24792
2014
TCNXXX10.1177/1043659614524792Lum et al.Journal of Transcultural Nursing
International Department
Challenges in Oral Communication for Internationally Educated Nurses
Journal of Transcultural Nursing 2015, Vol. 26(1) 83–91 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659614524792 tcn.sagepub.com
Lillie Lum, RN, PhD1, Penny Dowedoff, MA2, Pat Bradley, RN, PhD1, Julie Kerekes, PhD3, and Antonella Valeo, PhD4
Abstract Achieving English language proficiency, while key to successful adaptation to a new country for internationally educated nurses (IENs), has presented more difficulties for them and for educators than previously recognized. Professional communication within a culturally diverse client population and maintaining collaborative relationships between nurses and other team members were perceived as new challenges for IENs. Learning an additional language is a long-term, multistage process that must also incorporate social and cultural aspects of the local society and the profession. This article provides a descriptive review of current research literature pertaining to English language challenges, with a focus on oral language, experienced by IENs. Educational strategies for teaching technical language skills as well as the socio-pragmatics of professional communication within nursing programs are emphasized. Bridging education programs must not only develop students'academic language proficiency but also their ability to enter the workforce with the kind of communication skills that are increasingly highlighted by employers as essential attributes. The results of this review are intended to facilitate a clearer understanding of the English language and communication challenges experienced by IENs and identify the implications for designing effective educational programs. Keywords Internationally educated nurses, English language education, professional communication While an abundance of studies examine the nature of English learning across a variety of disciplines, there has only been a limited research focus on the experiences of internationally educated nurses working in English-speaking countries (Epp, Strawychny, Bonham, & Cumming, 2002; Sherman & Eggenberger, 2008). The term internationally educated nurse (IEN) describes a nurse educated outside of North America in a predominantly non-English-speaking country and who is either a nonnative English speaker or speaks a non–North American type of English. This term is synonymous with an international RN and a foreign-trained or foreign-educated nurse. Despite the fact that there is increased support for both IENs and nursing students for whom English is an “additional language,” there are a significant number who continue to struggle in both academic and employment settings due to their limited English skills. This suggests that, despite passing language and licensure exams, they may experience communication deficits that are not presently recognized in the current educational system. Learning new terminology and ways of communicating with clients and team members is a complex challenge that has not been adequately examined. Major and Holmes (2008) have concluded that more research is needed to better understand the technical and social aspects of effective nursing
communication. Achieving adequate proficiency is a longterm, multistage process that must also incorporate social and cultural aspects of the local society. O’Neill (201l) describes this process as IENs having to negotiate between three or four different worlds: the world of “learning the rules of the English language,” the world of “learning the nursing specific terminology,” the world of “learning the discourse of the nursing profession and the culture of the Canadian health care system,” and finally the world of “learning the Canadian language culture” (p. 1127). This article provides a descriptive review of current research literature pertaining to English language challenges, 1
School of Nursing, Faculty of Health, York University, Toronto, ON, Canada 2 Department of Sociology, York University, Toronto, ON, Canada 3 Department of Curriculum, Teaching and Learning, OISE, University of Toronto, Toronto, ON, Canada 4 Department of Languages, Literatures & Linguistics, York University, Toronto, ON, Canada Corresponding Author: Lillie Lum, RN., PhD, Associate Professor, School of Nursing and School of Health Policy and Management, Faculty of Health, York University, 4700 Keele Street, Toronto, Ontario, M3J 1P3, Canada. Email: [email protected]
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with a focus on oral language, experienced by IENs. Although it is difficult to separate comprehension, reading, speaking and writing components of language, this article focuses on the oral aspect of the English language since the ability to communicate orally is an essential nursing skill (Hearnden, 2007), as well as being a dominant way to achieve social and cultural integration into any given society or profession. The results of this review are intended to facilitate a clearer understanding of the English language and the communication challenges experienced by IENs and consider the implications for designing effective educational programs. The authors also attempt to describe current research gaps and areas needing further attention.
Language Proficiency and Social Integration The globalization of the health care workforce in Englishspeaking countries such as Australia, Canada, Great Britain, New Zealand, and the United States has led to a much greater cultural diversity within the nursing profession. Achieving a competent level of English language proficiency or communication skill, while key to successful adaptation to a new country, has presented more difficulties than previously recognized (Kawi & Xu, 2009). The literature has documented that one of the greatest barriers to workplace integration for new immigrants is the lack of adequate professional communication skills. Based on Australia’s experience, O’Neill (2011) noted that new immigrants meet challenges in the Western workforce that extend beyond simply achieving technical language proficiency but also include navigating the role of a language learner as a means of integrating into a new professional culture. Learning the technical components, such as correct grammar and pronunciation, is not the most important factor in communicating competently in a new language. Holmes (2000) concluded that new immigrant health professionals with prior experience are usually experts in their profession but need to learn how to manage the social and interpersonal aspects of their role, which are based on effective communication, workplace interaction, and health care practices. Although little attention has been directed to professionspecific language issues, empirical evidence in the immigration literature illustrates the relationship between immigrant English language competency and social integration into a new society. The literature reflects a strong emphasis on the benefits of language proficiency, and economic outcomes such as successful employment and earnings. In Canada, language ability is a strong predictor of labor market success (Akresh & Frank, 2010). Greater proficiency in the second/ official language enhances the effect of previous education and pre-immigration work experience. Tufts, Damsbaek, Phan, Kelly, and Maryse (2010) studied national census data of recent Canadian immigrants and found that more than half the immigrants who speak English or French, Canada’s official languages, “very well” find work in a field related to
their education/training, compared to fewer than one in five for immigrants with poor language skills. For both men and women, after 4 years in Canada, poor language ability leads to unemployment rates double those of male and female immigrants who can speak English or French “very well.” Language proficiency has also been shown to lead to early employment success. The initial year in Canada is critical for immigrants to obtain a job in their intended field (Grenier & Xue, 2011). After that period, the likelihood of finding employment in the intended occupation decreases. Four main factors have been found to facilitate access to gainful employment: education, English language ability, Canadian work experience, and friend networks. Language proficiency has been found to have a positive effect on employment probabilities but, conversely, the lack of English fluency leads to earning losses. Immigrants with better skills in English or French were more likely to see an increase in their participation and unemployment rates, and decrease in average length of jobless spells over time. Immigrants’ language abilities are not fixed and can improve following their immigration. Kelly, Damsback, and Lemoine (2010) used national immigration census data to show that lower levels of language proficiency tend to be associated with lower rates of labor market participation and higher rates of unemployment for new immigrants. An individual may move from one category of language skill level, that is, lower to higher over the course of their first four years in Canada. This finding supports the importance of identifying lower levels of language proficiency experienced by immigrants during the early settlement period to be followed up with language education. Failure to develop adequate English language proficiency has also been shown to lead to higher dropout rates for international nursing students in the United States (Alvarez & Abriam-Yago, 1999). The opportunity to improve one’s English language proficiency in postsecondary education programs is important to the academic engagement of recent adult immigrants in Canada who seek to upgrade their education (Lum & Grabke, 2012). The lack of English language competency was found to have a negative effect on their academic success and potential employment. Donnelly, McKiel, and Hwang (2009) reported that new immigrant nurses in a Canadian bachelor’s degree program experienced more difficulties than domestic students due to their lack of adequate English skills, which interfered with all components of learning including understanding textbooks, lectures and teacher’s expectations, and the wording of written examinations and writing academic papers.
