Effective Communication for aGlobal Workforce

December 2017392 Nurse Leader

Carol Gregory, MSN, MBA, RN, NEA-BC

This purpose of this article is to describe

an innovative onboarding program

implemented to overcome language barriers and

smooth enculturation to the practice setting in

this country for foreign-born nurses. The program

promotes cross-cultural understanding for patient

safety and is offered as a celebration of a rich

diverse workforce within Medical City Healthcare,

a large health care system located in Dallas/Fort

Worth, Texas.

BACKGROUNDThe stakes are high in health care when it comes to patientsafety. The Joint Commission has established standards whichrequire hospitals to embed effective communication, culturalcompetence, and patient-centered care into their organizations.1

As a common cause of sentinel events, miscommunication can

mean the difference between life and death. Communicatingfor mutual understanding therefore is paramount for safe patientcare. With growing numbers of foreign-born health care work-ers, the need for clear, practical advice to help a global work-force achieve effective communication was recognized andaddressed within our large urban health care system.

Nurses from diverse global backgrounds have become anintegral part of the health care sector, necessitating practicalcommunication training solutions.2 Regardless of whether ornot a shared heritage exists, international nurses (just as allnurses) can build authentic connections through purposefulcommunication and an expression of human caring. Forsome, this may be easier said than done.

Accented speech potentiates communication challenges.Although international nurses may be quite proficient withthe English language, a patient from the United States maynot be familiar with the sound of the nurse’s spoken lan-guage. When an accent is placed on a different syllable for agiven English word, it can make it difficult to understand forthe unaccustomed ear. Complicating this scenario is thepatient with a hearing deficit and/or when a mask is requiredfor the nurse as part of personal protective equipment (PPE).Accented speech resulting in communication difficulties cannegatively impact patient satisfaction, safety, or quality of care.Patients in clinical settings are vulnerable and may be reluc-tant to admit that they do not understand their caregivers.Language discordance, therefore, can create practice barriersand threaten desired patient outcomes.

Enculturating into a new nursing practice setting in aforeign country is likely to be a time of great stress. Speakers’accents affect how they are perceived.3 Bias and/or misun-derstanding may even result in the nurse being misperceivedas lacking in knowledge. If nurses fail to narrate their inter-ventions for patients to clearly understand, a gap in essentialpatient knowledge, as well as erosion in trust, may occur. Wedemonstrated that barriers to successful communication forour global nursing workforce could be overcome through aprogram of innovative guidance and onboarding support forthe foreign-born nurse.

TRAVERSING GLOBALIZATION HURDLESMedical City Healthcare is a large system of 13 hospitalsspanning the metropolitan areas of Dallas and Fort Worthwithin North Texas, and a division of HCA. I was privilegedto serve for 5 years as chief nursing officer (CNO) for ourflagship hospital, Medical City Dallas and Medical CityChildren’s Hospital, prior to moving into our system’s firstchief nursing executive (CNE) role. When I transferred fromDenver, Colorado, to take the job in Texas, I was delighted todiscover a more richly diverse workforce than I had previous-ly experienced. It wasn’t long, though, before I received feed-back both from physicians and patients as to the difficultythey were having in understanding some of our nurses. Withthe help of several passionate and dedicated nursingcolleagues, I was able to create and deploy an onboardingprogram for foreign-born nurses at our 3-time Magnet®-des-ignated flagship medical center while serving as CNO, andthen disseminate it across our system when I assumed mynew role as CNE.

Our system made a commitment to help nurses traversesome of the hurdles associated with enculturating into a newpractice setting with accented speech. With a comprehensiveleadership approach including cultural inclusivity, shared

leadership and inter-professional collaboration, the tactichelped reduce RN turnover, increase RN and physiciansatisfaction, and cement therapeutic communication amongnurses and patients.

BUILDING THE PROGRAMWe began by assembling a taskforce that included nurses fromChina, France, India, the Philippines, Mexico, and Thailand, aswell as from the United States. Over the course of 6 meetings,taskforce members discussed experiences and challenges eachhad when they began practicing in this country. We empathizedwhen we learned of the humiliation suffered by some on ourtaskforce whose patients asked for a change of nurse or whenphysicians preferred to speak to other nurses due to languagebarriers. We reviewed the literature and discussed variousapproaches for navigating enculturation. Through these discus-sions, a theme emerged regarding the advantages of maintaininga sense of humor and preserving self-esteem. Taskforce mem-bers all agreed that designing and offering a course for newinternational nurses would be beneficial. The discussions wereinformative for curriculum development.

In collaboration with then Director of Patient CenteredInnovation and Organizational Development for MedicalCity Dallas, Kathy Walton, BSN, MBA, RN, CPN, wedesigned a course curriculum around the acronym:“ACCENT.” A module was developed for each letter in theacronym, and a syllabus was written. After we were satisfiedthat the course content reflected our discovery process, Kathyand I taught the class to over 50 nurses. Participants were freeto choose to attend the class or not, which was important tothe staff in order to avoid any feelings of being profiled. Overtime, tenured nurses began to attend in addition to nursesnew to the hospital.

By sharing in the teaching responsibilities as CNO, I hadthe opportunity and pleasure to get to know and interface ona more personal level with staff who participated in the edu-cation. With each session, we learned something more abouthow to make the discussions resonate with the nurses fromvarious countries.

The class is designed to be offered as a facilitated discus-sion of each module versus a didactic presentation of thematerial. Participants are encouraged to share personal expe-riences and role play. They often end up helping one anotherwith tips for success. The curriculum, syllabus, and referencematerial are provided as a booklet for follow-up reading bythe participants outside of class. Participants are encouragedto practice the concepts discussed in the session immediatelythereafter in their clinical settings with their patients and toreview progress with their preceptors and/or managers.Typically, the class runs 60 to 90 minutes in length dependingon the size and amount of interaction.

Medical City Healthcare is a Studer Group partner. Thus,the term AIDET®, an acronym for acknowledge, introduce,duration, explanation, and thank you, was a familiar constructwithin our setting. AIDET is a component of evidence-basedleadership and a communication framework to be deployedin all interactions in order to improve patients’ perceptions of

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