Nurses’ Standard English Communication Difficulties: Native Undergraduate and Non-Native
Nurses’ Standard English Communication Difficulties: Native Undergraduate and Non-Native
2. On the job
4. Nurses’ role
7. Standard English
8. Role hierarchy
The shortage of registered nurses is a global issue; it’s especially difficult to recruit and retain RNs in the United Kingdom’s National Health Service (NHS), because opportunities are better elsewhere. Despite a dearth of UK research, understanding motivation and experience is key in the employing and supporting of nurses in the workplace. In recent years, the gap has been apparent on education programs (Beitz, 2019); decreasing new graduate interest in, and awareness of, employment opportunities.
With regard to communication, education is distinguishable as a central theme. Subsidiary themes include; workplace culture and teamwork; mental wellbeing; nurses’ perceptions of their role; the impact of the working environment on individuals and teams; training, acquisition of skills and competencies; communication and emotional intelligence; directly negative impacts of bullying and aggression, and the potential for influence of external factors, such as background noise, for example, music, which positively soothes some and negatively enrages others.
Studies focusing broadly on safety (Howell, 2015), and the impact on the wellbeing of nurses and patients (Eskola et al, 2016: 2), observe that for nurses’ communities within workplace culture, ‘... shared structures, routines, rules and norms that serve to guide and constrain behavior ..’, communication is of most concern.
Central is hospital teamwork (Sonoda et al, 2018) in addressing patients’ vulnerability, and dangers arising from potential error, because of attendant risk. As improved organisation and administration of work environments fosters effective teamwork (Bradley and Griffin, 2016), English language teaching (ELT) is indicated as essential for non-English speaking nursing staff.
Schwa is a most common sound. So, if you want to sound natural and clear, you need to know how and when to use it. Schwa, written as ǝ in the sound alphabet, that is, phonetics, is a relaxed sound used when pronouncing unstressed vowels in words. It’s normal if you’ve never heard about it before, because it’s not a letter but a sound, ‘uh’, and helps the stressed vowel sound. Without schwa pronunciation is clipped and unnatural with over-pronounced unstressed sounds that are misunderstandable, for example, hospitǝl isn’t pronounced hospitæl, which is an ‘ah’ sound, rather than an ‘uh’, while the æ sound is a common error with Mittel Europe peons.
Not pronouncing the ‘th’ sounds, voiced and voiceless fricatives, that is, dental sounds, means you need to place your tongue gently between your teeth to pronounce correctly, with the tongue behind the teeth, for example, leather (ð), made only with air, and thing (θ), made with vibration. Many non-native speakers pronounce them as /t/, which is incorrect and unfamiliar, for example, instead of ‘theatre’ with some non-native speakers it’s ‘teater’.
Syllable stress is important in speaking English. If not stressed correctly, speech isn’t clearly understandable. Stress can change meaning, for example, if the first syllable is stressed (Toçi, A., 2020: 116), PREsent means ‘here’ (noun), for example, the nurse has the surgical tools, whereas if the last syllable is stressed, preSENT can refer to the surgeon’s holding the surgical tools in readiness.
English doesn’t sound natural; unless the speaker is able to use ‘reduced speech’, which compacts words, for example: ‘catheter’ pronounced ‘car theatre’ isn’t a clarifying reduction. Blending sounds together, for example, bedpan, is more natural sounding than bed pan, here the /d/ sound is blended into the /p/ sound, be*pan, that is, ‘Would you like a b*pan?’ Using schwa for unstressed vowels, for example, bədpən, that is, buhdpuhn, and contractions such as don’ for don’t, are unnatural reductions productive of a lack of clarity that hinders communication and right action.
