EMPORIA STATE UNIVERSITY LIBRARY - MAIN
Health & Wellness Resource Center
Coping with differences in culture and communication in
health care.
Margaret Hearnden. Nursing Standard. Nov 19, 2008 v23 i11 p49(10).
Full Text: COPYRIGHT 2008 Royal College of Nursing Publishing Company (RCN)
Summary
Internationally recruited nurses (IRNs) provide valuable resources to address existing and
predicted nurse shortages. Once in employment many IRNs experience difficulties due to
differences in language and culture in their new country of practice. Barriers to effective
communication have implications for all nurses but particularly those functioning in a second
language and culture. This article suggests strategies for IRNs, UK-educated nurses,
managers and policy makers to improve the experience of IRNs and to ensure patients
receive the best possible care.
Keywords
Communication; Culture and religion; Language; Overseas nurses
These keywords are based on the subject headings from the British Nursing Index. This
article has been subject to double-blind review. For author and research article guidelines
visit the Nursing Standard home page at nursingstandard.rcnpublishing.co.uk For related
articles visit our online archive and search using the keywords.
Aims and intended learning outcomes
The aim of this article is to explore issues of language, culture and communication in health
care. It discusses the potential challenges for nurses who speak English as a second language
and the cultural differences they encounter. It examines how different communication
patterns can lead to miscommunication and can act as a barrier to providing appropriate care.
It also considers the positive effects on healthcare outcomes of having a multicultural
workforce that mirrors an increasingly multicultural patient population. Strategies that can be
used by all staff to make cross-cultural communication easier are examined.
After reading this article you should be able to:
* Describe potential communication issues experienced by all nurses and particularly non-
native English-speaking staff and patients.
* Discuss the impact of language and culture on patterns of communication.
* Identify strategies to improve communication between people of differing linguistic and
cultural backgrounds.
Introduction
Research indicates that in recent years many countries experienced the effects of nurse
shortages (Buchan and Calman 2005) and as a result have recruited nurses internationally
(Batata 2005). Internationally recruited nurses (IRNs) have helped address existing and
predicted nurse shortages in Australia, Canada, the UK and the United States (Buchan 2001,
Hawthorne 2001). From the late 1990s to early in this decade, the UK became increasingly
reliant on overseas nurses to maintain staffing levels in the NHS (Buchan and Seccombe
2006, Buchan 2006, Denton 2006), most coming from outside the European Union (EU)
from countries such as India, the Philippines, South Africa and Australia (Buchan et al
2006). Once in employment many IRNs experience difficulties caused by differences in
language and culture in their new country of practice (Epp et al 2002, Allan and Larsen
2003, Baumann et al 2006).
In 2005 IRNs accounted for more than 60% of the nursing workforce in some healthcare
organisations (Royal College of Nursing (RCN) 2005). The Nursing and Midwifery Council
(NMC) language proficiency requirements, along with the Overseas Nursing Programme
(Buchan and Seccombe 2006) and tighter restrictions on who is entitled to a work permit
(RCN 2007) have resulted in fewer IRNs entering the UK from countries outside the EU.
IRNs from EU countries are not required to take the International English Language Testing
System (IELTS) test and are not subject to the same immigration restrictions as IRNs from
outside the EU. It is likely that IRNs will continue to be employed in the UK.
Since February 1 2007 non-EU nursing applicants have been required by the NMC to have
an IELTS score of at least seven in all subsections of the test (listening, speaking, reading
and writing) (NMC 2007).
The UK is also becoming an increasingly diverse and multicultural society. For example, the
admittance of Poland into the EU in 2004 has meant an influx of Polish people into the UK
(Multicultural Matters 2007). Although it is not known how many people there are in the UK
whose first language is not English, it is estimated that at least three million people living in
the UK were born in countries where English is not the national language (National Literacy
Trust 2007).
Communication
Effective communication involves being able to produce contextually appropriate language
and understand the nuances of a given situation (Lyons 1996, Block 2003). It implies
knowing what and what not to say, whether to speak in a formal or informal register--for
example 'How are you?' as opposed to 'How's it going?'--which tone of voice is appropriate
and which vocabulary is most effective. This requires an understanding of the context as well
as a level of pragmatic competence.
