress and discomfort (MadocJones). In this spirit, receiving health or social services in the principal or official language of clients’ choosing leads to a sense of security on the part of clients and offers them quality services that facilitate their taking control of the situation.

Barriers to Access Faced by Linguistic-Minority Communities Betancourt, Green, Carrillo, and Ananeh-Firempong (2003) pointed out the barriers to access to health and social services that exist for minority populations in the United States, at clinical and organizational levels, some of them systemic or sociopolitical. Clinical barriers have been outlined above in the context of the interaction between the professional and the client or family. In the case of organizational barriers, Betancourt et al. noted that medical faculties and health and social services professionals do not generally reflect the cultural diversity of the local population; therefore, services available to minorities are not always tailored to their needs. Problems then arise in the administrative structure of organizations: (a) a shortage of interpretive services, translated material, and resources culturally adapted from a linguistic perspective (Semansky, Altschul, Sommerfield, Hough, & Willging, 2009); (b) repercussions stemming from services received in a language other than that of one’s choice; (c) long wait times; and (d) obstacles to receiving specialized treatment in the minority language. These all represent major impediments to achieving access to health and social services for minority populations. In various works addressing the linguistic barriers that minority communities face, three routes are generally proposed for overcoming such obstacles: (a) translated print materials, (b) collaboration with specialized

interpreters, and (c) optimizing the communications skills of bilingual health or social services professionals (Semansky et al., 2009). Minority-language clients usually outnumber the professionals capable of offering services in the minority language; the use of interpreters often proves helpful in surmounting linguistic barriers. Flores (2005) showed that in the United States, when patients who speak little or no English benefit from the services of a professional interpreter in a medical situation, communication flows more easily, and precise technical information is forwarded more efficiently than would be the case without such an interpreter or if a member of the family tried to translate. To ensure quality services, health and social services professionals need to continually adjust to each other; their trust-based relationships are reliant on the competence of the interpreters and are based on shared goals, respect for each other’s professional boundaries, and collaborative approaches (Hsieh, Ju, & Kong, 2010). Although resorting to interpreters who lack credentials might save money and seem convenient, there are inherent risks arising from unfamiliarity with technical terms, misinterpretation, oversight, overstatement, bias, and even breaches of confidentiality (Flores). The most effective means for ensuring open lines of communication is clearly to ensure linguistic rapport between the client and the professional; in other words, pairing the client with a professional who speaks the same language. Studies point to better interaction between the two sides in addition to a higher level of client satisfaction (Johnson, Noble, Mathews, & Aguilar, 1999). Finally, once measures are in place for casting aside obstacles to access to quality services, one observes a greater degree of use among other disciplines; this can be seen in the field of mental health (Snowden et al., 2011).

Issues Faced by Bilingual Health and Social Services Professionals With respect to specific issues professionals encounter when working in a bilingual context, considerable information has been gathered from various fields (e.g., psychotherapy and social service) whose practitioners assign a high level of importance to the expression of emotions and to in-depth analysis of life situations (Castano et al., 2007; Johnson et al., 1999; Santiego-Rivera, Altarriba, Poll, Gonzalez-Miller, & Cragun, 2009; Schwartz, Domenech Rodriguez, Santiego-Rivera, Arredondo, & Field, 2010). In this sense, speaking the same language paves the way for clients and professionals to establish a relationship based on trust and rooted in common ground. They will even switch back and forth between the minority language and English words. This often applies if the

298 professional is seeking the precise meaning of the client’s narrative, or if the client wants to find a familiar term to express an emotion (especially anger; Santiego-Rivera et al.). These authors stressed the point that adapting either the majority or minority language to the client’s style of speech depends on the choice of appropriate words rooted in the latter’s day-to-day milieu. Moreover, the words appear to have greater, more spontaneous emotional effect when they are from the client’s mother tongue; words used to convey feelings and life events are generally those that had been uttered at the time these situations first came to pass (Santiego-Rivera et al.). Because minority languages are rarely spoken in the public sphere and are more often heard in private and social circles (Piller & Takahashi, 2011)—as is the case with French in minority Francophone circles (Boudreau & Dubois, 2008)—few printed workplace tools exist in the minority languages, and professionals must therefore adapt or translate them (Castano et al., 2007; Verdinelli & Biever, 2009). As for the roles played by health and social services professionals that lie beyond the direct provision of services, these embrace the following: furnishing specialized information to clients, including medical facts (Cioffi, 2003); consulting in support of other workplace colleagues; serving as brokers for linguistically adapted services (Johnson et al., 1999); and developing community-level services adapted to specific populations (Mitchell, Malak, & Small, 1998). In the late 1990s, Mitchell et al. argued in support of making the necessary organizational adjustments to ensure that bilingual professionals can reach their full potential; all the same, organizational issues still exist more than 10 years later. Engstrom, Piedra, and Won Min (2009) cautioned against the overwhelming workload that can be placed on the shoulders of bilingual professionals when organizational adjustments fail to take such double duty into account. Bouchard and Vézina (2009) arrived at the same conclusion with respect to the Francophone minority in Canada, where the majority language is English. This lack of recognition can lead to a major problem of staff retention. Given the extra responsibility associated with their bilingual service, these professionals resort to seeking help from peers and setting up collaborative networks among colleagues (Verdinelli & Biever, 2009). The situation as outlined adds relevance to the questions that serve as the foundation of this article.