IENs Transitioning to a New Professional Culture Language proficiency is an essential component to achieving cultural integration into a profession. Despite the fact that IENs possess prior nursing experience from their countries
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Lum et al. of origin, they must learn to adapt to an unfamiliar professional nursing culture following immigration. They face a host of economic, professional, and social challenges in adapting to a new working environment during the initial settlement period (Donnelly et al., 2009; Wang, Singh, Bird & Ives, 2008). Many of these challenges stem from intercultural communication problems attributable to unfamiliarity with unique aspects of the local culture, consequently leading to difficulties with social conversation in that culture, and unfamiliarity with communication norms of the workplace (Holmes, Marra, Newton, Riddiford, & Vine, 2011). In other words, understanding the language expectations of the local culture, that is, cultural competency, has a direct influence on IEN professional integration. Lampley, Little, Beck-Little, and Xu (2008) define “cultural competency” as the ability to demonstrate a set of skills and behaviors that enables nurses to work effectively within the cultural context of the client (that is, individual, family, or community). In order to demonstrate cultural competency, new immigrants need to acquire new knowledge, behaviors, and attitudes. However, the opportunities for gaining these skills may not be readily available. Lampley et al. (2008) noted that gaining cultural competency presented challenges for IENs, who reported less confidence in providing culturally competent care to patients from diverse cultures. The most frequently cited challenges include ineffective communication, the lack of knowledge of health beliefs, and understanding the behavior of people from different cultures. This knowledge deficit can exacerbate problems of low language proficiency for nurses who are less experienced with practicing in multicultural contexts. New immigrants are thus fundamentally disadvantaged because of their lack of social power due to unfamiliarity with societal norms of the local culture. Difficulty with cultural competency can manifest itself as communication challenges. Many communication issues contain some element of cultural difference. For example, practicing in a new culture that is more collaborative and autonomous can pose major challenges for IENs in Canada (Epp et al., 2002). Being assertive and managing team conflict were cited as problems. There may also be a tendency to be either too passive or too aggressive in unfamiliar work situations. It is often difficult for IENs to express disagreement with authority figures such as physicians and managers. IENs in Canada reported that practice expectations were different in areas such as autonomous decision making, being more responsible for patient advocacy, engaging in inter- professional collaboration, and having more egalitarian relationships with physicians and other professionals (Tregunno, Campbell, & Gordon, 2009). Based on their personal experiences within a Canadian baccalaureate program, IENs noted that it is difficult to understand a new culture without understanding the language and its symbolic meanings. Conversing with patients, which was perceived as a low priority for some nurses in
their home countries, added to their difficulties with acculturation. They reported that understanding constructed scenarios that included examples of local sports or health issues as a means to teaching nursing were problematic due to an inadequate understanding of language and cultural knowledge (Donnelly et al., 2009). Simple topics such as choosing a type of food or discussing the weather with patients would present conversational challenges if the topic were unfamiliar. These differences in communication styles had not been anticipated by IENs. Another factor identified as adding to the complexity of professional communication competency within the health care setting is the highly multicultural nature of the patient population. IENs working in an urban center such as Toronto, Ontario, with its culturally diverse population experience new challenges (Tregunno et al., 2009, p. 189). Many IENs who have had experience with culturally homogeneous cultures are not prepared to care for the diverse cultural nature of Ontario’s patient population. IENs expressed concerns about not feeling adequately prepared for working in Canada since meeting these professional expectations requires a high level of oral language proficiency that IENs may not possess. IENs also experience differences in nursing practice expectations in Canada in areas such as increased verbal and written communication and the amount of electronic medical documentation (Hearnden, 2007, p. 96). They also note the emphasis on the psychosocial client-centered aspects of nursing practice in Canada in contrast to task-based approaches adopted in other countries. Professional communication within a culturally diverse client population, collaborative relationships between nurses and other team members, and regulations governing nursing practice, most specifically, regarding confidentiality, consent, and accountability, were perceived as new challenges for IENs. A review of the literature indicates that IENs experience more difficulties with acculturation into Western nursing practice than has been previously recognized. Table 1 summarizes six IEN studies describing language challenges cited in this review.
IEN Professional Communication Challenges Lacking an understanding of local communication norms and expectations can contribute to IENs failing to integrate successfully. A number of reasons for this have been identified in the literature. Accented English or technical language difficulties have frequently been reported as problematic for language learners (Epp et al., 2002). While these are important, more global language issues such as professional discourse difficulties may prevent effective communication. Defining language proficiency or competency in such a way as to capture the complexities of professional communication is essential. Although the need for language competency has been reported to be important for successful
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Table 1. Summary of Internationally Educated Nurses (IEN) Studies Cited. Authors
Country of Study
Population of IENs
Epp et al. (2002)
Canada
N = 10 IENs
Hearnden (2007)
Canada
N = 28; 19 IENs and 9 non-IENs.
Sherman & Eggenberger (2008)
United States
N = 21 IENs
Tregunno et al. Canada (2009)
N = 30 IENs
O’Neill (2011) Australia
N = 10 IENs
Murray (2012) Australia
N = 36 IENs
Findings Completed the CAN Test, which measures English language proficiency in 4 areas: speaking, listening, reading and writing. Mean scores are similar to results reported in the literature. Barriers include language proficiency and sociocultural competency. Lack of educational supports to overcome these barriers. Lack confidence in functioning at the BSN level in Ontario. Reported differences in nursing practice expectations and challenges with transitioning to a different culture and education system. Nursing orientation and continuing education strategies supporting the domestic nursing workforce is not as effective with IENs. Differences in the expectations of professional nursing practice and the role of patients and families in the decision-making process. Lack of English language fluency caused work-related stress and cognitive fatigue. Transitioning from the classroom to the clinical setting necessitates constructing new cultural and professional identities as well as English proficiency. The model/course comprised 39 hours of face-to-face teaching in which English language results suggest that a modest language intervention can have an impact on IENs' English language competency such as written communication.
integration into the general society as well as access into regulated occupations, such as nursing, there is a lack of consistency as to what constitutes English language proficiency in general and across professions. The manner in which “competency” is defined will influence performance expectations. If language benchmarks are not consistent with the expected performance in the workplace, this will have a negative impact on employment outcomes of professionals who are not able to meet the demands of the job. This variability in performance expectations may explain the different approaches to language assessment and education within any given profession. Every profession has its own unique practice language that must be learned in order for its members to be considered competent. The nursing profession in English-speaking countries has a complex, highly developed practice culture and language system, containing phraseology, medical terminology, acronyms, and abbreviations, all of which may remain unclear to anyone who was not educated in the local community or country (Hearnden, 2007). The technical
Design/Limitations Qualitative design; small sample size. The CAN Test can only test general English fluency and is not professional language/ discourse specific. Qualitative design; relatively small sample size.
Qualitative design; relatively small sample size.
Qualitative design; data not generalizable to the general IEN population in Canada.
