Aims of this project
The project aims to determine whether the existing
The IELTS English language requirements for internationally qualified nurses are suitable and sufficient for the professional environments they aim to enter This project will explore key research questions related to these standards.
1 What are the actual language requirements in terms of each skills area for overseas nursing practitioners seeking to practise their profession in the UK?
2 To what extent does the IELTS reflect the language needs of practising nurses?
Context
The context for the research will be different specialist areas in hospitals within the UK NHS.
Rationale
Each year, a significant number of complaints are filed against international nurses who received their qualifications outside the European Economic Area (EEA) These complaints stem from various reasons, but errors of judgment that would typically be viewed as minor mistakes in British-trained nurses are often categorized as clinical malpractice for internationally-trained nurses This discrepancy arises from perceived differences in training and standards.
‘poor interpersonal and communication skills’
Nurses play essential roles in healthcare communication, acting as advocates, caregivers, mentors, coordinators, collaborators, assessors, and confidantes They serve as mediators, translating complex medical terminology into everyday language and adapting their communication style to meet the needs of various patients and healthcare professionals (O’Hagan, Manias et al 2013; San Miguel & Rogan 2012; Apker, Propp et al 2006; Fleischer, Berg et al 2009; Bourhis, Roth et al 1989; Morse & Piland 1981).
Research has explored various aspects of nursing practice, including how nurses express their professional identities and navigate conflicts (Apker, Propp et al 2006; Morse & Piland 1981; Sheldon, Barrett et al 2006) Studies have also examined the diverse knowledge sources nurses utilize in patient care (Inger, Andershed et al 2010) and their role in facilitating the disclosure of private information (Candlin 1997; Ford 2009; Petronio & Sargent 2011) Additionally, nurses employ specific strategies to gather essential information from patients and colleagues (Apker, Propp et al 2006; San Miguel).
Numerous studies, including those by Rogan (2012), O’Hagan et al (2013), Epp & Stawychny (2002), and Rayo et al (2014), highlight the intricate nature of spoken communication in nursing These findings emphasize the importance of effective communication in addressing the needs of anxious patients, as supported by Apker et al (2006) and O’Hagan et al (2013).
Additional communicative demands are reported by (O'Hagan, Manias et al 2013; San Miguel & Rogan 2012; Candlin 1997; Fleischer, Berg et al 2009; McCabe
Recent changes in nursing practices have shifted from a task-based focus on physical needs to a more holistic approach addressing patients' psycho-social needs, requiring advanced communicative skills (Candlin, 1997, 2002) This evolution poses challenges for nurse communication, especially for those with professional identities and practices shaped by diverse cultural and linguistic backgrounds who are transitioning to work in the UK.
Recent data from Buchan and Seccombe indicate a significant increase in the registration of nurses from both EU and non-EU countries, with EU registrations doubling over the past two years The largest groups of EU nurses come from Romania, Portugal, Spain, and Ireland, while the primary non-EU contributors are from India.
The increase in nurse recruitment from the Philippines is due to a shortage of nurses in the UK, resulting from decreased funding for the training and hiring of British nurses, along with more stringent work permit and registration regulations for non-EU nurses.
The nursing shortages in the UK can be traced back to funding cuts for training programs in the late 1990s, which led to a reliance on internationally trained nurses as a temporary fix During this period, the recruitment of international nurses reached its highest levels.
In 2002, overseas nurses made up nearly half of the nursing workforce, but Buchan and Seccombe caution that it is premature to forecast a significant increase in this trend However, there is evidence of a reversal in the decline observed from 2002 to 2010 According to NHS Employers (2014), the ongoing shortage of nurses has prompted a proactive recruitment policy focused on attracting overseas talent, particularly from the EEA.
Two million candidates took the IELTS test in the
Twelve months before May 2013, the English language test, initially known as ELTS, was recognized by over 8,000 organizations globally, including numerous professional bodies It was specifically designed for university admission in the UK.
Language Testing System), it was revalidated in 1989 as the IELTS (International English Language Testing
System), in partnership with the International
Development Program of Australian Universities and
Merrifield (2007), who conducted an impact study into the use of IELTS by professional associations in the UK,
Canada and Ireland, observes that the test began to be increasingly adopted outside the universities as an
English language entry qualification between 2000 and
In 2009, the reasons behind the adoption of specific levels for health professionals seeking to practice in certain countries became unclear due to the unavailability of records However, the IELTS test remains appealing to organizations due to its broad accessibility, with test dates offered four times a month across over 135 countries and a wide network of test centers, ensuring a short waiting time for results The test is valued for its direct assessment of performance through authentic writing tasks and real-life interviews, rather than relying solely on grammatical and lexical competence Additionally, the security and integrity of the IELTS, along with robust quality assurance research, enhance confidence in its reliability.
Nonetheless, despite the assurances of quality, researchers have questioned the content validity of an
English language test, which was designed for university entry, but has come to be used as a language entry test for other professional contexts
Davies (2001) asserts that the later general version of the IELTS test is equally effective as earlier versions with specific purpose modules in assessing linguistic performance He emphasizes the importance of designing tests that evaluate language use for specific purposes (LSP), as candidates are primarily motivated by instrumental goals, such as professional registration Merrifield (2007) supports this view, advocating for an LSP test tailored for nurses, informed by research on communication needs in healthcare Her study highlights the endorsement from three UK health organizations, one in Canada, and one in Ireland for incorporating specific health content into the IELTS test to better serve this professional field.