Pragmatic competence is the ability to understand what is meant even if it has not been
explicitly stated (Yule 1996), as well as the ability to express one's own intended meaning in
a contextually appropriate way. For example, a statement such as 'It's cold in here', could be
understood as a statement of fact, a request to close an open window or a complaint about the
low temperature, depending on the context and those involved in the conversation. How we
communicate depends on the context, who we are interacting with and personal individual
differences in communication.
Simple differences in regional accent or dialect can mean that people from ostensibly the
same language background can have difficulty understanding each other. For example, a
Yorkshire accent might be unintelligible to an older person born and brought up in the East
End of London (Sully and Dallas 2005). In many instances, we do not say exactly what we
mean, as directness and indirectness are associated with levels of politeness, or 'socially
appropriate behaviour' (Bowe and Martin 2007). Whether it is appropriate to communicate
more or less directly in any given context varies from culture to culture (Bowe and Martin
2007).
Communication and culture
Various definitions of culture have been espoused. Some of these are outlined in Box 1.
Although culture is difficult to define because of its complexity, most interpretations of the
concept involve the idea that culture is dynamic and constantly changing. It is also learned
rather than innate. Culture may be considered in relation to the macro settings of countries
and societies, or in relation to the micro settings of a family, a community or a profession.
Language and culture are intimately connected; one necessarily influences the other
(Kramsch 1998). From turn-taking in a conversation, to the way we express ourselves and
the words we use, all are influenced by our culture. This also includes non-verbal
communication, such as gestures, facial expression and concepts of personal space (BarrajaRohan 2000).
When two people communicate, each tries to understand the other and be understood, using
their own cultural frames of reference. Pragmatic competence requires that we often
unconsciously rely on 'shared assumptions and expectations' (Scollon and Scollon 2001)
about a context or situation to make sense of our interactions. Although sharing cultural
similarities, background or life experiences can make reaching mutual understanding easier
(Scollon and Scollon 2001), how words are understood and used varies from person to
person and culture to culture. This is because we all give words our own meaning and
interpretation depending on the circumstance.
When people in conversation are from different communities, for example if they are of
different genders, ages, cultures, levels of education or linguistic backgrounds, the danger of
them misunderstanding each other is greater. We cannot be sure whether our 'assumptions
and expectations' are the same as those with whom we are communicating. For example how
people understand and articulate the concept of pain is influenced by cultural background
(Stein-Parbury 2004).
Communication and culture in nursing
Although effective communication is an essential skill for health professionals (Parkinson
and Brooker 2004), and arguably the most essential aspect of nursing practice, it is
frequently also the most underrated aspect (Arnold and Underman Boggs 2003). There is a
direct correlation between the care provided and the quality of the communication between
those involved (Candlin and Candlin 2002).
Communication between two healthcare professionals or a healthcare professional and
patient who share the same culture and language background is complex. Differences in
ethnicity, linguistic background or culture can pose significant challenges to developing
collegial or therapeutic relationships and to being able to offer congruent care (Samovar and
Porter 2004). Therefore, understanding how social and cultural factors are interconnected
with language is important to promote successful communication (Box 2). Understanding the
significance of culture is critical to providing appropriate health care because perceptions of
health and wellbeing, illness and disease, are culturally defined (Puebla Fortier et al 1999).
However, since culture is dynamic not monolithic (Cowan and Norman 2006), there is a
danger in trying to identify what is typical of a certain culture (Leininger and McFarland
2002) as this may lead to stereotyping and not take into consideration individual differences.
On the other hand, research indicates that knowledge of the cultural background of a patient
can make providing congruent care easier (Cowan and Norman 2006).
BOX 1
Definitions of culture
* '... the learned, shared and transmitted knowledge of values,
beliefs and lifeways of a particular group that are generally
transmitted intergenerationally and influence thinking, decisions,
and actions in patterned or in certain ways' (Leininger and
McFarland 2002).
* 'It is useful to think of culture as generally concerning
organisations, professions and groups that have shared assumptions
and beliefs which link with the shared values held. These values in
turn produce shared norms that govern patterns of behaviour' (Sully
and Dallas 2005).
* '... a learned and distinct dynamic way of viewing yourself, your
life activities, and the world' (Sieh and Brentin 1997).