Qualitative design; small sample size. Quantitative design; small sample size. Author notes that, while the results show a clear trend, they need to be interpreted with caution, particularly given the small sample size and low study retention rate of 30%.
language of a profession, that is, the formal terminology and the informal jargon, is often difficult for English language learners from distinctively different cultures. Understanding the culture of a new workplace is a challenge in itself but more so for IENs who have low levels of English language proficiency (Sherman & Eggenberger, 2008). Different words are used in other languages to describe conditions, and direct translation does not communicate the exact meanings. As a result, IENs tend to have inadequate vocabulary for describing the names of equipment and specific patient conditions, or using local idioms and slang as well as not understanding culturally specific words (Hearnden, 2007). New immigrants are usually experts in their professional areas but may lack the oral skills, that is, “small talk,” to manage the social and interpersonal aspects of workplace communication between the nurse and patient (Holmes, 2000). The socio-pragmatic or interactional aspects of professional conversation require a different set of communication skills. Language learners must have the ability to accurately interpret the sociocultural values expressed in an
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Lum et al. interaction and to respond in a way that is consistent with local norms (Holmes, Marra, & Vine, 2012). Holmes and Major (2003) analyzed different types of nursing communication or professional “talk” of native English speakers, making a distinction between medical, transactional, and nonmedical or social talk. They noted that the majority of nurses’ talk (about 60%) involved informal, nonmedical communication. This informal talk, including the use of “strategically positioned small talk and amusing anecdotes was balanced skillfully alongside medical talk to establish rapport and help patients feel comfortable in the medical environment and with medical procedures” (Holmes & Major, 2003, p. 5). Small talk or talking about noncontroversial, general interest topics between colleagues at work is also necessary to managing the inevitable tensions that arise in various professional and social roles (Holmes & Major, 2003, p. 127). Nonnative speakers often have difficulty in recognizing the importance of socio-pragmatic conversation as a major component of practice or lack the opportunity to develop these skills. These same socio-pragmatic difficulties were also identified as a problem for IENs working in the Canadian health care system (Deegan & Simkin, 2010; Hearnden, 2007). It is not enough for IENs to be proficient with the technical aspects of English, but they also must be able to communicate effectively in a variety of different professional situations and contexts. Eyre (2010) notes that “native” speakers are able to draw on their innate or intuitive knowledge of socio-pragmatic conventions and to adjust their speech in these linguistically complex ways in order to suit the purpose and context. IENs may lack knowledge of these pragmatic skills that may cause employers to “feel that workers seem unfriendly or uncomfortable at work and that they do not fit in smoothly” (Eyre, 2010, p. 14). In order to be language proficient, IENs need to learn the socio-pragmatic conventions of the nursing profession in the local employment context.
Educational Implications Although much attention has been directed toward assessing language deficits, there is much less focus on understanding why learning context appropriate English language may be a difficult process for IENs. As a result, there is a great deal of inconsistency in the way bridging education programs are designed. Designing bridging programs based on a conceptual understanding of the language learning process may lead to more standardized curriculum and would increase their educational value. Bridging programs need to be designed to accommodate IENs’ need to learn culturally specific professional language. The two English language learning models identified in the nursing-related literature were proposed by Cummins (1981, 1983) and Bachman (1990). The Bachman Model (Bachman, 1990) focuses on organizational competency, that is, the formal features or rules of language and pragmatic competency, which is concerned with how language
is used to achieve a particular goal such as explaining, persuading, or requesting within particular contexts. Bachman argued that individuals must not only have a proficient grasp of the rules of English but must also develop pragmatic skills in order to develop language competency. Choi (2005) and Abriam-Yago and Kataoka-Yahiro (1999) propose that a similar communication model such as the Cummins Model of Language Acquisition could form the basis for IEN bridging education since it provides a conceptual framework that connects language skill development with effective teaching strategies. In Abriam-Yago and Kataoka-Yahiro's paper, the focus is placed on the Cummins Model (Cummins, 1981, 1983) because it emphasizes two key aspects of language acquisition: learning the formal features or rules of the language and the social aspect of language used in everyday face-to-face conversations. As previously mentioned, the majority of nursing talk (about 60%) involved nonmedical, rapport-building communication among peers and patients. The Cummins Model offers a relevant framework to explore in more detail the social and cultural aspects of learning a language instead of the Bachman Model (Bachman, 1990), which simply focuses on its technical use to obtain a specific goal. The Cummins Model (Cummins, 1983) emphasizes the importance of understanding the learning context in which language is acquired. Context includes cognitive, structural, symbolic, and environmental elements pertinent to a particular situation or setting. This model proposes that language learners must develop proficiency in social and academic settings. The model describes two types of language skills: basic interpersonal communication skills (BICS) and cognitive academic language proficiency (CALP). The BICS include the social language in which students participate in daily face-to-face conversation. CALP requires opportunities for English as a second language (ESL) students to communicate in more cognitively demanding oral and written situations, such as class discussions and lectures, and in professional settings, such as hospitals and clinics. Cognitive academic language competency, which may be more difficult to acquire, is developed through reading a variety of academic texts and repeated exposure to academic terminology in activities such as lectures and class discussions. IENs may appear proficient in BICS and therefore be assumed to be proficient in CALP, but they need to be provided with an opportunity to develop both types of skills. Developing assessment strategies that utilize CALP in combination with other methods of assessment would provide a more comprehensive evaluation of the IENs’ language competency and facilitate a more learner-friendly educational environment for IENs. The Cummins Model (Cummins, 1981, 1983) also proposes that language competency can be conceptualized along two continua distinguishing between context-embedded and context-reduced communicative situations. Context-embedded “communicative situations offer contextual clues to assist in
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Table 2. Questions to Investigate IEN Learning Experiences and Course Expectations. 1. What is your first language? 2. When did you immigrate to this country (i.e., United States, Canada)? 3. How old were you when you came to this country? 4. How many years have you spoken English on a daily basis? 5. What are your expectations of your teacher? 7. Do you participate in class discussions? Why? Why not? 8. Do you like to work independently or work in groups? 9. What do you think is a good teacher-student relationship? 10. What teacher behaviors facilitate your learning? 11. What teacher behaviors inhibit your learning? 12. What strategies do you use to help yourself learn? 13. If any, what are your concerns about this course? Source. Adapted from Abriam-Yago and Kataka-Yahiro (1999, pp. 146–147).