Arakelian (2003) and Hearnden (2008) criticize IELTS as an inadequate English language qualification for nurses, arguing that its academic test tasks do not align with the communication skills required in nursing They point out that the writing component emphasizes argumentation and paragraph structure instead of essential skills like note-taking and record-keeping Furthermore, the assertion that IELTS is culture-free is deemed inappropriate, as nurses must effectively navigate communication within specific cultural contexts.
The sole IELTS benchmarking study focused on nursing communication was conducted by O’Neill et al (2007) for the National Council of State Boards of Nursing (NCSBN) in the United States This study aimed to propose a minimum English language requirement on the IELTS exam to ensure safe and effective nursing practice for licensing boards.
28 experts was convened for the study Most of the panel members were practising nurses, including international nurses who had taken the IELTS as an entry requirement
The NCSBN accepted the recommendation of a minimum IELTS score of 6.0 in each skill and an overall score of 6.5 based on the O’Neill study However, the study did not thoroughly assess the content validity of the IELTS test.
Theoretical framework
This project is grounded in a constructionist epistemological framework, emphasizing a non-positivist paradigm to address the specific questions related to nurses' work experiences To effectively understand their needs, we engaged in structured interactions with nurses and systematically monitored the linguistic demands they face throughout a typical working day.
In terms of test validation, this practice-based study links an understanding of a language domain, (Mislevy et al.,
The research from 2003 highlights the importance of aligning cognitive resources of practicing professionals with the specific language demands of their domain This connection enhances the relevance and effectiveness of assessments, as emphasized by Weir (2005) and further supported by O’Sullivan and Weir (2011).
O’Sullivan 2011), thus helping define the cognitive linguistic resources needed for an individual to communicate successfully in the domain
It also, crucially, provides information about linguistic performance requirements in the nursing domain and how these requirements are reflected in the test.
Research design
Ethical considerations
As the project was undertaken by CLARe, ethical approval was sought and obtained from the University of Roehampton’s Research Ethics Committee Ethical considerations included the following aspects
! Method of recruitment of participants Participants were recruited through personal contacts
No participants were recruited though the NHS
To ensure the preservation of participants' anonymity, each individual was assigned a coded identifier (e.g., N1 for nurse 1, N2 for nurse 2) during the transcription phase Importantly, names were never linked to participants in either the recordings or the transcriptions, maintaining strict confidentiality throughout the process.
All participants received two consent forms detailing the project's scope, participant count, duration, and associated risks and benefits They were required to sign one form while keeping the other for their records Additionally, participants were informed of their right to withdraw from the study at any time.
! Risks and benefits to participants
There were no perceived medical, physical or psychological risks associated with this project
The UK-based project adhered to local regulations, excluding participants under 18 years old, thus eliminating the need for CRB checks and overseas compliance Participants in the focus group and tracking study received a daily stipend of £20 to cover expenses, along with reimbursement for travel and refreshments Additionally, nurse advisors were compensated with an honorarium of £300 per day for their expertise and time.
Raw data: recordings have been stored in a password- protected folder held on a secure drive at the University of Roehampton
Numerical data: as above (all files are password protected and no names or other information to be used for identification purposes are contained in these files)
All data will be retained for a minimum of 10 years from the date of any publication that is based on it
! How ethical considerations arising from the project will be handled
The study examined the English language requirements for potential nurse applicants to the NMC register, focusing on non-native speakers without distinguishing between their nationality at birth or current citizenship.
NHS Research Ethics Committee approval
This project is a Service Evaluation rather than Research as defined in the NRES publication Defining Research
No patients were recruited through the auspices of the
Ethics approval from the NHS Research Ethics Committee was not necessary for this study, as the interviews with nurses were conducted during their personal time and outside of the hospital environment, eliminating the need for authorization from hospital management.
Data collection
The tracking study
The focus of this research is on non-native English-speaking nurses, including those from the EEA, as they are required to meet specific IELTS score criteria, making their perspectives more relevant to the study's objectives.
Four non-native English-speaking nurses (two trained within, and two outside, the EEA), all of whom were working in London hospitals, were each tracked for one month
Nurses were interviewed shortly after their shifts to discuss the communications they experienced during that time These interviews took place during their personal time, away from work, and were scheduled at various times and days to capture a comprehensive view of daily communication Prior to the final interview, the four participants completed a practice IELTS test, which was then used to review their accounts of communicative events during the interview.
The participants’ details are as follows
1 N1 is a male nurse from the Philippines working in the post-anaesthesia unit of a public hospital
2 N2 is a female nurse from India working in a surgical unit in a private hospital
3 N3 is a female nurse from Portugal working in the high dependency unit of a public hospital
4 N4 is a female nurse from Hungary working in the admissions department of a private hospital that specialises in plastic surgery
Among the two nurses from outside the EEA, only N2 was required to meet the necessary IELTS levels, as N1 arrived in the UK 13 years prior to the implementation of this requirement.
Before signing the consent form, the researcher circulated it among the participating nurses and arranged preliminary meetings, either via Skype or in person These meetings were designed to foster trust and rapport, creating a conversational partnership, as highlighted by Rubin & Rubin (2005), by sharing contextual information and encouraging participants to ask questions.
The researcher outlined the project's objectives and participant requirements, emphasizing confidentiality and the right to withdraw She also shared her role at the university and her interest in the project, inviting participants to ask questions and engage in discussion.
! their roles as nurses in their country of origin
! their roles as nurses in the UK
! their reasons for coming to the UK
! the length of time they had worked in the UK
! the number of years they had studied English and the nature of their language training, including opportunities for practising English before they came
! differences they had noticed between nursing practices and culture in their former country and the UK
During the meeting, the researcher recorded each nurse's bio-data, and by the end, established the rules of engagement, including the negotiation of future meeting times, locations, durations, and procedures for potential cancellations or rescheduling.