Methodology A qualitative research approach formed the basis of this study given its capacity to identify the values, language, and interactions of the various social actors working in health and social services. This approach also gave a voice to those who have fewer chances to be heard—the professionals who work directly with clients.

Qualitative Health Research 24(3) After having received the approval of the University of Ottawa ethics committee in the summer of 2011, we contacted 21 organizations offering health or social services in French in eastern Ontario with the aim of inviting bilingual Francophone professionals to participate in this study. Forty-three were interviewed, 21 of whom worked in the health field and 22 in social services. Their professions encompassed rehabilitation, social work, nursing, nutrition, psychology, and management. These participants came from a variety of milieux, including hospitals, community health centers, and schools. Eight focus groups were formed among these professionals: four with participants from child and youth services, four from services for seniors. Each group comprised between 3 and 10 participants. The focus groups were led by a researcher, with the assistance of a research coordinator who ensured the consistency of the process, as well as a research assistant responsible for recording field notes. Each interview lasted 90 minutes. The focus groups proved to be advantageous in that they led to discussions among participants based on open questions and allowed us to verify whether they shared common perceptions and were undergoing similar experiences (Geoffrion, 2009). An interview grid prepared by the research team featured the following elements: (a) services offered by the organizations where the professionals worked, (b) challenges they encountered in offering services in French, (c) successes they perceived in their interventions, (d) availability and adaptation of French-language evaluation and intervention tools, (e) referrals to and networking with other milieux, and (f) elements that distinguished their interventions with Francophones from those involving other clients. This grid ensured structure within the focus groups by presenting discussion themes and, at the same time, granting enough flexibility for other ideas to emerge. The interviews were audiorecorded then transcribed in their entirety. The transcriptions were subsequently imported into NVivo 9 software (QSR International, 2012) to facilitate content analysis. Two research assistants codified the data from the transcriptions according to a predetermined procedure: (a) reading 20% of the transcripts to identify emerging headings (general labels that referred to what was discussed in the extract of the corpus) and themes (more precise labels that specified what was covered in the extract of the corpus; Paillé & Mucchielli, 2008); (b) obtaining consensus on headings and themes from the research team comprising six different professions within the fields of health and social services; (c) developing a list of codes (abbreviated headings and themes) and their definitions; (d) obtaining consensus on codes from the research team; and (e) applying codes to the remaining transcripts while still allowing for new themes to emerge. In a similar fashion, the grid of categories was based on interpeer method and consensus.

Drolet et al. The data were analyzed in an inductive manner, and categories were compared through intergroup analysis (Huberman & Miles, 1991). The interpretive method applied to these findings followed that prescribed by Huberman and Miles. By the sixth and seventh group, it became evident that the same themes were surfacing among both clienteles (youth and seniors), and the eighth group confirmed that we had attained data saturation. In keeping with qualitative research methodology, a theoretical generalization should be arrived at in a gradual, measured way (Pires, 1997). This is because of the sheer number of participants and, even more so, because of the unique nature of each minority language milieu. Nevertheless, the consensus reached among the professions represented by the focus groups, as well as its consistency with other research, enhances the validity of this study (Laperrière, 1997).

Results: Constant Challenges for Health and Social Services Professionals The analysis of the focus groups reflected the fact that the participants devoted much more time to discussing challenges they encountered in a bilingual work setting as opposed to elements that facilitated their interventions with Francophone minority clients. In describing their daily routines and the ways they handled obstacles, many said things such as, “That’s just reality.” The results from those focus groups are presented below.