the understanding of language, such as facial expressions, gestures, and feedback from the speaker or listener” (AbriamYago & Kataoka-Yahiro, 1999, p. 145). This type of communicative situation generally occurs outside the classroom. Within the profession of nursing, this type of learning may be more easily acquired in a clinical learning context. Context-reduced communicative situations, such as lectures or textbooks, offer fewer clues and are more linguistically demanding. IENs will experience greater language challenges if they are learning primarily in context-reduced settings with less exposure to socio-pragmatic skills. Application of the Cummins Model is a strategy that can be used by nursing faculty to empower IENs in the educational setting. IENs may possess language and cultural beliefs that place them at a disadvantage from the dominant culture (Jalili-Greneir & Chase, 1997). Cummins (1981) contends that “students from ‘dominated societal groups’ are ‘empowered or disabled’ as a direct result of their interactions with educators in the schools” (p. 21). Enabling students to have “voice and agency” are central to critical teaching because without them there is no such thing as empowerment. This stresses individuals’ power to achieve their own goals. Education for empowerment demands: (a) taking seriously the strengths, experiences, strategies, and the goals of learners; (b) helping students to analyze the social structures that hinder them; and (c) acting in such a way as to reach their own goals successfully (Abriam-Yago & Kataoka-Yahiro, 1999). Nursing faculty play a major role in promoting language competency in how they design and plan their curriculum for IENs (Hammett-Zelanko, 2007). Abriam-Yago and KatakaYahiro (1999, p. 146) based on the Cummins Model, proposed a number of specific faculty-directed teaching strategies for ESL students, which could be applied to teaching IEN students. To gain a more in-depth understanding of students’ learning needs, nursing faculty need to identify the students’ prerequisite knowledge expected in the course. To
promote the adoption of new knowledge and ways of learning, discussions of students’ previous and current learning experiences are essential. Table 2 provides a set of exploratory questions that can be posed to students to identify previous classroom and literary experiences and as a means to promoting greater student engagement. Providing time for “thought questions” is another effective strategy to promote critical thinking. By having students document their thoughts about a given situation in advance, students have time to think about the issue and to formulate their opinion. Faculty could provide students with opportunities for self-expression of their individual identity. Students frequently indicate that establishing rapport with patients is stressful because they have difficulty engaging in casual social conversation. Assisting students by making educated guesses about topics that patients are likely to talk about in their home setting is recommended. Often, IENs need more opportunities to converse in bilingual, that is, English and other spoken languages and bicultural conversations. Faculty may gain insight from the student’s explanation of the cultural context surrounding working in an English-speaking environment. Managing group work has been cited by students as a new experience. Faculty may assign students to work in multicultural pairs and small groups. This is an effective contextembedded strategy because it organizes cross-cultural pairs, facilitates social contacts, and develops camaraderie (Abriam-Yago & Kataoka-Yahiro, 1999, p. 146). In order to provide IENs with a meaningful and useful education, nursing instruction should be presented in a context-embedded manner to facilitate acquisition of both basic and academic language (Choi, 2005). Nursing faculty need to account for and appreciate this learning difference when planning their curriculum (Bosher & Smalkoski, 2004). Nonnative speakers need opportunities to use language to achieve its intended purposes, such as explaining, informing, clarifying, and requesting, which are foundational to professional practice. They must also learn to use colloquialisms, include cultural references, and demonstrate the ability to use language in a “natural manner.” Exposure to target or everyday language is not enough since pragmatic features are not sufficiently noticeable to additional language learners and therefore not likely to be integrated even after considerable exposure. Explicit instruction is needed so that language learners have their attention drawn to the many subtle ways in which native speakers construct collegial relationships at work as well as indirect ways in which they construct their personal identity (Holmes et al., 2012, p. 537). Designing courses for IENs that provide opportunities that enhance their ability to learn and practice both the linguistic and sociocultural aspects of being a nurse within the context of the country’s health care system over longer periods needs to be considered. The challenges and complexities experienced by IENs and the time required to learn new professional language within an unfamiliar setting cannot be
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Lum et al. minimized. Nursing communication consists of multiple components, both academic and practice oriented. IENs, unlike locally educated students, usually do not have the same opportunities, time, or resources to learn these new skills. Efforts must be directed to designing effective programs in light of these constraints. With more educational opportunities that include communication skill development, the IEN is more likely to become language proficient. Ultimately, the goal for any educational program is to produce a workable and comprehensive strategy that provides IENs with the necessary support and that is both robust and flexible enough to respond to the group and individual needs of these nurses (Murray, 2012). Educators need to identify specific needs of the learner, which in the case of IENs may be quite diverse, and provide well-designed learning opportunities (Choi, 2005). It is important to recognize that language instruction for professionals must be based on a more holistic view of English competence. Murray (2012) asserts that irrespective of the type of program, any model of English language support needs to embed discipline-specific literacies. It must develop not only students’ academic proficiency but also their ability to enter the workforce with the kind of communication skills that are increasingly highlighted by employers as essential attributes.
Limitations and Recommendations Although this review discusses communication issues concerning IENs, only a small number of papers focusing specifically on this group were identified. Epp et al. (2002) described a nationwide study analyzing the language demands for the nursing profession in Canada. IENs were identified as a group currently experiencing language challenges; however, these data were collected predominantly from locally educated nurses and not from IENs. The issues reported by the IENs in this study were similar to those previously identified by other authors, but more empirical research needs to be conducted to explore in more depth their specific language and social integration needs in order to increase the validity of the findings being reported in the literature. The small sample sizes of the reported studies in this review make it difficult to generalize to larger populations. Accessing potential participants, recruitment and retention within IEN studies have been consistently cited as a design limitation. The primary method used for data collection included either individual or focus group interviews with small numbers of IENs. Other than the one study conducted by Donnelly et al. (2009), no in-depth studies were identified which explored the context of language and culture and its impact upon the employment integration of IENs. Most of the literature reported on the experiences of individual countries thus limiting the ability to generalize to other locations. Cross-population studies that identified similarities
and differences among educational practices by different countries were not identified. Studies exploring the impact of IENs’ previous language experiences on their ability to integrate into new professional contexts are needed in order to better understand how personal history affects language acquisition. If researchers used a survey design, an important constraint having an impact on the reliability of the results is that self-assessed English proficiency has not been found to correlate directly with objective evaluation tools. The majority of data sets used in observational studies employ a measure of English that is assessed by the respondent. Past studies have relied solely on self-rated English ability and have tended to ignore the connection between self-/other assessments (Akresh & Frank, 2010). These authors reported that new immigrants to the United States tend to either under- or overestimate their English language abilities. Akresh (2006) further illustrated that this can lead to negative performance outcomes in terms of employment and economic success. In particular, new immigrants who overestimate their language ability tend to earn less and to experience lower occupational prestige. A significant implication for future research is that appraisal of English language ability, aside from self-appraisals, needs to include either objective tests or appraisal by others. Professional language benchmarks and methods for evaluating communication competency appear to vary widely among countries, educational programs, and employment settings. It was beyond the scope of this review to attempt a critique of the effectiveness of current competencybased language systems and proficiency requirements in any given country or program. Further research is needed in this area.
Conclusion Although the majority of IENs meet the English language entry criteria intended to serve as a gatekeeping mechanism to the nursing profession, this literature review clearly documents that they continue to struggle with communication proficiency within bridging programs and further on into employment settings. Since all new immigrants are faced with challenges associated with integrating into the culture of a new country, being proficient in the official language is an essential skill to achieving this goal. The lack of language proficiency has been documented to lead to lower rates of employment and lower socioeconomic status. Although this review identified a number of papers describing communication issues concerning ESL nursing students in basic degree or bridging programs, only a small number of research papers pertain specifically to IENs. Nevertheless, this literature review provides preliminary evidence that for IENs seeking to practice in English-speaking countries, their educational needs, specifically in areas related to nursing communication, may not be adequately addressed in bridging education programs or further into employment. In order to address this
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knowledge gap, prospective, longitudinal studies exploring IEN experiences and their implications for language education are recommended. In order to provide IENs with a beneficial education, nursing curricula must include language education components in order for them to improve their language proficiency. IENs have to not only develop a proficient grasp of the technical rules of English but must also develop pragmatic competence, that is, an ability to use forms appropriate to the particular context and purpose. In other words, language competency consists of acquiring a combined knowledge of the nursing context of the local country in which they intend to practice and proficient use of language strategies (Eyre, 2010). Any remedial courses focusing solely on the technical components of English language fail to address their need to develop pragmatic competence. The social, professional context in which English language is practiced must be integrated into IEN education to promote successful integration in the nursing profession. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding Disclosure The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The preparation of this article was funded by the Ontario Ministry of Citizenship and Immigration, Ontario, Canada.