Permission was sought from, and granted by, all the participants for the forthcoming interviews to be recorded
The interviews were open-ended Nurses were asked to take the researcher through the previous shift from the beginning to the end, focusing on their communications
The interviewer engaged as an active listener, utilizing back-channeling techniques and seeking clarification to enhance communication To ensure accuracy and capture important insights, notes were taken during the interviews as a backup for potential recording failures, emphasizing key points identified by the interviewee.
Interviews typically lasted around one hour and took place in convenient cafés, allowing nurses to relax with food and non-alcoholic beverages While background noise occasionally interfered with the recordings, the natural redundancy in the conversations ensured that there was no significant loss of information.
Prior to the final interview, all four participants received practice IELTS papers for reading, listening, and writing, which they were required to complete beforehand They were also asked to reflect on the relevance of these tests to their nursing roles During the final interview, the nurses listened to excerpts from each listening task and evaluated recordings of spoken performance and writing responses using the IELTS public criteria for each skill area They then compared the practice materials for each skill with the communications they encounter in their nursing practice.
The focus groups
Two focus groups of practicing nurses were organized to gain deeper insights into the various activities and interactive events within specific nursing contexts, as well as to pinpoint the actual language requirements essential for effective communication in these settings.
Details of the focus groups are as follows
Venue: A London training centre for nurses on the
Participants: Four nurses who trained overseas and who are non-native speakers of English Specifically, the participants were:
! a female nurse from India working in admissions in a private hospital
! a male nurse from the Philippines working in recovery in a London public hospital
! a female nurse from the Philippines working on a ward in a London public hospital
! a female nurse from the Philippines working in a public nursing home
Venue: A training suite in a busy NHS hospital
Participants: Seven female nurses who trained in the UK and are native speakers of English Specifically, the participants were:
The research team, consisting of Dr Carole Sedgwick, Dr Mark Garner, and Ms Isabel Vicente-Macia, actively facilitated the focus groups by asking questions and providing prompts Prior to the formal discussions, participants enjoyed refreshments and engaged in social interactions to create a warm and trusting atmosphere, setting the stage for meaningful dialogue.
All participants received a copy of the consent form outlining the project and their ethical rights, which was further clarified verbally at the start of each focus group meeting They had the opportunity to ask questions and withdraw from the study if they wished Participants were also asked for permission to audio-record the discussions, with assurances that only researchers would access the recordings and transcriptions Any published extracts would be anonymized, and participants could request the removal of specific items from the transcript, either during the session or afterward.
The following prompts were then used to generate discussion between participants relating to their communications
1 Think of a recent example of a communication in your workplace that was challenging
Describe the communication to the group and say why it was challenging
2 Brainstorm: with whom do nurses communicate in their work, and for what purposes?
3 Describe a recent exchange involving you, a doctor and a patient
4 What do you think is typical of the various kinds of communication that nurses have to engage in? What is typical about them?
5 Anything more about communications that has not been mentioned.
Analysis
Recording and transcription
The interviews and focus groups were recorded using a
DS5000 digital recorder and uploaded onto a Mac PC using DSS player software The interviews were transcribed in standard written form using an AS5000
The Digital Transcription Kit emphasizes the transformation of data at each stage of the transcription process, prioritizing the analysis of key themes over detailed linguistic elements By including false starts and hesitations, the kit captures the nuances of discussions, showcasing participants' careful word choices and challenges in expression This approach aids in the analysis while balancing accuracy, readability, and representation concerns, as noted by Duff & Roberts (1997).
Analysis
The research team utilized Dropbox for collaborative access to collected data, transcriptions, and ongoing analyses NVivo 10 for Mac software was employed to analyze the transcriptions, while the original recordings served as a reference for accuracy and enhanced data interpretation.
(Flick 2009) The analysis focused on the participants in daily hospital communications (spoken and written) involving nurses, and the nature, frequency, purposes, and challenges of those communications
Material provided for teachers on the Cambridge ESOL
The IELTS website provides comprehensive information on the examination, including descriptions, practice tests, resources, and assessment criteria Research on the IELTS test was analyzed to determine the evaluation methods for each skill area: speaking, listening, reading, and writing This analysis was then compared with nurses' accounts of their communication practices gathered from a tracking study and focus groups, alongside their perceptions of the relevance of practice materials and the public criteria necessary for achieving a pass level of 7.0 for registration in the UK.
Feedback
A draft of the final report was evaluated by four expert readers, including a nurse, a nurse trainer, and two long-term patients They confirmed that the project accurately represented their experiences with nurse communications Minor suggestions for detail modifications were provided and successfully integrated into the final report.
The tracking study
Speaking
Nurses play a crucial role in patient care by guiding patients through their hospital experience, gathering and verifying information for medical records, ensuring patients are well-informed, seeking their cooperation, and addressing their needs effectively.
Social conversation is crucial for building strong relationships, which can enhance a patient's hospital experience and promote effective healthcare communication This vital communication skill is explored in greater detail below.
Ward nurses in private hospitals play a crucial role in patient care by gathering and verifying personal information and medical history at various stages of the admission process.
…have to check the patient’s main basic details, like the name, date of birth and the spelling If something is wrong, then you have to start the process
Nurses have to find ways to elicit information about negative reactions to medication:
During the admission process, I ensure that the patient completes the pre-operative checklist and encourage them to share any adverse reactions they may have experienced with medications.