As with stress, intonation is a key factor in non-native English speaking. Not using intonation when asking questions, for example, causes unnatural sounds, for example, with WH- questions (what, who, when, where) , voice is pitched down at the last, which is falling intonation: ‘What are you DOing?’ ↘ With questions that can be answered with a negative or an affirmative, pitch rises, that is, rising intonation: ‘Are you coMING?’ ↗ Obviously incorrect intonation is productive of confusion, for example, ‘Where are you go[W]ING?’ Of course the same can be said of UK dialects, for example, in the northern county of Yorkshire, England, ‘Wh’ is’t tha’ GO, Win’?’ I don’t know who Win is.
Most commonly, incorrect pronunciation of ‘the’, which is found in almost every spoken English sentence, sounds unnatural to native speakers, for example, if the following word starts with a consonant, schwa is pronounced; thǝ book. However, if the following word starts with a vowel, /iy/ is sounded, that is, thiy end. Unnatural examples would include th/ǝ/ǝ/tre, that is, th-uh-uh-tre, for th/iy/tre (theatre).
In hospitals pronunciation problems can be the result of tiredness, rather than laziness, which results in slowness of speech resembling brain damage, or quickness of speech indicating the desire to resemble efficiency when memory impairment, because of exhaustion, intrudes on effective action.
Fig.1 Phonetic alphabet chart
Referring to the international phonetic alphabet (IPA), English sounds are unique, for example, the upside down ‘r’ in phonetic notation is used to describe words where the sound remains unpronounced (see Figure 1), for example, nɹ̩s for nurse, which though clear to native speakers in the United States, might be met with blank looks in the UK. To what extent US pronunciation is attractive, because of Asian difficulties in pronouncing ‘l’ instead of ‘r’, remains moot, but it’s clear that nulse isn’t going to be pronounced if nurse has a soundless ‘r’ as in nɹ̩s, which is standard American English, while such Asian pronunciation in UK hospitals remains problematic for its native speakers.
2. On the job
Radford and Fotis (2018) found the experiences of nurses heavily influenced by organisational culture; service pressures produced by NHS cuts; managers’ teaching methods, and amount of time available for Continuing Professional Development (CPD). Strengthening interpersonal relations and teamwork; continuing education in communicative work, and collective decision-making, for example, regular meetings, addressing NHS service issues, required an educational platform: especially relevant to non-native speakers of English and those for whom improvement in standard English was a priority issue. According to Chang et al (2017) friendly communication environments are optimal; smoothing conflict through openness and clear communication: eliciting change. Mediating peer relations minimised workplace incidents (Purpora and Blegen, 2015); regardless of gender, ethnicity, or education level. Impact on team dynamics from stress through conflict (Smith et al, 2018), revealed communication was essential protection for patients potentially harmed by misunderstandings arising from mispronunciation and poor command of English language.
Strengthening employees’ interpersonal skills prevented communication issues (Clayton, Isaacs and Ellender, 2016), identified in NHS reports as vital for the ‘safety of care’ (NHS, 2017: 5). Kaldheim and Slettebø (2016) found ‘failure to communicate’, a phrase, made infamous by the prison guard, actor Strother Martin, while addressing actor Paul Newman as Lucas ‘Luke’ Jackson, part of a chain gang in leg irons, in the movie Cool Hand Luke (1967), and apposite. Non-collaborative behavior, such as impatience, made nurses feel degraded. For Sandelin et al (2019), dialogue was a sine qua non, while Matziou et al (2014) found physicians’ non-understanding of nurses’ perceptions of their role in decision-making processes as negatively impacting on patient outcomes.
As health service doctors were often immigrants from the Asian subcontinents of India or Pakistan, that is, Hindu and Moslem, used to being in conflict with their neighbor on religious grounds, because Islam is monotheist, while Hinduism is polytheistic, together with a propensity for misogyny, as evidenced by the problem posed by the Taliban regime in Afghanistan, that prior to 9/11, 2001, had provided a locale for the training of the Islamic extremist terror group, Al Qaeda, which hijacked civil airliners to crash into the Twin Towers of the World Trade Centre in New York and other targets, so representing an additional source of conflict in a workplace setting where nursing staff, primarily young women seeking permanent careers, experienced nebulous feelings of intimidation: un-resolvable for on-native speakers.