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TCNXXX10.1177/1043659614524792Lum et al.Journal of Transcultural Nursing
International Department
Challenges in Oral Communication for Internationally Educated Nurses
Journal of Transcultural Nursing 2015, Vol. 26(1) 83–91 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659614524792 tcn.sagepub.com
Lillie Lum, RN, PhD1, Penny Dowedoff, MA2, Pat Bradley, RN, PhD1, Julie Kerekes, PhD3, and Antonella Valeo, PhD4
Abstract Achieving English language proficiency, while key to successful adaptation to a new country for internationally educated nurses (IENs), has presented more difficulties for them and for educators than previously recognized. Professional communication within a culturally diverse client population and maintaining collaborative relationships between nurses and other team members were perceived as new challenges for IENs. Learning an additional language is a long-term, multistage process that must also incorporate social and cultural aspects of the local society and the profession. This article provides a descriptive review of current research literature pertaining to English language challenges, with a focus on oral language, experienced by IENs. Educational strategies for teaching technical language skills as well as the socio-pragmatics of professional communication within nursing programs are emphasized. Bridging education programs must not only develop students'academic language proficiency but also their ability to enter the workforce with the kind of communication skills that are increasingly highlighted by employers as essential attributes. The results of this review are intended to facilitate a clearer understanding of the English language and communication challenges experienced by IENs and identify the implications for designing effective educational programs. Keywords Internationally educated nurses, English language education, professional communication While an abundance of studies examine the nature of English learning across a variety of disciplines, there has only been a limited research focus on the experiences of internationally educated nurses working in English-speaking countries (Epp, Strawychny, Bonham, & Cumming, 2002; Sherman & Eggenberger, 2008). The term internationally educated nurse (IEN) describes a nurse educated outside of North America in a predominantly non-English-speaking country and who is either a nonnative English speaker or speaks a non–North American type of English. This term is synonymous with an international RN and a foreign-trained or foreign-educated nurse. Despite the fact that there is increased support for both IENs and nursing students for whom English is an “additional language,” there are a significant number who continue to struggle in both academic and employment settings due to their limited English skills. This suggests that, despite passing language and licensure exams, they may experience communication deficits that are not presently recognized in the current educational system. Learning new terminology and ways of communicating with clients and team members is a complex challenge that has not been adequately examined. Major and Holmes (2008) have concluded that more research is needed to better understand the technical and social aspects of effective nursing
communication. Achieving adequate proficiency is a longterm, multistage process that must also incorporate social and cultural aspects of the local society. O’Neill (201l) describes this process as IENs having to negotiate between three or four different worlds: the world of “learning the rules of the English language,” the world of “learning the nursing specific terminology,” the world of “learning the discourse of the nursing profession and the culture of the Canadian health care system,” and finally the world of “learning the Canadian language culture” (p. 1127). This article provides a descriptive review of current research literature pertaining to English language challenges, 1
School of Nursing, Faculty of Health, York University, Toronto, ON, Canada 2 Department of Sociology, York University, Toronto, ON, Canada 3 Department of Curriculum, Teaching and Learning, OISE, University of Toronto, Toronto, ON, Canada 4 Department of Languages, Literatures & Linguistics, York University, Toronto, ON, Canada Corresponding Author: Lillie Lum, RN., PhD, Associate Professor, School of Nursing and School of Health Policy and Management, Faculty of Health, York University, 4700 Keele Street, Toronto, Ontario, M3J 1P3, Canada. Email: [email protected]
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with a focus on oral language, experienced by IENs. Although it is difficult to separate comprehension, reading, speaking and writing components of language, this article focuses on the oral aspect of the English language since the ability to communicate orally is an essential nursing skill (Hearnden, 2007), as well as being a dominant way to achieve social and cultural integration into any given society or profession. The results of this review are intended to facilitate a clearer understanding of the English language and the communication challenges experienced by IENs and consider the implications for designing effective educational programs. The authors also attempt to describe current research gaps and areas needing further attention.
Language Proficiency and Social Integration The globalization of the health care workforce in Englishspeaking countries such as Australia, Canada, Great Britain, New Zealand, and the United States has led to a much greater cultural diversity within the nursing profession. Achieving a competent level of English language proficiency or communication skill, while key to successful adaptation to a new country, has presented more difficulties than previously recognized (Kawi & Xu, 2009). The literature has documented that one of the greatest barriers to workplace integration for new immigrants is the lack of adequate professional communication skills. Based on Australia’s experience, O’Neill (2011) noted that new immigrants meet challenges in the Western workforce that extend beyond simply achieving technical language proficiency but also include navigating the role of a language learner as a means of integrating into a new professional culture. Learning the technical components, such as correct grammar and pronunciation, is not the most important factor in communicating competently in a new language. Holmes (2000) concluded that new immigrant health professionals with prior experience are usually experts in their profession but need to learn how to manage the social and interpersonal aspects of their role, which are based on effective communication, workplace interaction, and health care practices. Although little attention has been directed to professionspecific language issues, empirical evidence in the immigration literature illustrates the relationship between immigrant English language competency and social integration into a new society. The literature reflects a strong emphasis on the benefits of language proficiency, and economic outcomes such as successful employment and earnings. In Canada, language ability is a strong predictor of labor market success (Akresh & Frank, 2010). Greater proficiency in the second/ official language enhances the effect of previous education and pre-immigration work experience. Tufts, Damsbaek, Phan, Kelly, and Maryse (2010) studied national census data of recent Canadian immigrants and found that more than half the immigrants who speak English or French, Canada’s official languages, “very well” find work in a field related to
their education/training, compared to fewer than one in five for immigrants with poor language skills. For both men and women, after 4 years in Canada, poor language ability leads to unemployment rates double those of male and female immigrants who can speak English or French “very well.” Language proficiency has also been shown to lead to early employment success. The initial year in Canada is critical for immigrants to obtain a job in their intended field (Grenier & Xue, 2011). After that period, the likelihood of finding employment in the intended occupation decreases. Four main factors have been found to facilitate access to gainful employment: education, English language ability, Canadian work experience, and friend networks. Language proficiency has been found to have a positive effect on employment probabilities but, conversely, the lack of English fluency leads to earning losses. Immigrants with better skills in English or French were more likely to see an increase in their participation and unemployment rates, and decrease in average length of jobless spells over time. Immigrants’ language abilities are not fixed and can improve following their immigration. Kelly, Damsback, and Lemoine (2010) used national immigration census data to show that lower levels of language proficiency tend to be associated with lower rates of labor market participation and higher rates of unemployment for new immigrants. An individual may move from one category of language skill level, that is, lower to higher over the course of their first four years in Canada. This finding supports the importance of identifying lower levels of language proficiency experienced by immigrants during the early settlement period to be followed up with language education. Failure to develop adequate English language proficiency has also been shown to lead to higher dropout rates for international nursing students in the United States (Alvarez & Abriam-Yago, 1999). The opportunity to improve one’s English language proficiency in postsecondary education programs is important to the academic engagement of recent adult immigrants in Canada who seek to upgrade their education (Lum & Grabke, 2012). The lack of English language competency was found to have a negative effect on their academic success and potential employment. Donnelly, McKiel, and Hwang (2009) reported that new immigrant nurses in a Canadian bachelor’s degree program experienced more difficulties than domestic students due to their lack of adequate English skills, which interfered with all components of learning including understanding textbooks, lectures and teacher’s expectations, and the wording of written examinations and writing academic papers.