Strategies to facilitate this include replacing vague general terms with more concrete examples that patients are likely to understand:
We can ask the patient: ‘Do you have any allergy, drug allergy?’ The patient said: ‘No’ and then…
[you find] they are allergic to seafoods [They say]
When discussing allergies, it's important to note that a seafood allergy often indicates an allergy to iodine, as seafood is a significant source of this element.
Such examples require nurses not to make cultural assumptions:
We have to check about their jewellery or body piercing, they have any contact lenses hearing aids
During a surgical procedure, an elderly patient revealed to the anaesthetic nurse that she had a belly piercing, a detail I had overlooked during our initial consultation This highlights the importance of thoroughly asking patients about all body piercings prior to surgery to ensure their safety and address any potential complications.
Another essential strategy is to check against the hospital records information that is given to the nurse:
To ensure accurate identification, individuals must provide their full name and date of birth for verification purposes.
Before proceeding with patient care, we must revisit the necessary paperwork, ensuring that consent forms are signed and any prior surgeries, such as knee or hip surgeries, are clearly noted At the outset, we inform patients that certain questions will be asked repeatedly for clarity and safety.
Eliciting information about the patient’s condition is an essential part of monitoring a patient’s recovery:
I always ask: ‘How’re you feeling?’ ‘Do you have any pain?’ ‘Do you feel sick?’ (N4, Interview 2)
We do full assessments of the patients…So things like
In assessing a patient's condition, we begin by asking, "How are you feeling?" This allows us to gauge their pain level effectively Patients communicate their pain on a scale from 0 to 10, where 0 indicates no pain and 10 represents the worst pain imaginable It is essential to document this information accurately for proper treatment and care.
Nurses may need to check a patient’s willingness to allow others to be present during a potentially embarrassing examination:
There was one situation where I had to do a twelve
During the electrocardiogram (ECG) procedure, the patient chose to keep her family present despite the need for chest exposure, highlighting her comfort in having their support during the process.
One important function of the capacity to engage in social conversation, mentioned above, is that it can assist the nurse to elicit essential information:
During conversations, individuals often engage in various activities, but when prompted with a question like, "Are you in pain?" they tend to focus and acknowledge their discomfort, responding with, "Uh, yes, there is some – a little bit in my –" highlighting the importance of attentive communication in recognizing underlying issues.
He will close his eyes, and he will hold his chair very tightly, so I’ll ask: ‘Are you in pain?’ and he'll say:
‘There's cramping pain’ So, because when they are talking, we can…understand the emotion, like if anybody is in pain, they won’t be able to talk normally (N2, Interview 3)
Nurses need to orient the patient to the hospital environment, as well as explain facilities, processes procedures, and recovery
To begin, we should greet them appropriately, either with "Good morning" or "Good afternoon." Next, it's essential to introduce ourselves by stating, "My name is X, and I will be guiding you through the admission process and preparing you for the procedure."
We have to explain the process what I’m going to do, and then… (N2, Interview 2)
Upon arrival, guests are warmly welcomed at reception and escorted directly to their room They are introduced to the ward, including the location of the nurses' station for any assistance needed The room features an en-suite bathroom for convenience, eliminating the need to use the corridor Guests are informed about the TV and encouraged to make themselves comfortable Additionally, a spacious wardrobe is available for their belongings, and essential information, such as fire alarm procedures, is provided for their safety.
We have to explain to the patient like what procedure they had and how long it will take for them to recover (N2, Interview 2)
They may have to explain such matters to the patient’s family over the phone:
He requested that I speak with his wife on the phone to discuss what items she could bring during her visit to the hospital that afternoon She wanted to know specifically what would be helpful, including toiletries, slippers, and entertainment options In this case, he mentioned that he had an iPad, which would serve as a source of entertainment for him.
Cooperation from patients is essential for effective pre- and post-operative care, particularly regarding adherence to recovery instructions After discharge, patients receive a written discharge letter that outlines crucial behaviors to support their recovery, which should also be clearly explained verbally by the nursing staff.
Listening
Listening is a crucial element of every verbal interaction
Effective communication in nursing involves not only speaking but also the ability to listen actively across diverse interactions Nurses engage with individuals who have varying relationships with them, each communicating for distinct purposes and using different language styles and accents.
Effective handover in patient care is crucial, as highlighted earlier It encompasses both verbal and written communication; the outgoing nurse must verbally elaborate on the written notes, providing clarification and detailed explanations to ensure comprehensive understanding.
The handover process typically consists of two stages, with the initial stage occurring in front of all nurses This approach ensures that nurses can assist with any patients who may not yet be assigned to them, promoting collaborative care and enhancing patient safety.
During the second stage of patient care, the outgoing nurse transfers responsibility for each patient to the incoming nurse, ensuring a smooth handover between shifts.
The first stage is necessarily brief, communicating essential information about each of the patients
In assessing patient conditions, we focus on critical indicators such as breathing, circulation, and levels of distress Key considerations include identifying patients who require high doses of oxygen or medications to stabilize blood pressure Effective communication about which patients are designated for resuscitation is essential During brief meetings, typically lasting 5–10 minutes, we prioritize discussing patients in critical condition while omitting those who are stable and progressing well, as they do not require immediate attention.
In a public space, meetings are conducted in front of a whiteboard that displays only limited written details about the patient to ensure security and maintain privacy Consequently, nurses are required to pay close attention to the verbal elaboration of this information.
The information displayed on the board often lacks clarity for outsiders, making it difficult to interpret For instance, critical details such as a patient's do-not-resuscitate (DNR) order are not included on handover sheets to maintain confidentiality, as these documents could be inadvertently viewed by unauthorized individuals.