Dror Ben Ami, writing in The Jerusalem Post (2015), has a not uncommon explication of the meaning of Jesus’ death, which amounts to an extreme religious terrorist perspective, ‘Paul of Tarsus never said that the animal sacrifices of the Jews didn’t remove sins. To the contrary: he agreed they removed sins. The point Paul of Tarsus was trying to make was that the blood sacrifice of Jesus was a more effective way to remove sins, because it was only needed once, whereas Jewish blood sacrifices needed to be repeated year after year.’
Doubtless, the killers of 6,000, 000 Jews, and the builders of the ovens to burn the corpses in ‘death camps’ at northern Belsen, lower Saxony, southern Dachau, Bavaria, and Auschwitz, Lesser Poland (Małopolska) province, southern Poland, for example, during the period of power exercised by National Socialism’s (Nazism’s) democratically elected leader, Adolf Hitler, in Germany’s failed Second World War (1939-45) to enslave the human race for blood sacrifice, felt better.
The concept of human death within a hospital framework, as being necessary for the redemption of the sins of the religious, is anathema, while the belief in human death as a redemptive act on the part of the psychopathic killer seems to have become a universalized abomination antithetical to the basic principles of the Bible and Christianity, which for Jesus, the Messiah, was ‘Love your neighbour as you love yourself.’ (Mk: 12. 31) The point about Jesus being killed, as a dissident Jew, was his resurrection and ascension to heaven afterwards; despite being sacrificed like an animal.
Ben Ami’s argument is that Jesus, ‘Christ’, ‘the chosen’, was born and raised, as the ‘special one’; a blood offering in Satanism to appease ‘the god of this world’, who was then Emperor Tiberius Augustus of Rome, but any ghoul with cash for ‘snuff’ movies, that is, the recorded killing of people for entertainment, in the modern era, so that the voyeur and coward can experience the feel good factor too amongst the collective herd by Mr Average: Satan. The promise in Jesus’ resurrection and ascension to heaven was salvation and redemption for the slain, and eternal unendurable pain (perdition) for the evil, as God’s punishment for their sin of murder. Ben Ami’s advocating the categorization of non-Jews as animals to be killed for ‘the chosen people’ to improve their ‘feel good factor’. In the tower of Babel that is the nurses’ teaching hospital framework, it’s pertinent to explain that nurses and patients aren’t patiently waiting for the me tax.
A feature of nursing is learning on the job (Radford and Fotis, 2018) to acquire a broader skills set. Although feelings of anxiety are reducible through preparation (Willemsen-McBride, 2010), for Lydon and Burke (2012) mentorship was associated with negative learning experiences; feelings of inadequacy and exclusion. Crafoord and Fagerdahl (2018) found newly graduated nurses disaffected with clinical learning environments, supervised by mentors who, promoting clinical depression in the learners, rejected their point of view. Pupkiewicz et al (2015) found themes relating to novice and senior nurses’ perceptions of training; challenges to proficiency; fear; expectations; need for support, and adaptation. As the aim is to conceive change conducive to learning, nurses’ dependence on senior staff's ability to effectively mentor is the issue.
Nurses, regularly exposed to patient suffering, risk burnout, that is, mental health disorder through stress (Yaribeygi et al, 2017: 1057). Considered from a physiological perspective, stress, as well as exposure to the Cov-SARS 2 virus, becoming a global epidemic, after its discovery at a Wuhan city hospital, Hubei province, China, in December 2019, affects brain function, that is, adverse memory retention, and cognitive brain damage, which prevents learning. The crucial relation is between brain functioning and job satisfaction. Driving people to develop the skills needed to cope, that is, adapt to new situations, is stressful for those with impaired brain function, (Singh et al, 2018). In other words, the driver causes stress, because it’s brain damaging; so the trainee remains permanently educable, which is the aim of the religious demon, who wants the sheepish and the cowed for their self-sacrificing nature; beside and upon the altars of their operating theatres.