IENs Transitioning to a New Professional Culture Language proficiency is an essential component to achieving cultural integration into a profession. Despite the fact that IENs possess prior nursing experience from their countries
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Lum et al. of origin, they must learn to adapt to an unfamiliar professional nursing culture following immigration. They face a host of economic, professional, and social challenges in adapting to a new working environment during the initial settlement period (Donnelly et al., 2009; Wang, Singh, Bird & Ives, 2008). Many of these challenges stem from intercultural communication problems attributable to unfamiliarity with unique aspects of the local culture, consequently leading to difficulties with social conversation in that culture, and unfamiliarity with communication norms of the workplace (Holmes, Marra, Newton, Riddiford, & Vine, 2011). In other words, understanding the language expectations of the local culture, that is, cultural competency, has a direct influence on IEN professional integration. Lampley, Little, Beck-Little, and Xu (2008) define “cultural competency” as the ability to demonstrate a set of skills and behaviors that enables nurses to work effectively within the cultural context of the client (that is, individual, family, or community). In order to demonstrate cultural competency, new immigrants need to acquire new knowledge, behaviors, and attitudes. However, the opportunities for gaining these skills may not be readily available. Lampley et al. (2008) noted that gaining cultural competency presented challenges for IENs, who reported less confidence in providing culturally competent care to patients from diverse cultures. The most frequently cited challenges include ineffective communication, the lack of knowledge of health beliefs, and understanding the behavior of people from different cultures. This knowledge deficit can exacerbate problems of low language proficiency for nurses who are less experienced with practicing in multicultural contexts. New immigrants are thus fundamentally disadvantaged because of their lack of social power due to unfamiliarity with societal norms of the local culture. Difficulty with cultural competency can manifest itself as communication challenges. Many communication issues contain some element of cultural difference. For example, practicing in a new culture that is more collaborative and autonomous can pose major challenges for IENs in Canada (Epp et al., 2002). Being assertive and managing team conflict were cited as problems. There may also be a tendency to be either too passive or too aggressive in unfamiliar work situations. It is often difficult for IENs to express disagreement with authority figures such as physicians and managers. IENs in Canada reported that practice expectations were different in areas such as autonomous decision making, being more responsible for patient advocacy, engaging in inter- professional collaboration, and having more egalitarian relationships with physicians and other professionals (Tregunno, Campbell, & Gordon, 2009). Based on their personal experiences within a Canadian baccalaureate program, IENs noted that it is difficult to understand a new culture without understanding the language and its symbolic meanings. Conversing with patients, which was perceived as a low priority for some nurses in
their home countries, added to their difficulties with acculturation. They reported that understanding constructed scenarios that included examples of local sports or health issues as a means to teaching nursing were problematic due to an inadequate understanding of language and cultural knowledge (Donnelly et al., 2009). Simple topics such as choosing a type of food or discussing the weather with patients would present conversational challenges if the topic were unfamiliar. These differences in communication styles had not been anticipated by IENs. Another factor identified as adding to the complexity of professional communication competency within the health care setting is the highly multicultural nature of the patient population. IENs working in an urban center such as Toronto, Ontario, with its culturally diverse population experience new challenges (Tregunno et al., 2009, p. 189). Many IENs who have had experience with culturally homogeneous cultures are not prepared to care for the diverse cultural nature of Ontario’s patient population. IENs expressed concerns about not feeling adequately prepared for working in Canada since meeting these professional expectations requires a high level of oral language proficiency that IENs may not possess. IENs also experience differences in nursing practice expectations in Canada in areas such as increased verbal and written communication and the amount of electronic medical documentation (Hearnden, 2007, p. 96). They also note the emphasis on the psychosocial client-centered aspects of nursing practice in Canada in contrast to task-based approaches adopted in other countries. Professional communication within a culturally diverse client population, collaborative relationships between nurses and other team members, and regulations governing nursing practice, most specifically, regarding confidentiality, consent, and accountability, were perceived as new challenges for IENs. A review of the literature indicates that IENs experience more difficulties with acculturation into Western nursing practice than has been previously recognized. Table 1 summarizes six IEN studies describing language challenges cited in this review.
IEN Professional Communication Challenges Lacking an understanding of local communication norms and expectations can contribute to IENs failing to integrate successfully. A number of reasons for this have been identified in the literature. Accented English or technical language difficulties have frequently been reported as problematic for language learners (Epp et al., 2002). While these are important, more global language issues such as professional discourse difficulties may prevent effective communication. Defining language proficiency or competency in such a way as to capture the complexities of professional communication is essential. Although the need for language competency has been reported to be important for successful
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Table 1. Summary of Internationally Educated Nurses (IEN) Studies Cited. Authors
Country of Study
Population of IENs
Epp et al. (2002)
Canada
N = 10 IENs
Hearnden (2007)
Canada
N = 28; 19 IENs and 9 non-IENs.
Sherman & Eggenberger (2008)
United States
N = 21 IENs
Tregunno et al. Canada (2009)
N = 30 IENs
O’Neill (2011) Australia
N = 10 IENs
Murray (2012) Australia
N = 36 IENs
Findings Completed the CAN Test, which measures English language proficiency in 4 areas: speaking, listening, reading and writing. Mean scores are similar to results reported in the literature. Barriers include language proficiency and sociocultural competency. Lack of educational supports to overcome these barriers. Lack confidence in functioning at the BSN level in Ontario. Reported differences in nursing practice expectations and challenges with transitioning to a different culture and education system. Nursing orientation and continuing education strategies supporting the domestic nursing workforce is not as effective with IENs. Differences in the expectations of professional nursing practice and the role of patients and families in the decision-making process. Lack of English language fluency caused work-related stress and cognitive fatigue. Transitioning from the classroom to the clinical setting necessitates constructing new cultural and professional identities as well as English proficiency. The model/course comprised 39 hours of face-to-face teaching in which English language results suggest that a modest language intervention can have an impact on IENs' English language competency such as written communication.
integration into the general society as well as access into regulated occupations, such as nursing, there is a lack of consistency as to what constitutes English language proficiency in general and across professions. The manner in which “competency” is defined will influence performance expectations. If language benchmarks are not consistent with the expected performance in the workplace, this will have a negative impact on employment outcomes of professionals who are not able to meet the demands of the job. This variability in performance expectations may explain the different approaches to language assessment and education within any given profession. Every profession has its own unique practice language that must be learned in order for its members to be considered competent. The nursing profession in English-speaking countries has a complex, highly developed practice culture and language system, containing phraseology, medical terminology, acronyms, and abbreviations, all of which may remain unclear to anyone who was not educated in the local community or country (Hearnden, 2007). The technical
Design/Limitations Qualitative design; small sample size. The CAN Test can only test general English fluency and is not professional language/ discourse specific. Qualitative design; relatively small sample size.
Qualitative design; relatively small sample size.
Qualitative design; data not generalizable to the general IEN population in Canada.