Because of the high premium on listening, nurses have to check understanding if they are uncertain about information that has been communicated orally
I try to verify That’s the best thing: to verify, because in nursing environment you’re not allowed to make mistakes, actually (N1, Interview 2)
Despite any irritation it may cause other medical staff
You probably feel anxious sometimes…because some doctors can be stroppy because you didn’t get straightaway what they meant (N1, Interview 1)
In the second stage of patient care, it is crucial for the incoming nurse(s) to attentively listen to the outgoing nurse(s) to maintain continuity and ensure that each patient's care remains appropriate This includes understanding what information has been communicated to the patient by the outgoing nurse(s).
During handovers, it's crucial to listen attentively to the other nurse's account of events While written handovers provide essential information, verbal communication often conveys additional insights that may not be documented Effective listening enhances patient care and ensures all relevant details are shared.
What I tried to explain was, [the patient] was very anxious and scared because it was her second operation So, she [the outgoing nurse] wrote something like: ‘patient was reassured and we had a conversation about every aspect of the procedure as she wants to be informed of every detail…of our nursing care’…And then I verbally handed over to the nurse in the ward, exactly that, that she needed a lot of support (N3, Interview 3)
There may be additional challenges to listening at handover, as Nurse 1 explained in several places in
There are moments when you have to adjust your hearing because they [non-native English speaking nurses] have different intonations – compared to
She works over nights and she’s probably tired…
At times, I find myself asking her to repeat what she said, as I struggle to understand her when she's in a hurry to leave for home The clarity of her intonation often diminishes, especially compared to our morning conversations.
I have to adjust my ear to the tune because she is not the same
She engaged in conversation with me while focused on her computer screen, making communication challenging Although face-to-face interaction is often straightforward, her attention to the screen complicated our dialogue.
…At least it helps, the movement of the mouth and expression on her face I couldn’t sometimes figure out if there’s something that I really have to pay attention to
Further difficulties may arise from the use of ambiguous or unfamiliar expressions
Here was a situation where the senior nurse…gave me a piece of paper and I asked her: ‘What do you want me to do with this piece of paper?’ She said:
While I was contemplating the number 22, I felt a bit embarrassed to ask the nurse-in-charge about her instructions to "give it to the porter twenty to." Trying to clarify, I leaned in and asked, "What do you mean by 22?" She chuckled and clarified that she was actually referring to 20 minutes until 3 o'clock, which was quite different from what I had initially thought.
Additionally, terms can have specific technical meanings in a hospital context
N: She asked me to get ready for the surgeon’s patient, so when she said ‘get ready’ means you have to put all the things that you need to minimise any delayed nursing care, so you have to get ready… all the things that you might think were possible in an emergency, and make sure all the beds are vacant and you have to prepare the (inaudible) meter, 6, you already have to set up to the standard setting
C: So all they say to you is, ‘Get ready’ They don’t give you any other instructions?
N: They don’t give instructions When the manager said: ‘Get ready’, you should know what you need to do (N1, Interview 2)
Staff may be offered or expected to attend local seminars, where they listen to presentations and discussions
One hospital in this study ran a weekly forum to discuss medical and ethical issues of concern to the hospital
However, it seems that the presentations delivered by doctors can be difficult for native, as well as non-native
English-speaking nurses, to comprehend
Different doctors they do the presentation We were there to listen…Sit and listen, and sometimes they
[his colleague] ask me: ‘Do you understand that?’
(laughs) So, I don’t really understand, even some of the English, because maybe it's me, because I’m not
English So I asked some of the English colleagues
I said: ‘Do you what they’re talking?’
‘I don’t really know what they’re talking about’
So I feel better because it’s not me
Reading
There is very limited reading material involved in day-to-day nursing As Nurse 2, in Interview 4, said:
We don’t need to read that much information
Nurses primarily engage in reading notes, headings, checklists, and essential information regarding medication dosages, saturation levels, and expiry dates This reading is manageable for nurses familiar with medical terminology, including various abbreviations However, newly arrived nurses in the UK may find terminology challenging due to differences in medical terms and abbreviations across cultures.
The patient’s medical notes form the core documentation that nurses have to deal with
Reading patient notes is essential for providing effective care, as they contain vital information that helps understand each patient's unique needs Every patient is different, and having access to their specific details allows healthcare professionals to tailor their approach and ensure the best outcomes Without this information, it becomes challenging to deliver personalized care.
The notes contain a doctor’s report, which can be a source of difficulty
Medical terminology can often be confusing for patients, requiring additional research to fully understand Doctors typically dictate their findings, which are then transcribed by a medical secretary into a report This report is added to the patient's medical notes, ensuring that all documentation remains with the patient during their hospital stay, as it is a rule that notes should not be removed from the patient's location.
When going for an x-ray, it's essential to bring medical notes, as they provide emergency personnel with critical information about allergies, contraindications, and medications necessary for patient resuscitation in case of any complications.
Any terms in the notes that the nurse does not understand can be clarified via a computer, or with the help of the medical team
We don’t need to read that much information
In our medical practice, we meticulously review the notes written by doctors, utilizing our computer systems for efficiency For any unfamiliar information, we have access to the Internet for research, as well as local policies and procedures to ensure compliance If any staff member feels uncertain or lacks competence in a task, they can easily contact the sister-in-charge for guidance and support.
N: We have difficulty to read the doctors’ notes (laughs) sometimes
C: Do you have to ask the doctor to explain sometimes, then?