Working in a Bilingual Context: A Continuing Challenge of Access The participants highlighted numerous challenges that arise from working in a bilingual context. These relate to three themes: linguistic issues affecting Francophone minority clients, a shortage of services offered in French, and organizational issues having an impact on access to services. Linguistic issues affecting Francophone minority clients. The study participants brought up linguistic issues they had observed during their interventions with Francophone clients which hindered the latter’s access to health and social services. They explained how they strove to accommodate clients whose language skills varied in keeping with their educational levels. Indeed, some of their senior clients, who had to leave school early, could barely read or write. One respondent related that the vocabulary and level of language usage of clients from a low-income milieu were markedly different from “professional French” (occupational therapist [OT]). To relate well to people with a wide range of language skills, health and

299 social services professionals needed to have a flexible approach to this aspect of diversity: “We do our best to summarize as much as possible, to simplify things, to explain things in their terms and make sure they understand; it’s about making services accessible” (nurse [N]). All the same, the respondents also described a feeling of being pulled in an opposite direction, reluctant as they were to contribute to a weakening of the French language. Although the professionals were unanimous in pointing out that minority Francophone communities face complex issues when asking for services in their own language, these occur at opposite extremes. Some held the opinion that Francophones increasingly demand that services be offered in their language. Many others stated that at times of need, clients simply want to receive service and the language does not matter: “They are so desperate . . . their needs are so acute, they think, ‘Look, we’ll take it in English or French, but come on, give us the help we need’” (N). As well, the participants observed a tendency toward assimilation, which they associated partly with self-effacing seniors who shied away from demanding French-language services out of deference to Anglophone staff or their own immediate circle: “Well, my daughterin-law speaks English. My son’s on my side. . . . We’ll all carry on in English” (social worker [SW]). The participants commented that, in the same vein, the assimilation of Francophones and their reluctance to assert their right to French-language services tie in with the movement among many Francophones to blend in with the Anglophone majority, which they consider a more attractive option: “It’s almost as if there’s a mentality associated with it, a lack of pride in being Francophone” (SW). Shortage of French-language services. With respect to health and social services offered in French, the professionals frequently referred to a lack thereof. They cited a shortage of financial resources and personnel capable of offering specialized services in French, as well as a dearth of Francophone or bilingual organizations to which they could refer clients: “When I close a file, it’s often a case where I say to myself, ‘Well, I’ve made my recommendations but the resources just aren’t there. Good luck!’ You know, I can’t do otherwise, and that’s the hardest part” (management [Mgmt]). They identified many regions where it is the most difficult to receive French-language services, namely, the extreme south of Ontario, northern Ontario, and rural eastern Ontario. Several of them even declared that it is often difficult to receive specific services in French in Ottawa, a city considered to be bilingual. The participants further noted that when services are available in French, Francophone clients do not necessarily receive the “complete package” on a continuing basis

300 in their language. They pointed out that some organizations and institutions that are designated bilingual offer only partial service in French; for example, long-termcare seniors’ residences staffed by just one Francophone nurse can only guarantee French-language service part of the time. They also indicated that a large number of employees in major health care centers have no Frenchlanguage skills; this forces Francophone patients to do their best to get by in a second language, and gives them the impression that they are in an Anglophone establishment: “You have to search for a specialist who makes an attempt to speak French . . . or a volunteer who tries to do so. It’s not as if the service is bilingual in the fullest sense” (N). The professionals commented that, despite their best efforts, they were not in a position to offer an intervention completely in French because they had to resort to programs, tools, or printed information that were in English: “It’s a personal issue, and an ethical one too, because my service to that parent should in principle be offered in French, but I can’t go the whole distance . . . and if I hold back information [only available in English], well, I think he’s going to miss out on something” (speech therapist [ST]). During the focus groups, professionals emphasized how important it is to receive health and social services in the language of one’s choice, and described the level of anxiety that results when this is not feasible. Such anxiety is felt especially by children and seniors and, by extension, by their caregivers and family members. This feeling applies equally to professionals who might not be familiar with their client’s language. Other participants stressed the particular importance of receiving services in one’s mother tongue when certain health conditions are part of the picture. They pointed to examples such as clients with mental health problems who are inclined to become aggressive if a caseworker or a nurse speaks a different language; crises involving children or adolescents that can evolve into complex events; one-on-one support situations whereby the client becomes engaged at an emotional level; or cases involving people with speech or hearing impairments—already enough of a barrier without the added context of language: “A client who had a bedsore and had already been seen by an Anglophone nurse, this client was deaf, and what’s more he was Francophone. . . . The issue at hand was that bedsore, that was the crucial consideration. . . . It called for careful followup, and it called for clear understanding of instructions. It’s a question of patient safety!” (OT). In the same context, these respondents pointed out that a lack of full service in the language of a client undermined the scope, quality, efficiency, and benefits of their interventions. By way of illustration, one social worker cited situations in which she had to fill out an Englishlanguage form for a Francophone client, an action that