Qualitative design; small sample size. Quantitative design; small sample size. Author notes that, while the results show a clear trend, they need to be interpreted with caution, particularly given the small sample size and low study retention rate of 30%.
language of a profession, that is, the formal terminology and the informal jargon, is often difficult for English language learners from distinctively different cultures. Understanding the culture of a new workplace is a challenge in itself but more so for IENs who have low levels of English language proficiency (Sherman & Eggenberger, 2008). Different words are used in other languages to describe conditions, and direct translation does not communicate the exact meanings. As a result, IENs tend to have inadequate vocabulary for describing the names of equipment and specific patient conditions, or using local idioms and slang as well as not understanding culturally specific words (Hearnden, 2007). New immigrants are usually experts in their professional areas but may lack the oral skills, that is, “small talk,” to manage the social and interpersonal aspects of workplace communication between the nurse and patient (Holmes, 2000). The socio-pragmatic or interactional aspects of professional conversation require a different set of communication skills. Language learners must have the ability to accurately interpret the sociocultural values expressed in an
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Lum et al. interaction and to respond in a way that is consistent with local norms (Holmes, Marra, & Vine, 2012). Holmes and Major (2003) analyzed different types of nursing communication or professional “talk” of native English speakers, making a distinction between medical, transactional, and nonmedical or social talk. They noted that the majority of nurses’ talk (about 60%) involved informal, nonmedical communication. This informal talk, including the use of “strategically positioned small talk and amusing anecdotes was balanced skillfully alongside medical talk to establish rapport and help patients feel comfortable in the medical environment and with medical procedures” (Holmes & Major, 2003, p. 5). Small talk or talking about noncontroversial, general interest topics between colleagues at work is also necessary to managing the inevitable tensions that arise in various professional and social roles (Holmes & Major, 2003, p. 127). Nonnative speakers often have difficulty in recognizing the importance of socio-pragmatic conversation as a major component of practice or lack the opportunity to develop these skills. These same socio-pragmatic difficulties were also identified as a problem for IENs working in the Canadian health care system (Deegan & Simkin, 2010; Hearnden, 2007). It is not enough for IENs to be proficient with the technical aspects of English, but they also must be able to communicate effectively in a variety of different professional situations and contexts. Eyre (2010) notes that “native” speakers are able to draw on their innate or intuitive knowledge of socio-pragmatic conventions and to adjust their speech in these linguistically complex ways in order to suit the purpose and context. IENs may lack knowledge of these pragmatic skills that may cause employers to “feel that workers seem unfriendly or uncomfortable at work and that they do not fit in smoothly” (Eyre, 2010, p. 14). In order to be language proficient, IENs need to learn the socio-pragmatic conventions of the nursing profession in the local employment context.
Educational Implications Although much attention has been directed toward assessing language deficits, there is much less focus on understanding why learning context appropriate English language may be a difficult process for IENs. As a result, there is a great deal of inconsistency in the way bridging education programs are designed. Designing bridging programs based on a conceptual understanding of the language learning process may lead to more standardized curriculum and would increase their educational value. Bridging programs need to be designed to accommodate IENs’ need to learn culturally specific professional language. The two English language learning models identified in the nursing-related literature were proposed by Cummins (1981, 1983) and Bachman (1990). The Bachman Model (Bachman, 1990) focuses on organizational competency, that is, the formal features or rules of language and pragmatic competency, which is concerned with how language
is used to achieve a particular goal such as explaining, persuading, or requesting within particular contexts. Bachman argued that individuals must not only have a proficient grasp of the rules of English but must also develop pragmatic skills in order to develop language competency. Choi (2005) and Abriam-Yago and Kataoka-Yahiro (1999) propose that a similar communication model such as the Cummins Model of Language Acquisition could form the basis for IEN bridging education since it provides a conceptual framework that connects language skill development with effective teaching strategies. In Abriam-Yago and Kataoka-Yahiro's paper, the focus is placed on the Cummins Model (Cummins, 1981, 1983) because it emphasizes two key aspects of language acquisition: learning the formal features or rules of the language and the social aspect of language used in everyday face-to-face conversations. As previously mentioned, the majority of nursing talk (about 60%) involved nonmedical, rapport-building communication among peers and patients. The Cummins Model offers a relevant framework to explore in more detail the social and cultural aspects of learning a language instead of the Bachman Model (Bachman, 1990), which simply focuses on its technical use to obtain a specific goal. The Cummins Model (Cummins, 1983) emphasizes the importance of understanding the learning context in which language is acquired. Context includes cognitive, structural, symbolic, and environmental elements pertinent to a particular situation or setting. This model proposes that language learners must develop proficiency in social and academic settings. The model describes two types of language skills: basic interpersonal communication skills (BICS) and cognitive academic language proficiency (CALP). The BICS include the social language in which students participate in daily face-to-face conversation. CALP requires opportunities for English as a second language (ESL) students to communicate in more cognitively demanding oral and written situations, such as class discussions and lectures, and in professional settings, such as hospitals and clinics. Cognitive academic language competency, which may be more difficult to acquire, is developed through reading a variety of academic texts and repeated exposure to academic terminology in activities such as lectures and class discussions. IENs may appear proficient in BICS and therefore be assumed to be proficient in CALP, but they need to be provided with an opportunity to develop both types of skills. Developing assessment strategies that utilize CALP in combination with other methods of assessment would provide a more comprehensive evaluation of the IENs’ language competency and facilitate a more learner-friendly educational environment for IENs. The Cummins Model (Cummins, 1981, 1983) also proposes that language competency can be conceptualized along two continua distinguishing between context-embedded and context-reduced communicative situations. Context-embedded “communicative situations offer contextual clues to assist in
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Table 2. Questions to Investigate IEN Learning Experiences and Course Expectations. 1. What is your first language? 2. When did you immigrate to this country (i.e., United States, Canada)? 3. How old were you when you came to this country? 4. How many years have you spoken English on a daily basis? 5. What are your expectations of your teacher? 7. Do you participate in class discussions? Why? Why not? 8. Do you like to work independently or work in groups? 9. What do you think is a good teacher-student relationship? 10. What teacher behaviors facilitate your learning? 11. What teacher behaviors inhibit your learning? 12. What strategies do you use to help yourself learn? 13. If any, what are your concerns about this course? Source. Adapted from Abriam-Yago and Kataka-Yahiro (1999, pp. 146–147).