* '... culture can be defined as membership in a discourse community
that shares a common social space and history and common
imaginings. Even when they have left that community, its members
may retain, wherever they are, a common system of standards for
perceiving, believing, evaluating and acting. These standards are
what are generally called their "culture"' (Kramsch 1998).
BOX 2
Factors and methods influencing cross-cultural communication
Factors
Age * Gender * Context * Level of familiarity with each other.
Methods
* Turn-taking in conversation, for example whether speakers wait
for each other to finish talking completely or talk over each
other.
* Levels of directness, for example 'Could you open the window?'
versus 'It's hot in here' which is a hint to open the window.
* Topics considered appropriate to discuss.
* Forms of address, such as using first names or surnames.
* Attitudes and beliefs about how to communicate appropriately in
different social groups.
* Attitudes and beliefs about how to communicate appropriately
according to social hierarchy.
(Adapted from Bowe and Martin 2007)
There is a tension between using cultural 'knowledge' and inadvertently stereotyping what it
means to have a certain cultural background. 'A significant task for nurses is to consider the
communication styles and preferences of the people with whom they come into contact, and
who may be from a different culture. This informed knowledge, however, should not be used
to assume that everyone from a specific culture would behave in a specific way or require
specific considerations; rather it provides the nurse with options that are available to be used
as required' (Stilly and Dallas 2005).
Defining cultural competence in nursing is complicated and there is no agreed definition
(Cowan and Norman 2006). Factors that have been identified as essential to cultural
competence include (Burchum 2002):
* Awareness.
* Knowledge.
* An understanding of and sensitivity towards different cultures.
* Recognition that culture is not static and continues to change over time.
Cultural competence also includes the awareness, knowledge, understanding and sensitivity
that recognises the uniqueness of each patient (Arnold and Underman Boggs 2003), as well
as differentiating factors such as gender, class and sexual orientation (Abrums and Leppa
2001).
Guttman (2004) asserts that linguistic competence is a fundamental part of cultural
competence. Since this also includes the need for accurate and honest communication
between healthcare providers and patients, there are implications for the communication
skills of all nurses, but potentially more so for those practising in a new culture and a second
language.
As with any professional group, nursing also has its own specific professional culture, which
characterises its practices (Leininger and McFarland 2002). It cannot be assumed that a
native speaker of a language will automatically be a good communicator in a nursing
context. Communication skills exist on a continuum for everyone. One person might be more
adept at dealing with one situation than another but less so in differing circumstances.
Although it is difficult to define exactly what constitutes effective communication, Sieh and
Brentin (1997) have listed possible indicators of good interpersonal communication:
* It is clear and well organised.
* The listener understands the message of the speaker.
* The interaction is two-way.
* The non-verbal communication is appropriate to the context and situation.
* The language used is appropriate to the listener.
Variability in communicative ability can be a particular issue for non-native speakers of a
language whose overall proficiency might differ depending on the situation. For example,
someone can appear highly proficient in making small talk in an appropriate manner, but can
be unable to demonstrate equal competence when delivering palliative care, given the
differing linguistic and cultural demands of each situation.
Learning to speak the language of a profession involves learning terminology specific to the
relevant professionals' area of practice (Lave and Wenger 1991). IRNs might be in the
problematic situation of needing to demonstrate proficiency in using 'nursing English' but the
only way to improve proficiency is to become a member of the nursing community.
Participation in any community relies, in part, on how experienced members of that
community make active participation in the community easier or more difficult.
The language of nursing
The context of health care provides particularly complex and often stressful situations in
which nurses are required to communicate (Balzer Riley 2004). Appropriate communication
is critical to effecting best healthcare outcomes. Language is therefore a powerful tool. Yet in
many countries, including the UK, the language proficiency tests that many IRNs are
required to take are not specific to nursing and do not reflect the specific linguistic demands
of the profession.
In Australia the Occupational English Test (OET) has been designed to assess language used
in health care. It is aimed at qualified medical and health professionals from abroad, for
whom English is not a first language, and consists of reading, listening, writing and speaking
sections, although only the latter two sections are specific to the profession. The speaking
assessment involves taking part m two role plays with an interlocutor. lasting up ;o eight
minutes each, after a warm-up of three to five minutes.