N: We can’t really, because by the time they [are] in theatre again with another patient or they’ve left, because they hand over to the recovery nurse, so they know the post-op plan and everything, so they just hand over to me…the recovery nurse will write it down, and then she will tell me
Nurses also read the prompts and headings required to complete the computerised charts and forms that are in the patients’ notes
Every hour, I, along with a nurse, input essential patient details into the computer system, which is a crucial part of our workflow This system is designed to streamline the process, starting with pre-operative checklists that include simple yet vital statements, such as confirming whether the patient had a shower the night before or if they have been nil by mouth since midnight Each item is checked off to ensure comprehensive patient care and adherence to protocols.
Nurses are required to engage with complex reading materials found in the protocols they must learn and adhere to These protocols outline nursing procedures mandated by specialists and are articulated through commonly understood medical routines.
It's quite tricky to remember everyone's protocol
We have them written down as well, so we don’t know something, we can always look up…sometimes they don’t have any protocol, so they just tell you that
‘Oh just keep an eye on her just watch out for haematoma’ for example and that’s it…
When new staff members join, they are provided with protocols to help them learn the necessary procedures gradually These protocols are typically sent via email, which can be printed for easy reference One particular surgeon is known for his strict adherence to his detailed protocols, which span several pages and must be included in each patient's notes For instance, one critical protocol states that patients must be "nil by mouth," meaning they cannot eat or drink before surgery Additionally, the surgeon specifies the type and rate of intravenous (IV) fluids to be administered on the first day post-operation.
IV medications play a crucial role in patient care, dictating the specific types and frequencies of administration needed throughout the day It's essential to determine when patients can begin to sip water and stay hydrated, as well as when they are cleared for mobilization Understanding these key aspects ensures a smooth recovery process and enhances overall patient well-being.
Nurses not only complete essential medical documentation, such as notes, charts, protocols, and policy statements, but they also have the opportunity to conduct independent research on the medications they administer and the medical procedures they perform.
This involves extracting information from material, which is often presented in note form
First of all on every ward we’ve got BNF [British
The British National Formulary (BNF) is an essential resource for healthcare professionals, providing comprehensive information on medications Updated biannually, the BNF includes guidelines on the appropriate routes, strengths, and dilution methods for various medications, including injections Familiarity with the BNF is crucial to ensure safe and effective medication administration, as it also outlines contraindications and best practices for each drug.
Nurses may also gain quick and easy access to up-to-date medical information online
If I enter any medicine in Medusa, and I click on
- Search for detailed information about medication, including its main components and contraindications - Understand the reasons for using the medication and identify the most effective administration route for patients - Be aware of potential side effects to monitor - Present this information in bullet points for clarity and ease of reference.
In today's digital age, it's common for individuals to search for information online, especially when encountering unfamiliar medications or health-related topics Patients often mention medication names that healthcare providers may not recognize, prompting the need for quick online research to better understand these terms and provide informed responses.
Our hospital recently hosted a unique prostate surgery performed by a doctor, a procedure we had not encountered before To ensure optimal patient care, we thoroughly researched the condition and the surgical technique, familiarizing ourselves with the symptoms patients typically present before entering the operating room.
Writing
Compiling records, of various kinds, of patient care is the only writing typically required of nurses, but it is extremely important
Documentation is crucial in patient care, as it ensures that all actions taken are recorded accurately Depending on the patient's condition and any complications, thorough documentation is necessary to track medications administered, such as noting the dosage in the drug chart Additionally, all activities, including changing dressings, assisting with toileting, and providing food and drink, must be documented This practice is essential for maintaining continuity of care, as it informs incoming staff about the patient's status and the care provided Therefore, comprehensive record-keeping is vital for effective communication and patient safety.
Records must be concise and created under time constraints, often comprising checklists, forms, tables, and charts filled with numerical data, abbreviations, and standardized expressions Additionally, they include a brief narrative summarizing events that occurred during the shift, which is essential for handovers, patient records, and critical incident reports.
Each hour, you input numbers and scores, with designated spaces for comments For instance, yesterday, I recorded a patient's high temperature at a specific hour, noting it in the remarks section.
3.30, let’s say And I do a remark saying what happened at that specific time So at that specific time, I’ve spoken to my MDT [Multi-Disciplinary
During a recent case discussion, doctors noted that the patient presented with a fever After consulting with their adviser, it was determined that taking blood cultures would be the most appropriate course of action All communications regarding this decision were meticulously documented by me at that specific moment If there are no abnormalities, I do not make any remarks in the documentation.
As noted above, abbreviations do not necessarily translate across cultures
When I started they gave us this like booklet of introduction, and there’s a whole list of abbreviations that they use, I have never seen so many abbreviations There's loads
Writing involved in these records tends to consist of formulaic expressions used within the medical community
In the admission process, we complete a checklist and then provide written notes confirming the patient's admission, stating, "Patient admitted No known drug allergies."
Nurses meticulously document their activities during shifts through detailed handwritten notes, which they later use to update observation sheets and complete patient records During handover, they reference and expand upon these notes or digital records Given its vital importance, effective note-taking is a skill that deserves more emphasis in nursing training.
N: I always take notes because sometimes when there’s an emergency, you tend to focus on what’s going on You tend to kind of forget what happened in the conversation, so I always take notes…sometimes, if you’re used to the handover, you kind of making your own abbreviation It’s…your own style of abbreviation because if, for example, they said what procedure was done, instead of using the word
‘procedure’, you just write ‘pro’ and then said
‘cardio-pulmonary’ You just abbreviate, like
C: Did they teach you to do notes?
C: No, you just picked it up yourself?