the understanding of language, such as facial expressions, gestures, and feedback from the speaker or listener” (AbriamYago & Kataoka-Yahiro, 1999, p. 145). This type of communicative situation generally occurs outside the classroom. Within the profession of nursing, this type of learning may be more easily acquired in a clinical learning context. Context-reduced communicative situations, such as lectures or textbooks, offer fewer clues and are more linguistically demanding. IENs will experience greater language challenges if they are learning primarily in context-reduced settings with less exposure to socio-pragmatic skills. Application of the Cummins Model is a strategy that can be used by nursing faculty to empower IENs in the educational setting. IENs may possess language and cultural beliefs that place them at a disadvantage from the dominant culture (Jalili-Greneir & Chase, 1997). Cummins (1981) contends that “students from ‘dominated societal groups’ are ‘empowered or disabled’ as a direct result of their interactions with educators in the schools” (p. 21). Enabling students to have “voice and agency” are central to critical teaching because without them there is no such thing as empowerment. This stresses individuals’ power to achieve their own goals. Education for empowerment demands: (a) taking seriously the strengths, experiences, strategies, and the goals of learners; (b) helping students to analyze the social structures that hinder them; and (c) acting in such a way as to reach their own goals successfully (Abriam-Yago & Kataoka-Yahiro, 1999). Nursing faculty play a major role in promoting language competency in how they design and plan their curriculum for IENs (Hammett-Zelanko, 2007). Abriam-Yago and KatakaYahiro (1999, p. 146) based on the Cummins Model, proposed a number of specific faculty-directed teaching strategies for ESL students, which could be applied to teaching IEN students. To gain a more in-depth understanding of students’ learning needs, nursing faculty need to identify the students’ prerequisite knowledge expected in the course. To
promote the adoption of new knowledge and ways of learning, discussions of students’ previous and current learning experiences are essential. Table 2 provides a set of exploratory questions that can be posed to students to identify previous classroom and literary experiences and as a means to promoting greater student engagement. Providing time for “thought questions” is another effective strategy to promote critical thinking. By having students document their thoughts about a given situation in advance, students have time to think about the issue and to formulate their opinion. Faculty could provide students with opportunities for self-expression of their individual identity. Students frequently indicate that establishing rapport with patients is stressful because they have difficulty engaging in casual social conversation. Assisting students by making educated guesses about topics that patients are likely to talk about in their home setting is recommended. Often, IENs need more opportunities to converse in bilingual, that is, English and other spoken languages and bicultural conversations. Faculty may gain insight from the student’s explanation of the cultural context surrounding working in an English-speaking environment. Managing group work has been cited by students as a new experience. Faculty may assign students to work in multicultural pairs and small groups. This is an effective contextembedded strategy because it organizes cross-cultural pairs, facilitates social contacts, and develops camaraderie (Abriam-Yago & Kataoka-Yahiro, 1999, p. 146). In order to provide IENs with a meaningful and useful education, nursing instruction should be presented in a context-embedded manner to facilitate acquisition of both basic and academic language (Choi, 2005). Nursing faculty need to account for and appreciate this learning difference when planning their curriculum (Bosher & Smalkoski, 2004). Nonnative speakers need opportunities to use language to achieve its intended purposes, such as explaining, informing, clarifying, and requesting, which are foundational to professional practice. They must also learn to use colloquialisms, include cultural references, and demonstrate the ability to use language in a “natural manner.” Exposure to target or everyday language is not enough since pragmatic features are not sufficiently noticeable to additional language learners and therefore not likely to be integrated even after considerable exposure. Explicit instruction is needed so that language learners have their attention drawn to the many subtle ways in which native speakers construct collegial relationships at work as well as indirect ways in which they construct their personal identity (Holmes et al., 2012, p. 537). Designing courses for IENs that provide opportunities that enhance their ability to learn and practice both the linguistic and sociocultural aspects of being a nurse within the context of the country’s health care system over longer periods needs to be considered. The challenges and complexities experienced by IENs and the time required to learn new professional language within an unfamiliar setting cannot be
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Lum et al. minimized. Nursing communication consists of multiple components, both academic and practice oriented. IENs, unlike locally educated students, usually do not have the same opportunities, time, or resources to learn these new skills. Efforts must be directed to designing effective programs in light of these constraints. With more educational opportunities that include communication skill development, the IEN is more likely to become language proficient. Ultimately, the goal for any educational program is to produce a workable and comprehensive strategy that provides IENs with the necessary support and that is both robust and flexible enough to respond to the group and individual needs of these nurses (Murray, 2012). Educators need to identify specific needs of the learner, which in the case of IENs may be quite diverse, and provide well-designed learning opportunities (Choi, 2005). It is important to recognize that language instruction for professionals must be based on a more holistic view of English competence. Murray (2012) asserts that irrespective of the type of program, any model of English language support needs to embed discipline-specific literacies. It must develop not only students’ academic proficiency but also their ability to enter the workforce with the kind of communication skills that are increasingly highlighted by employers as essential attributes.
Limitations and Recommendations Although this review discusses communication issues concerning IENs, only a small number of papers focusing specifically on this group were identified. Epp et al. (2002) described a nationwide study analyzing the language demands for the nursing profession in Canada. IENs were identified as a group currently experiencing language challenges; however, these data were collected predominantly from locally educated nurses and not from IENs. The issues reported by the IENs in this study were similar to those previously identified by other authors, but more empirical research needs to be conducted to explore in more depth their specific language and social integration needs in order to increase the validity of the findings being reported in the literature. The small sample sizes of the reported studies in this review make it difficult to generalize to larger populations. Accessing potential participants, recruitment and retention within IEN studies have been consistently cited as a design limitation. The primary method used for data collection included either individual or focus group interviews with small numbers of IENs. Other than the one study conducted by Donnelly et al. (2009), no in-depth studies were identified which explored the context of language and culture and its impact upon the employment integration of IENs. Most of the literature reported on the experiences of individual countries thus limiting the ability to generalize to other locations. Cross-population studies that identified similarities
and differences among educational practices by different countries were not identified. Studies exploring the impact of IENs’ previous language experiences on their ability to integrate into new professional contexts are needed in order to better understand how personal history affects language acquisition. If researchers used a survey design, an important constraint having an impact on the reliability of the results is that self-assessed English proficiency has not been found to correlate directly with objective evaluation tools. The majority of data sets used in observational studies employ a measure of English that is assessed by the respondent. Past studies have relied solely on self-rated English ability and have tended to ignore the connection between self-/other assessments (Akresh & Frank, 2010). These authors reported that new immigrants to the United States tend to either under- or overestimate their English language abilities. Akresh (2006) further illustrated that this can lead to negative performance outcomes in terms of employment and economic success. In particular, new immigrants who overestimate their language ability tend to earn less and to experience lower occupational prestige. A significant implication for future research is that appraisal of English language ability, aside from self-appraisals, needs to include either objective tests or appraisal by others. Professional language benchmarks and methods for evaluating communication competency appear to vary widely among countries, educational programs, and employment settings. It was beyond the scope of this review to attempt a critique of the effectiveness of current competencybased language systems and proficiency requirements in any given country or program. Further research is needed in this area.
Conclusion Although the majority of IENs meet the English language entry criteria intended to serve as a gatekeeping mechanism to the nursing profession, this literature review clearly documents that they continue to struggle with communication proficiency within bridging programs and further on into employment settings. Since all new immigrants are faced with challenges associated with integrating into the culture of a new country, being proficient in the official language is an essential skill to achieving this goal. The lack of language proficiency has been documented to lead to lower rates of employment and lower socioeconomic status. Although this review identified a number of papers describing communication issues concerning ESL nursing students in basic degree or bridging programs, only a small number of research papers pertain specifically to IENs. Nevertheless, this literature review provides preliminary evidence that for IENs seeking to practice in English-speaking countries, their educational needs, specifically in areas related to nursing communication, may not be adequately addressed in bridging education programs or further into employment. In order to address this
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knowledge gap, prospective, longitudinal studies exploring IEN experiences and their implications for language education are recommended. In order to provide IENs with a beneficial education, nursing curricula must include language education components in order for them to improve their language proficiency. IENs have to not only develop a proficient grasp of the technical rules of English but must also develop pragmatic competence, that is, an ability to use forms appropriate to the particular context and purpose. In other words, language competency consists of acquiring a combined knowledge of the nursing context of the local country in which they intend to practice and proficient use of language strategies (Eyre, 2010). Any remedial courses focusing solely on the technical components of English language fail to address their need to develop pragmatic competence. The social, professional context in which English language is practiced must be integrated into IEN education to promote successful integration in the nursing profession. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding Disclosure The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The preparation of this article was funded by the Ontario Ministry of Citizenship and Immigration, Ontario, Canada.
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