Deng et al (2019: 2) differentiate between two types of stress; hindrance and challenge: ‘Challenge stress refers to the job stress that individuals feel they can overcome, and that benefits their career development; such as job load, job responsibility, and time urgency. Hindrance stress [is] … stress that individuals feel they cannot overcome, and which prevents their career development; such as role conflict, organisational politics, and work insecurity.’ While English language learning is in the category, ‘challenge stress’, training per se promotes hindrance, because slave systems prefer brain damage. Burnout, that is, mental collapse, through prolonged periods of psychological and physical strain, occurs because slavers don’t want communication, but rather loss of information, perceived as ‘hindrance stress’, and ultimate loss of motivation for the sacrificial enslaved.
A major mediator of burnout is the personality that resists enslavement, that is, contrary to widely held belief, based on training providers’ self-publicizing, the human isn’t extravert, agreeable, conscientious, and/or open to experience. Perez-Fuentes et al (2019), utilizing the Brief Burnout Questionnaire (CBB), that is, Netherlands’ organisational psychologist Wilmar Schaufeli’s (2000) Utrecht Work Engagement Scale (UWES), ostensibly designed to determine vigor, dedication and absorption levels in terms of workers’ engagement with their role, and The Big Five Inventory-10 (BFI-10), which is a single minute test measuring extroversion, agreeableness, openness, neuroticism, and conscientiousness, found above-mean neuroticism, that is, slave-driving produces a disposition of neurotics on the verge of burnout, experiencing ‘... anger, anxiety, self‐consciousness, irritability, emotional instability, and depression.’ (Oltmanns et al 2018: 144) Those displaying neurosis tended toward ‘depression and anxiety’, and ‘irritability and anger’. (Brandes and Tackett, 2019: 238) As the ability to communicate in English is an anti-slavery sine qua non for non-English speakers, as well as native-speaking nursing undergraduates in NHS teaching hospitals, ELT has a positive role to play.
Lack of effective communication, that is, nurses not being able to speak up regarding patient safety issues, together with management’s perceived unwillingness to assess communication failure, resulted in increased risk of stress-based disease; for example, Tang et al (2013) identified interpersonal relations as the fourth most prevalent source of such illnesses; after workload, time pressure, and management issues. Consequences of a lack of effective communication in preparation for tasks, such as those requiring complex and specialised skills (Vowels et al, 2012), are serious. Utilizing the views and experiences of abused nurses was indicated as best supportive practice. However, being able to communicate in English was a requisite to which non-native speakers hadn’t recourse.
As stress is a trigger factor in nurses' absenteeism, caused by high-intensity communications, and related organisational factors, ELT for non-English speakers is a priority. The main causes are mental, and behavioral disorder; manifesting as diseases of the musculoskeletal system and connective tissue (Mininel et al, 2013: 1293-1294). Predominant factors are physiological, that is, uncomfortable, or inappropriate, positions during work, which along with psychic workloads; restrictive supervision; abuse, and lack of a collective defence, are ameliorable for native and non-English speakers through ELT course programs; offering stress-relieving role play orthopedically assisted to ease interpersonal conflict through improved communication:
Dr: ‘Hi Jessica. How are you feeling today?’
Nurse: ‘A bit better.’
Dr: ‘That's good to hear. Are you still feeling nauseous?’
Nurse: ‘No, I haven't felt sick to my stomach since you switched my medication.’
Dr: ‘Great. Say, your test results came in this morning.’
Nurse: ‘It's about time. Is it good news or bad?’
Dr: ‘I guess it's a bit of both. Which do you want first?’
Nurse: ‘Let's get the bad news over with.’
Dr: ‘Okay. It looks like you're going to need surgery to remove the lump from your abdomen. After the operation you're going to have to stay off your feet for at least three weeks. That means no soccer.’
Nurse: ‘I was afraid you were going to say that.’
Dr: ‘Now for the good news. It's not cancerous. We're going to take it out anyway just to be on the safe side.’