N: Yes, and make that sure you understand what you’re writing because people have different ways of abbreviating (N1, Interview 2)
Handover notes play a crucial role for nurses transitioning between shifts, ensuring vital patient information is effectively communicated These notes are typically documented on a form that can be digitally transferred and printed for the incoming nurse During the handover process, the incoming nurse can augment these notes while receiving updates from the outgoing nurse However, once the shift concludes, the handover notes are disposed of to maintain confidentiality.
Notes written by nurses in the patient record are vitally important for other medical staff to consult, to ensure accountability, and to maintain continuity of care
In nursing documentation, it is essential to accurately record all relevant information in the nursing plan, including any recommendations from consultants for patient investigations This should be done using clear and concise bullet points rather than lengthy paragraphs or abbreviations While some statements may require full sentences, the focus should be on brevity and clarity This ensures that, in the absence of the original caregiver, others can easily review the nursing notes to understand the patient's history, the actions taken, and the outcomes observed.
Some patients may refuse treatment, and it is crucial to document their refusal accurately, including the date and time We must revisit the patient to confirm their decision, and if they decline again, we must record this as well According to the Nursing and Midwifery Council (NMC), we have legal responsibilities for documentation, making it imperative to ensure all records are precise, as any oversight could have serious consequences.
Nurse 1 provided an example of nursing notes:
13:15- complained of sudden shortness of breath at
5LPM [litre per minute] 02 [oxygen] given via face mask as temporary measure while waiting for the doctor
Duty doctor informed, salbutamol given as prescribed
Blood test done and sent to the lab)
Chest X-Ray done Awaiting doctor's review
(Name of nurse) Staff Nurse 1345- Patient slightly feel better
OR 1345- Patient condition remains the same
OR 1345- Patient oxygen level has dropped from 95% to 88% Patient is conscious but agitated Duty doctor informed immediately Oxygen increased from 5LPM to 15LPM
In private hospitals, detailing of treatment and reasons for the treatment may also be needed for insurance purposes
In the private healthcare sector, it is essential to ensure that patients are properly insured, especially for day cases that require an overnight stay If a patient needs to stay longer than initially planned, it is crucial to document the clinical reasons in the clinical incident book This documentation serves as evidence for insurance claims, ensuring that the additional overnight stay is covered Without proper justification, insurance companies may deny payment for the extended stay.
Sometimes that doctor will come, they will say:
While there may be no clinical evidence, it is essential to document that the patient experienced pain and opted to stay, especially in cases where there are delays in the operating theater This information should be recorded in the incident book to clarify the reasons for the patient's extended overnight stay.
In addition to the routine nursing records, nurses may need to complete additional documentation, for example, to record discussions they have had with patient and family
When addressing specific concerns during family patient discussions, we utilize a designated form to document the issues affecting the patient and their family This form captures the events that have transpired, the problems identified, the actions taken, and the conversations held at that time.
In addition to nurse notes and handover documentation, nurses are often required to complete an incident report, which can be filled out in note form, as described by Nurse 1.
In certain situations, it is essential to create a comprehensive report detailing a patient's care, particularly following significant incidents Healthcare professionals often need to stay after hours to thoroughly document these events, such as when a patient's blood pressure drops and medication is increased Accurate and detailed notes are crucial in these cases to ensure proper patient care and compliance with medical protocols.
There is an imperative to record detailed information in the case of an incident
Focus group 1 (overseas trained nurses)
Listening and reading
Nurses in the focus group highlighted similar communication practices to those identified in the tracking study, including handover procedures and the maintenance of predominantly handwritten patient records They noted that unclear spoken communication can lead to difficulties when relying on a nurse's notes, emphasizing the importance of clear verbal exchanges in patient care.
When receiving a handover, clear and well-organized notes are essential for understanding the information being conveyed If the notes are poorly written or unclear, it can lead to confusion and uncertainty, leaving you without the necessary guidance to proceed effectively.
Sometimes you can’t read the writing, but sometimes you can’t really understand what’s they're talking about It’s purely nonsense It does happen (F1N3)
Nurse 4 illustrates the range of written material a nurse has to scan for information at the beginning of a shift:
To ensure comprehensive patient care, I routinely review patient notes to identify any missed information from the night staff, such as requests for x-rays or morning blood tests This involves checking previous doctor and nurse notes, as well as the drug chart, to confirm if patients are due for any medications.
It is important to hear a doctor explain procedures before they are written down:
When visiting patients, it's essential for nurses to be present during discussions to ensure they are informed about the patients' needs Additionally, nurses must document their observations and notes before leaving the ward, especially if no verbal communication has occurred.
However, the information is not always delivered orally first:
Effective communication in healthcare is crucial, as some staff may assume that written notes are sufficient for conveying important information While some colleagues may kindly inform you verbally about updates, others expect you to read their notes and become frustrated when tasks are overlooked This highlights a significant communication gap; relying solely on written instructions without verbal clarification can lead to misunderstandings and errors Engaging in direct conversation is often more efficient than expecting others to interpret written messages alone.
The tracking study revealed a significant time pressure that prompts individuals to seek clarification when written communication is unclear Additionally, it highlights the importance of challenging doctors when potential errors are suspected.
Speaking and listening
Participants highlighted their interactions with various individuals, including medical and non-medical staff, patients, and their families, across different hospital hierarchies Their insights aligned with findings from a previous tracking study, emphasizing that social conversations, especially those relating to life beyond the hospital, significantly enhance patient care and well-being.