In Canada the Centre for Canadian Language Benchmarks (CCLB) was commissioned in
2002 to create an English language assessment tool to make it easier for IRNs to join the
profession. As part of this project an analysis of language used in the profession was
conducted to provide an accurate description of the language skills needed to be an effective
nurse in Canada. One thousand nurses across the country were surveyed on their use of
English. For example, they were asked to describe how they would 'express sympathy
formally'.
Based on information from various sources, including observation of nurses at work, the
overall findings of the report by Epp et al (2002) concluded that oral abilities were more
important than written competence. Figure I shows the major language tasks identified as
being used in nursing. It categorises the nature of each task and percentage of time identified
spent on it. The most frequent task involves asking for information (22%), following by
explaining (21%), giving instructions (9%) and informing (7%).
Internationally recruited nurses in the workforce
Effective communication in nursing requires staff to be able to use language in the ways
identified by Epp et al (2002). Although this study was carried out with Canadian nurses,
many of the linguistic demands of nursing are the same in all Western, English speaking
countries. Nurses also need:
* The ability to understand and use the 'code' of a language in a grammatically
comprehensible and accurate way.
* The ability to understand and use vocabulary that a lay person would understand, but also
the appropriate medical terminology expected when writing a care plan or communicating
with other healthcare professionals.
* Intelligible pronunciation.
* Knowledge of different levels of speech--casual, formal or professional.
* Knowledge of how culture influences the way people speak and the implications of this for
nursing. For example, a person's culture will affect whether they make requests using direct
or indirect language.
* In the UK and elsewhere a recognition that, with a diverse population, not everyone will be
communicating according to local cultural norms.
Many of these skills can be difficult to acquire when working in one's first language, but
become significantly more problematic when speaking a second language and working in a
new cultural setting. This is particularly the case if the culture someone comes from differs
significantly from the one in which they are now working.
Research conducted on the experiences of IRNs working in countries other than that in
which they were initially educated has identified the following themes:
Negative perceptions Nurses feel that they are perceived differently and sometimes
negatively due to their accent, ways of nursing and skin colour (DiCicco-Bloom 2004).
Nurses frequently have to respond to negative comments from patients. This becomes more
of a problem if one has to answer in a second language, particularly if the negative comment
is about one's accent, skin colour or ethnicity.
Language difficulties and cultural learning IRNs have reported general difficulties with
language and a continual process of cultural learning (Sochan and Singh 2007, Yi and
Jezewski 2000). For example, trying to find appropriate vocabulary to express an idea while
focusing on a task is more of a challenge when working in a second language. If a patient has
any cognitive or physiological issue that impedes the ability to communicate clearly, this
makes the task of listening challenging for any nurse, but particularly for those listening to a
foreign language.
Communicating by telephone, writing and reading charts Communicating by telephone as
well as writing and reading patient charts may also be problematic for IRNs (Epp et al 2002).
IRNs are often familiar with the technical vocabulary of their profession but have difficulty
with the more idiomatic expressions used by patients.
Workplace culture and variations in the nurse's role The culture of workplaces and nurses'
roles vary between countries (Epp et al 2002, Schmidt 2000). Knowing when to speak in a
formal manner and when to be less formal is difficult to gauge in a different culture and also
requires a broad range of vocabulary. Non-verbal communication, gender roles, cultural
points of reference such as food items, and assertiveness can also provide major challenges.
Stigma There is stigma attached to being a nurse
from overseas (Baumann et al 2006). They can experience inadequate orientation, difficulty
in becoming part of the healthcare team and problems adjusting to the social and cultural
norms of the host nursing community. They may also have a lack of knowledge about the
local healthcare system.
A study involving 19 IRNs working in Toronto, Canada, identified their communication
needs (Hearnden 2007) (Table 1).
In 2003 the RCN commissioned a study into the experiences of IRNs working in the UK
(Allan and Larsen 2003). IRNs from 18 countries working in different geographical areas
and healthcare sectors around the UK took part in focus group interviews. Some had a
positive initial experience, with appropriate support being available when they started work.
Others felt isolated from their colleagues, undervalued, discriminated against and, in some
cases, exploited. Some felt deskilled and others that their competence was queried, despite
years of experience.
Communication was a particular issue for IRNs in the Allan and Larsen (2003) study, not
only in terms of their understanding local dialects and colloquialisms, but also with respect to
colleagues and patients understanding their accents and dialects. IRNs sometimes felt
socially isolated or misunderstood due to cultural differences.