Nurse: ‘Wow, that's a load off my mind. Thanks Doctor.’
Dr: ‘Don't get too excited. We still need to get to the bottom of all of this weight loss.’
Nurse: ‘I've probably just been so worried about this stupid lump.’
Dr: ‘These things often are stress related, but we're still going to do a few blood tests just to rule a few things out.’
Nurse: ‘Things like what?’
Dr: ‘I'm thinking along the lines of some sort of parasite.’
According to Social Identity Theory (Hogg, 2016), groups thrive on self-improvement, and Role Theory (McGarvey et al, 2004), that is, acting out socially defined categories, such as that of doctor and nurse, which is what ELT does.
4. Nurses’ role
In violation of its social norms, nurses who protest at workshift schedules are punished by their society, which is harmful to patient outcomes. However, offering support into nurses’ concerns over breakdowns, in useful communication ‘role play’ (RP) through ELT, effects improvement through SIT methods, as a normative exercise in conflict management, rather than have vulnerable nursing staff appear attractive to the punitive.
For Karanikola et al (2018), as worth appraisal depends on positive feelings associated with clinical effectiveness and adequacy, for example, perceptions of themselves as having a ‘mission’, as part of an in-group, nurses’ self-worth can be collectively strengthened through SIT improvements allied to ELT RP.
Ethnographically, McGarry et al (2018) examined non-native speakers’ descriptions of their role, and the extent to which their behavior and practice, that is, RP, corresponded. Momentum of people and needed equipment was a key theme. Between ‘flow’, that is, attending, and safety, tensions could be alleviated through ELT based RP allied to SIT self-improvement.
In terms of systemic, organisational impact, according to the Systems Engineering Initiative for Patient Safety (SEIPS) model, nurses’ workload produces cognitive reductions, particularly during training (Oblak and Skela-Savič, 2017); deleterious in terms of patient outcomes (Silerro and Zabalegui, 2018). Any ELT approach decreasing workload would already have achieved a notable objective.
Keers et al (2013) found interruptions from non-native speaking colleagues resulting in wrong site surgery; retained foreign objects, and insertion of the wrong implant or prosthesis (NHS, 2017). For Serou et al, 2017, surgical incidents cause loss of self-confidence. ELT based SIT and RP reduced such effects by supporting discussion; resulting in the implementation of changes in practice. Pratt et al (2012) found nurses feeling ‘depressed’, ‘fearful’, and/or ‘guilty’ (Chard and Tovin, 2018: 75), because of error, which led to avoidance and denial strategies. Without improved SIT based planning, for those who find contact confrontational, because it requires language they don’t have, errors repeat (Cabilan and Kynoch, 2017); resulting in job loss. This is counteracted in non-English speakers, and standard English speaking natives with communication difficulties, because of stress and burnout, for example, by prescribing a gentle ELT course with therapeutic RP:
1 Why did Jessica switch medication?
a) The parasite gave her a lump
b) She was allergic to the parasite
c) The parasite upset her stomach
2 What bad news does the doctor give her?
a) The parasite had given her a lump
b) The lump had given her a parasite
c) The parasite was a lump
3 What medical procedure has Jessica already undergone?
a) It wasn’t a medical procedure
b) Pest control
c) Physical examination
Concerning numbers of staff working in individual units, Kalisch, Russell, and Lee (2013) noted smaller nursing teams as more cohesive. There was reduced physical distance, which closeness improved communication, so suggesting the usefulness of small groups in RP and SIT based ELT programs. Eskola et al (2016) attributed person-centeredness as necessary to efficient communication. Closeness revealed individual nursing team members’ strengths and weaknesses, while communications made for more efficiency and procedurally adeptness. SIT and RP based ELT, focusing on ‘improvement in action’, as ‘person-centring’, made individuals more responsible. While financial constraints, under which the NHS operates, means nurses generally fulfil their role as part of a reduced team, it’s paradoxically useful for ELT provision, as small groups facilitate that efficiency of communication which is dependent on person-centeredness.