Qualitative Health Research 24(3) jeopardized her client’s empowerment, her accountability, and autonomous professional conduct given the lack of appropriate French-language tools. She mentioned as well an element of insecurity and anxiety that exists among certain Francophones, especially seniors and some parents, who refrain from speaking or interacting during group discussions or workshops conducted in English. Social services professionals were concerned that these clients do not benefit as fully from interventions as do Anglophones. Working with Francophones in a bilingual context requires an especially attentive and caring attitude from staff to offset the linguistic barriers encountered. This need is most evident in situations where a Francophone client is referred to an agency that might not necessarily offer services in French: “They are Francophone, they are reminded of their minority status, they feel marginalized . . . they often need to be accompanied through the process, to be reassured throughout” (SW). Organizational issues that affect access to services.  In terms of the provision of services in French, the participants also brought forth organizational issues linked to the shortage of bilingual or Francophone personnel. Moreover, numerous situations outlined by these professionals cast light on the complex logistics associated with the provision of services in two official languages. Although many managers sought to refer Francophone clients to Francophone or bilingual staff, such measures are not uniformly set in place throughout all service agencies. In establishments that have the mandate to provide services to exogamous families (in which one of the parents or caregivers is Francophone and the other Anglophone), an Anglophone parent might accompany a bilingual child to a professional offering primarily French-language services: “You search for your words, the vocabulary isn’t quite the same, you’re not chatting about the weather but are discussing emotions, relationships, and sensitive subjects” (psychologist [Psy]). In addition, the participants pointed out that English is the dominant language in many work teams; accordingly, case files are completed in English despite the fact that the policy for access to information stipulates that clients should be able to consult their files on demand and understand them. Given the insufficient numbers of Francophone or bilingual professionals working in various spheres of health and social services, staff that are bilingual become overwhelmed on the job: they are seen as a rare resource, ensuring bilingual access. In this linguistic-minority context, they take on additional tasks that are not readily acknowledged as being part of their workload: “It’s a lot of work for us. It’s fine to have a manager around who can understand and all that, but in the long run, it makes the workload pile up” (N). Office mates often expect that

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Drolet et al. their bilingual colleagues will regularly translate all sorts of materials and adapt work tools into French. In addition, they end up accompanying a wider circle of clients through interventions to compensate for the professionals on their team who cannot work with them in French: “When there was an opening elsewhere, I took a transfer because I could see as time passed that instead of undertaking work related to my own profession, I had become an interpreter and translator for my Anglophone colleagues” (SW).

Better Serving the Clients: Strategies Put in Place by Professionals To overcome the above-cited challenges in terms of access and quality of services, the professionals who participated in this study instituted a range of strategies to facilitate the provision of minority-language services and interventions for Francophone clients in eastern Ontario. They were clearly attuned to the minority fact and the linguistic insecurity associated therewith. Their strategies touched four aspects: (a) adapting the language, (b) compensating for a lack of services, (c) making the best of each situation, and (d) working in a network. The participants in the discussion groups demonstrated considerable capacity for linguistic flexibility in their communications, workplace tools, and written documentation. As stated previously, they obviously adapted their ways of working so that health and social services could be fully accessible to Francophones—and in particular, the most vulnerable among them. Francophone personnel offered a wide range of skills in responding to the complex needs of their client base and to the challenges inherent in accessing and providing services in a linguistic minority context. They placed high value on “putting yourself in their shoes in an effort to understand their predicament” (service coordinator [SC]). Accordingly, they shed light on their sense of professional commitment and compensated for the shortage of services or resources. Not content with any half measures, they took extra steps in their daily activities to set in motion a range of good-quality services adapted to the needs of Francophones. This demanded perseverance and practicality: “As for me, I like to place a call and hear someone say, ‘I will arrange that for you’” (project coordinator [PC]). In terms of their daily routine, there was a sincere willingness on the part of these professionals to assume a role in solving the problems of access and associated workplace issues. During interviews, they often underscored the fact that additional demands are regularly placed on Francophone and bilingual professionals; all the same, they managed to make the best of each situation with