Buchan's (2003) study identified that from a managerial perspective the main challenges for
IRNs related to language (including accent and colloquialisms), differences in clinical and
technical skills, racism in the workplace and the reaction of patients. Migrant nurses working
in London who took part in Cowan and Norman's (2006) study experienced problems with
culture shock in and outside work. They had difficulty understanding English spoken with
different accents, jargon, cultural differences in styles of communication and role
relationships. For example, patients had more autonomy in their treatment in the UK than
elsewhere, and colleagues and patients demonstrated a lack of understanding of overseas
nurses, sometimes resulting in racism.
Such issues can go beyond language proficiency and refer to the ways in which people
respond to differences in culture, and how new members of a community of practice are
supported by and interact with experienced members of that community.
Strategies to improve cross-cultural communication in nursing
In any encounter all those involved share responsibility for ensuring all participants
understand what is meant by what is said. In nursing, colleagues can be a source of support
or stress (Stein-Parbury 2004). Making communication between nurses of different cultural
backgrounds easier is essential to ensure appropriate patient care and to promote a better
working environment for all.
To help IRNs feel part of the healthcare team and welcome in the workplace, UK educated
nurses can help by adopting the following strategies:
Making the first move If you are speaking your native language, you have a communicative
advantage over anyone who is using a second language. He or she may lack the confidence
culturally and linguistically to initiate conversation, particularly as the way this is done
differs between cultures.
Sharing break times Sitting with IRNs during breaks and helping them integrate socially.
Awareness Being aware that thinking and speaking in a second language take a few seconds
longer than going through the same process in your native language.
Speaking slowly and clearly Speaking more slowly and avoiding unnecessary use of slang
and idioms. Taking time to explain slang that is commonly used.
Writing clearly It is important that others can easily read your handwriting. It is harder to
guess what something says if you are reading a foreign language.
Being supportive If an IRN asks a question you should be supportive, even if the question
seems to have an obvious response. We all have different cultural frames of reference which
influence how we make sense of a situation.
Being respectful IRNs can be new to nursing in the UK but they are frequently experienced
nurses with valuable knowledge and skills.
IRNs can help by adopting some of the following strategies.
Take communicative risks Initiating conversation in a second language can be challenging,
but the more opportunities you have to interact with first language speakers, the more you
will improve your language proficiency.
Explain yourself to colleagues Explaining to colleagues how and why you interpret and react
to situations in certain ways will help to promote cultural understanding.
Smiling Be aware of your
facial expressions. Thinking hard about how to say something or failing to understand can be
misunderstood as being annoyed or dissatisfied. Smiling goes a long way to making good
communication easier.
Making the time to improve language skills This takes motivation and commitment which
can be hard when working in a demanding profession.
Being respectful to others Remember that sometimes local nurses may not have experience
of cultural diversity. You should be respectful of nurses from different cultures. The UK
does have a diverse population which may be unlike the situation in which you are used to
nursing.
Management and policy makers can help by adopting the following strategies. Ensuring
adequate orientation time Ensuring IRNs have adequate orientation time to get used to local
ways of working (RCN 2005).
Introductions Introducing new IRNs to colleagues and patients. Explaining their
qualifications so that IRNs feel that their expertise is recognised, and that from the outset
they feel more accepted by those with whom they are working (RCN 2005).
More time for handovers Allowing extra time for handovers between shifts to allow IRNs to
ask questions and to clarify anything about which they are unsure.
Providing help with written information Providing assistance and models for writing care
plans and completing documentation.
Support for familiarisation Offering direction and extra support to familiarise IRNs with the
expectations of reflective practice and self-study (RCN 2005).
Mentorship and supervision Ensuring new IRNs have access to appropriate mentorship and
supervision (RCN 2005), as well as to IRNs who have had experience over a longer period of
working in the UK to offer support and guidance.
Information Giving new IRNs a list of common acronyms, abbreviations, jargon and slang
used by staff and patients. This should be relevant to the facility or geographical location.
Also supply a list of the most common medications and their abbreviations.
Knowledge sharing Providing opportunities for IRNs to share nursing and cultural
knowledge and expertise from their country of origin with local nurses to make the provision
of congruent care easier for a diverse patient base.