7. Standard English
The Health Foundation (2019) report into NHS staffing trends found 24% of those starting nursing degrees did not complete, which indicates poor standard English language skills. According to the 2015 NHS Staff Survey, 72% worked extra hours, which suggests working longer shifts to keep jobs otherwise incapable of, because of role illiteracy, which ELT emphasis on SIT and RP ameliorates, at least with regard to non-native speakers. There’s a need for implementing a combined standard English language and English as a foreign language (EFL) program. Trajano et al (2017) found interpersonal relationships strengthened in coping collectively through work, which suggests the validity of a SIT based program implementation; focusing on interpersonal RP and communicative skills.
8. Role hierarchy
Higgins and Macintosh (2010) identify role hierarchy as a source of abuse of nurses; the negative psychological results having a deleterious effect on patient-safety. Conflict and aggression within team dynamics, according to Bezemer et al, (2016), arise from a lack of role understanding, for example, nursing requests are perceived by surgeons as disruptive, rather than enabling. As resonant leadership decreases negative outcome, such as stress and burnout (Fallatah and Laschinger, 2016), for Yin et al (2018) a human-oriented approach is indicated, for example, RP guiding others, where it’s important in terms of de-personalization to mitigate managerial style. As an exclusionary practice, Johnson (2016) viewed gossip as fostering schizophrenia, that is, bullying creates a second unwanted personality, who has to respond. Managers’ role in dealing with discrimination and bullying is critical in addressing communications and conflict, where the utility of RP is evident. Where mistreatment is evident, burnout occurs. Absence of bullying is the legitimate sign of peer support, which RP can enable through ‘role modelling’ (RM) adopted by staff to defuse volatility:
Dr: ‘Do you have a minute?’
Nurse: ‘Sure, what’s up?’
Dr: ‘Nothing so far. I need a favor.’
Dr: ‘It’s a small one.’
Dr: ‘Yes, very small.’
Nurse: ‘What is it?’
Dr: ‘Well, I need to show you something, and I want you to promise not to get mad.’
Nurse: ‘Uh oh. What did you do?’
Dr: ‘It’s small.’
Nurse: ‘Fine, I promise.’
Discrimination relates to cultural differences; linked to burnout. Due to NHS problems with finance, a dense population of international nurses found it of benefit to move to the UK, escalating multiculturalism within workforces, which unguided led to breakdown in peer relations. SIT based solutions, as applied by Hewstone and Rubin (1998), improved in-group discriminatory behavior and conflict, that is, where minimals discriminate to maintain their own positive social identity, while learning professional body language, providing RP facilitates more appropriate responses. (Bambi et al, 2017)
Batnitzky et al (2011) focused on migrant nurses from Caribbean and Asian countries. Post-1945 ethnic minorities were stereotypically restricted from engaging with vital specialist nurses’ training, for example, conceived as an obstacle to career advancement and professional recognition, according to Baptiste, M. (2015), labor stratification negatively impacted on patient care, because for nationalists racism is a transcendent ideological perspective.
Clayton, Isaacs, and Ellender (2016), focusing on multicultural communications within a nursing group, found ‘failure to communicate’, amongst the chain gang in leg irons, impairing patient care, that is, the denial of specialized training, based on ethnicity, threatened patients safety in the style of terrorism, while integration, through social gathering, was neutralizing, rather than empowering. Although Schilgen et al (2017) observed migrant nurses built a sense of community by sharing commonalities, patient safety was a concern, because such ethnic minority groupings, while protective of their own status, neglected the impact on patient safety of a covering up of their own paucity of English language communication skills. For Oikarainen et al (2019) such educational interventions as ELT RP could assist staff developing cultural competence.
Language barriers, in adjusting to workplace practices (Yu et al, 2018), are allied to communication barriers, because of personal and professional differences, producing illness and/or timidity in task completion, which issues are resolvable in ELT; promoting listening to, and understanding of, undergraduate nursing trainees and non-native English language speaking nursing staff.
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