finesse: “It’s a do-the-best-you-can system, really. I’m the only one. . . . I don’t have any Francophone colleagues and I find it quite difficult, but rewarding” (Mgmt). They placed a priority on offering good-quality health and social services in French that were on a par with those received by clients from the Anglophone majority. Comments from the participants also reflected the solid spirit of collaboration they created with their workplace colleagues, caseworkers from other organizations, and members of affiliated professions, all with the goal of providing services in a client’s language of choice. They emphasized that team work and collaboration among colleagues become vital in a minority context; successful practices were in large measure attributed to cooperative efforts among professional colleagues from various “sister” organizations. Although establishing such partnerships is complex given the shortage of Francophone resources, these participants managed to maintain ties to other agencies that were informal, collegial, and effective; they attributed such affinity to the common bond of belonging to a minority community. The most productive working relationships were characterized by direct lines of contact, flexible procedures, and the support of management: “We succeeded in establishing good contacts with different managers and an easygoing way of getting things done. There’s no heavy-handed bureaucracy. We know each other, we can make a call . . . and we’re on the same wavelength” (Psy).

Discussion: Constant Struggles Can Affect the Well-Being of Professionals The aim of this study was to highlight a number of important challenges related to access to health and social services for minority-language clients. Focus groups were conducted from among 43 bilingual professionals in the health and social services sectors who worked in a bilingual context with minority Francophone clients from eastern Ontario. Through the observations they shared, it is possible to ascertain the main challenges they confronted in providing services in French, as well as elements that facilitated their interventions from a linguistic perspective. The professionals encountered in this study reported facing numerous challenges inherent in the active offer of French-language health and social services. Every day, health and social services professionals encounter challenges in the actual provision of services to minority Francophones. From a clinical perspective (Betancourt et al., 2003), they have to deal with clients with a mixed language colored with English words and distinctive to their region. Because they must regularly face up to the

302 fact that their language skills are basic in both languages, and given societal expectations of higher levels in spoken French and English, many Francophones harbor a sense of linguistic inferiority and a profound awareness of their minority status (Boudreau & Dubois, 2008). In this respect, the study participants emphasized that they must demonstrate flexibility to modify their spoken French, to be understood, and to support and accommodate their clients’ access to services every step of the way. Along the lines of Santiego-Rivera et al. (2009), these professionals will adapt their manner of speaking by incorporating colloquial expressions familiar to their clients and by alternating between French and English. Some participants were of the opinion that the minority “fact” favors the creation of a sense of belonging that helps to establish common ground. All the same, it is from an operational angle (Betancourt et al., 2003) that professionals encounter constant and demanding challenges that have a direct effect on their clients’ access to health and social services. These challenges have a bearing on the way the professionals conduct their daily work and on their capacity to make decisions that affect their clients. In fact, whatever their discipline or clientele, all participants pointed to insufficient resources, a shortage of Francophone or bilingual staff who could offer a full range of services in French, and a lack of Francophone or bilingual organizations to which clients could be referred. They were not in a position to offer their interventions entirely in French, and constantly devoted time to adapting and compensating for limitations in their interventions to meet their clients’ needs. Indeed, in studies on workplace health, it has been shown beyond doubt that the health of staff is affected by major risk factors such as a combination of increased demands and lack of autonomy, especially in the day-today management of responsibilities (Karasek & Theorell, 1990). Moreover, this lack of French-language service highlights the disparity that exists between the official bilingual label of eastern Ontario and the actual level of services available in French. Such access issues fall in line with those applicable to Manitoba, a province where Francophones account for 4% of the population, similar to the situation in Ontario (Statistics Canada, 2012). De Moissac, De Rocquigny, Roch-Gagné, and Giasson (2011) presented that French-language services are not always available in establishments that are designated as being bilingual. They also pointed out the constant challenge that health and social services professionals face when trying to refer their Francophone clients to another Francophone professional, given the shortage of specialists capable of offering services in French. Specifically, they identified an excess of systemic impediments, among them a lack of awareness of which professionals can be called on for French-language services.