Translation aids Compiling a list of languages or dialects spoken by different members of
staff--along with self-assessed levels of proficiency--in case translation is needed.
Education Providing education for all staff in terms of promoting a positive attitude to
diversity in the workforce.
Conclusion
The effects of greater ease of travel and migration are being felt across the UK. Large and
small communities are becoming increasingly diverse. It is evident that it is desirable and
necessary to use the linguistic skills and different cultural knowledge of IRNs about their
country of origin and nurse education to provide congruent care for a multicultural
population. Nevertheless many IRNs experience challenges with language and culture when
coming to a new country. While the responsibility of effective communication lies with all
professionals, strategies can be implemented that can enable IRNs to make a valuable
contribution to health care. UK nurses and IRNs need education that enhances cultural
competence and makes mutual understanding and tolerance easier
Time out 1
Where do you identify yourself as coming from and which language(s) do you speak? Think
about your colleagues and patients. Where do they come from and what languages do they
speak? Have you noticed any ways in which language serves to define, or perhaps confuse,
what we mean by nursing care?
Time out 2
Think about your most recent day at work. List some of the people, contexts and situations
where you interacted with someone. How did the communication differ in each situation?
For example, consider the use of professional vocabulary with a colleague and more
straightforward terminology with a child, or casual speech with a friend and a more formal,
less direct tone with your manager.
Time out 3
What do the definitions of culture in Box 1 have in common and what are the differences?
Write a definition of culture as you understand it. How does this definition relate to your
nursing practice?
Time out 4
Write a list of the factors you think are essential to cultural competence in nursing. You may
wish to check your answer with the information provided below.
Time out 5
In a nursing setting reflect on what factors you consider contribute to good communication
and those that detract from it.
Time out 6
List the different kinds of communication you engaged in during the past two days at work-for example offering advice, or the use of persuasion and emphasis. What do you think you
use most of in your daily practice and which requires greater sophistication in terms of
conveying meanings and understanding the experiences or needs of another person?
Time out 7
If you are a nurse from the UK If you have ever travelled or lived abroad it is likely that you
will have experienced difficulties communicating with people in a new place. Think of an
experience when you were having trouble making yourself understood. How did you feel?
Now imagine how that would feel if you were nursing abroad. What difficulties do you think
you might have? You might like to discuss this with a colleague.
If you are an IRN
Think of an experience when you had difficulty understanding or making yourself
understood. What do you think the main reason was? How did you feel? What was the
reaction of the person you were interacting with?
Time out 8
Summarise in your own words the ways in which effective cross-cultural communication can
be made easier by UK-educated nurses, international nurses and management and policy
makers.
Time out 9
Now that you have completed the article you might like to write a practice profile.
Guidelines to help you are on page 60.
learning zone assessment
Communication
TEST YOUR KNOWLEDGE AND WIN A 50 [pounds sterling] BOOK TOKEN
HOW TO USE THIS ASSESSMENT
This self-assessment questionnaire (SAQ) will help you to test your knowledge. Each week
you will find ten multiple-choice questions which are broadly linked to the learning zone
article.
Note: There is only one correct answer for each question.
Ways to use this assessment
* You could test your subject knowledge by attempting the questions before reading the
article, and then go back over them to see if you would answer any differently.
* You might like to read the article to update yourself before attempting the questions.
The answers will be published in Nursing Standard two weeks after the article appears.
Prize draw
Each week there is a draw for correct entries. Send your answer on a postcard to: Nursing
Standard, The Heights, 59-65 Lowlands Road, Harrow, Middlesex HA13AW, or via email
to: zena.latcham@rcnpublishing.co.uk
Ensure you include your name and address and the SAQ number. This is SAQ No 468.
Entries must be received by 10am on Tuesday December 2 2008.
When you have completed your self-assessment, cut out this page and add it to your
professional portfolio. You can record the amount of time it has taken you. Space has been
provided for comments and additional reading. You might like to consider writing a practice
profile, see page 60.
1. A factor that influences
communication is:
a)
b)
c)
d)
Age
Gender
Context
All of the above
[]
[]
[]
[]
2. Good interpersonal
communication is characterised by:
a) Inappropriate language
b) Inappropriate non-verbal
communication
c) Two-way interaction
d) Poor organisation
[]
[]
[]
[]
3. Staff can assist internationally
recruited nurses to feel welcome by:
a)
b)
c)
d)
Speaking quickly
Using slang
Sharing break times
Being disrespectful
[]
[]
[]
[]
4. How many people living in the UK
were born in countries where English
is not the national language?
a)
b)
c)
d)
One million
Two million
Three million
Five million
[]
[]
[]
[]
5. From the late 1990s onwards,
many overseas nurses to the UK
came from:
a)
b)
c)
d)
Russia
The Philippines
Brazil
Argentina
[]
[]
[]
[]
6. Which of the following is true?
a) Culture is innate
b) Language and culture are
connected
c) Culture does not influence
communication
d) Culture does not involve shared
values
[]
[]
[]
[]
7. IELTS means:
a) International English Literature
Test of Syntax
b) International English Language
[]
Testing System
c) International English Literature
Testing Scheme
d) International English Language
Teaching System
[]
[]
[]
8. Internationally recruited nurses can
feel part of the healthcare team by:
a) Initiating conversations
in English
b) Not explaining why they have
reacted in a certain way
c) Being annoyed
d) Not taking the time to improve
language skills
[]
[]
[]
[]
9. A factor that is essential to
achieving cultural competence is:
a) Sensitivity towards different
cultures
b) Lack of awareness
c) Lack of knowledge
d) Belief that culture is static
[]
[]
[]
[]
10. Culture influences:
a)
b)
c)
d)
Gestures
Facial expressions
Concepts of personal space
All of the above
[]
[]
[]
[]
This self-assessment questionnaire was compiled by Lisa Berry
Report back
This activity has taken me--hours to complete.
Other comments:-Now that I have read this article and completed this assessment, I think my knowledge is:
Excellent
Good
Satisfactory
Unsatisfactory
Poor
[]
[]
[]
[]
[]
As a result of this I intend to:--
Answers Answers to SAQ no. 467
1. d 2. a 3. a 4. a 5. b 6. d 7. c 8. a 9. a 10. c
USEFUL RESOURCES
* CARE: Centre for Internationally Educated Nurses www.care4nurses.org/ (Last accessed:
October 27 2008).
* Parkinson J, Brooker C (2004) Everyday English for International Nurses. A Guide to
Working in the UK. Churchill Livingstone, London.
* Royal College of Nursing (2005) Working Well Initiative. Success with Internationally
Recruited Nurses. RCN Good Practice Guidance for Employers in Recruiting and Retaining.
RCN, London.
* Royal College of Nursing international department www.rcn.org.uk/nursing/
internationaldepartment (Last accessed: October 27 2008).
Date of acceptance: August 7 2008.
References
Abrums ME, Leppa C (2001) Beyond cultural competence: teaching about race, gender,
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TABLE 1
Communication problems faced by internationally recruited nurses in
Canada
Issue
Example
Lack of lay and professional
vocabulary.
Insufficient vocabulary to be
able to chart the quality and
location of an injury accurately.
Limitations in pragmatic
competence.
Linguistic difficulties in
dealing with abusive or aggressive
patients.
Social and cultural differences
Differences in the professional
between working in Canada and the
country of origin.
relationship between nurses and
doctors. In Canada, as in the UK,
nurses are expected to question
doctors' authority, if necessary.
In some countries, this would be
unacceptable.
Fear of talking on the telephone
because of lack of confidence in
language skills and not being
sure of cultural norms in
telephone interaction.
Cultural differences in making
'small talk', which is part of
developing relationships with
colleagues and patients.
Psychological and emotional
issues related to starting work
in a new country.
Feelings of isolation, having
left family and friends at home.
Lack of support from institutions
or colleagues.
Lack of practical support in
terms of mentorship. Feeling
isolated at work because
colleagues do not interact with
you.
Intolerance towards
internationally recruited nurses.
Being called stupid or being
ostracised because of differences
in accent or nursing practice.
(Hearnden 2007)
FIGURE 1
Language tasks in nursing
requests information:
explains:
gives instructions:
informs:
describes:
suggests:
responds to questions:
small talk:
discusses:
comforts:
telephones:
asks for help:
offers help:
clarifies:
apologises:
22%
21%
9%
7%
6%
6%
6%
5%
5%
4%
3%
2%
2%
1%
1%
(Adapted from EDD et al 2002)
Record Number: A190196721
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