Qualitative Health Research 24(3) In the same context as that explored by Engstrom et al. (2009), the professionals interviewed for this study described a constantly heavy workload that encompassed duties associated with their field of expertise, in addition to the tasks necessary in a bilingual work setting (e.g., translating material, interpreting among colleagues, increased time spent with clients or referring them to other agencies, and so forth). These observations confirm the failure on the part of some organizations to recognize the dual nature of work requirements and adjust themselves thereto (Engstrom et al.; Mitchell et al., 1998). Such situations lead to constant stress, place increased psychological demands on health and social services professionals, and have a negative effect on day-to-day workplace conditions. Engstrom et al. suggested that insufficient recognition of extra efforts made by staff can result in problems of retention and, in the longer term, a shortage of qualified bilingual professionals. Moreover, researchers of workplace health insist that an insufficient recognition of tasks accomplished will increase the risk factor of an impact on staff health (Siegrist, 2001). Notwithstanding these issues, the 43 study participants clearly indicated their willingness to be part of a solution to such daily challenges. They contributed to an active offer of good-quality services as defined by the Office of the Commissioner of Official Languages and the Consortium national de formation en santé. They adhered to such an active offer in the form of “a proactive approach that considers the . . . historical lack of Frenchlanguage health services . . . it implements positive actions . . . to guarantee quality service and equitable benefits for all Francophone citizens of Canada, regardless of their minority status” (Consortium national de formation en santé, 2012, p. 10). This active offer of service in the official language of minority clients has become an essentially made-in-Canada response to the issue of access. As evidenced by comments from participants, it represents a commitment on the part of professionals to “go the extra mile” in serving the clientele with whom they share a minority-community bond (Santiego-Rivera et al., 2009). All of the study participants clearly put in place informal collaborative partnerships among their coworkers or colleagues from other organizations to overcome the barriers they described, to ensure a credible active offer of French-language services. In essence, they created an opportunity to benefit from a collaborative network which could bring social support. Indeed, Karasek and Theorell (1990) defined workplace social support as a mutual trust that can be found in interactions among colleagues or managers. It can also be viewed as help and assistance offered by others in the accomplishment of tasks (Vézina, Bourbonnais, Marchand, & Arcand, 2008). The participants expressed particular support for this second, more instrumental context. In the area of workplace

Drolet et al. studies, social support and collaborative networking emerge as an avenue to offset such difficulties (Vézina et al.). By adopting strategies for better serving their clients, the participants in this study equipped themselves with the means to maintain their mental and physical wellbeing in the face of professional challenges. All the same, this coping mechanism might well prove to be detrimental in the long term. Access to health and social services for minority populations, and the active offer of such services, should not be permitted to rest solely on the shoulders of professionals in those fields. Looking beyond statements of good intention, these professionals will need to receive precise organizational support and strategies and policies to witness concrete, positive, and measurable results in the course of their daily work and in the lives of their clients. Indeed, there is little research calling for more studies that focus on the views of bilingual professionals and their workplace organization. In fact, we propose that it is logical and perhaps imperative to consider the views of the individuals who implement the interventions on a daily basis and whose health can be affected. Moreover, our study indicates that they are well placed for building networks and sharing opinions that are adapted for managing settings. Acknowledgments We thank the University of Ottawa chapter of the Consortium national de formation en santé for its financial support, as well as Health Canada for making this study possible.

Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: University of Ottawa chapter of the Consortium national de formation en santé.

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305 Jacinthe Savard, PhD, is an assistant professor of occupational therapy at the School of Rehabilitation Sciences at the University of Ottawa in Ottawa, Ontario, Canada. Josée Benoît, PhD, is a research associate and part-time professor at the School of Social Work at the University of Ottawa in Ottawa, Ontario, Canada. Isabelle Arcand, PhD, is an independent researcher in special education and a recent graduate of the Faculty of Education at the University of Ottawa in Ottawa, Ontario, Canada. Sébastien Savard, PhD, is an associate professor at the School of Social Work at the University of Ottawa in Ottawa, Ontario, Canada. Josée Lagacé, PhD, is an assistant professor in the audiology and speech therapy program at the School of Rehabilitation Sciences at the University of Ottawa in Ottawa, Ontario, Canada.

Author Biographies

Sylvie Lauzon, PhD, is a full professor at the School of Nursing at the University of Ottawa in Ottawa, Ontario, Canada.

Marie Drolet, PhD, is an associate professor at the School of Social Work at the University of Ottawa in, Ottawa, Ontario, Canada.

Claire-Jehanne Dubouloz, PhD, is a full professor of occupational therapy at the School of Rehabilitation Sciences at the University of Ottawa in Ottawa, Ontario, Canada.

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