A lot of the discussion among members of the group
(all of whom were originally from outside the UK) concerned the difficulties that newly-arrived nurses encounter in adapting to British accents, usage, and speech styles
The delivery and volume of speech among Filipinos often give the impression of conflict, contrasting with the calm demeanor of English nurses Cultural differences in language usage, such as interpreting "mad" to mean angry rather than crazy, highlight the nuances of communication These language barriers can lead to amusing misunderstandings, prompting reflection on how we perceive and express emotions across cultures.
Experiencing the healthcare environment firsthand is significantly different from merely observing it For newcomers, starting their nursing journey can be challenging, especially when it comes to understanding doctors and nurses Reflecting on my own experience in 2010, I struggled to communicate effectively, which made it difficult to connect with others However, after working as a nurse for some time, I now find it easier to express myself and communicate with doctors, highlighting the importance of time and experience in overcoming language barriers in healthcare.
When I was new in this country, at that time, yes, the telephone conversation was a problem because of this noise, and sometimes we can't understand accent (F1N4)
These difficulties had in some cases been exacerbated by negative attitudes towards nurses from abroad on the part of patients and their relatives
Navigating social interactions can be challenging, as people's behavior often varies based on circumstances This stress is amplified by language barriers and the stigma associated with not being a native English speaker Overcoming these obstacles is essential for integration and personal well-being.
Many individuals, despite knowing you are a nurse caring for their family members, may underestimate your role and expect you to fulfill personal tasks, such as fetching drinks from the fridge Even with clear communication and explanations, some people choose to disregard what you say, illustrating a lack of understanding and respect for your professional responsibilities.
Focus group 2 (UK trained nurses)
Speaking and listening
Nurses play a crucial role in patient care by introducing themselves and familiarizing patients with their surroundings They must also effectively communicate and negotiate necessary actions with patients to foster cooperation, as highlighted by Nurse 1's experience This strategy is essential for overcoming challenges related to patient non-cooperation, as identified in the tracking study.
In discussing the daily care plan with patients, it's essential to address their hygiene needs, such as assistance with showering For instance, if a patient requests help with a shower, you can confirm by saying, "Yes, that’s fine," and propose a specific time for the shower, like "Shall we aim for half nine?" After breakfast, you can guide them to their scheduled shower, demonstrating the importance of negotiation and collaboration in delivering effective patient care.
In accord with findings in the tracking study and Focus
Nurses engage in social conversations with patients to create a relaxed atmosphere and gather valuable information that can enhance treatment This approach also helps to alleviate any potential embarrassment when performing duties in front of the patient or their relatives.
Our facility offers single rooms, ensuring privacy for both you and the patient, along with a family member if present This setup can sometimes create a quiet atmosphere, making conversations essential to avoid any awkwardness.
So, you know, they’re just watching you do something So, I always try and chat to them when
I’m making the bed, when I’m doing my obs (F2N2)
As discussed in Focus Group 1, social talk performs a bridge between the world of the hospital and the world outside
Patients in hospitals often struggle with feelings of isolation due to being away from their family and friends They rely on healthcare providers for companionship and conversation, as well as updates on current events when they are unable to read the news themselves Providing this support is crucial for their emotional well-being.
Often patients will ask, ‘What’s it like outside?’
That’s one of the questions you get asked a lot
Nurses effectively communicate with patients and their families who have limited English proficiency by employing strategies such as using pictures, gestures, and acquiring essential vocabulary in the patient's language.
UK nurses often collaborate with interpreters and utilize translated hospital literature to effectively communicate with patients who speak different languages They recognize the challenges faced by nurses in Focus Group 1, particularly those from abroad, highlighting the importance of language support in providing quality care.
Non-English speakers in the UK often face challenges when communicating over the phone, particularly when discussing a patient's serious condition with their relatives, who may employ indirect language.
Families often communicate in indirect ways, which can be confusing, especially for non-native speakers This roundabout approach can make it difficult to grasp the underlying meaning of their questions and the context from which they arise.
Nurses play a crucial role in reassuring distressed patients, although this effort may not always yield positive results, as some patients may respond with abusive behavior In these challenging situations, it is vital for nurses to manage their frustration and refrain from confronting the patient.
She was verbally abusive to the registrar, calling him all the names under the sun…and he said, ‘Stop right there I’ve had enough’, she carried on, whereas
I felt I should have stepped in and said, ‘OK, that’s enough’, but I just couldn’t I froze in the situation, and I didn’t know what to say I was just so shocked,
I think I was just absolutely shocked by the way she lost her temper, and was throwing things around the room (F2N3)
Many people have experienced moments of disbelief when confronted with disrespectful communication, leaving them unsure of how to respond Common reactions might include requests for respectful dialogue or reminders to consider others, but these often go unacknowledged This can lead to a sense of shock and frustration, highlighting the need for better communication in challenging situations.
‘cos you just don’t expect to be treated or spoken to in such a way (F2N7)
Nurses have to keep a detailed record of incidents of abuse, which may be needed if the patient raises a complaint:
They wrote a letter of complaint…and we were all asked to write our responses, which everyone who was involved did (F2N7)
Participants emphasized the importance of questioning doctors when they struggle to understand medical instructions Some felt compelled to challenge a doctor's methods, particularly in instances where they perceived insensitivity One participant confronted a doctor for their casual demeanor in front of the medical team and other patients, believing it was inappropriate and disrespectful to those in care.
So I asked him to step outside, and I had a chat with him, and said that wasn’t appropriate, and that then he needs to think about his communication (F2N5)
After she had consoled the patient, the nurse reported the incident to the doctor’s line manager
I recommended to his supervisor that he enroll in a communication training program Before I could discuss this with his boss, I took the opportunity to check in with the patient to ensure her well-being.
Some doctors have inadequate proficiency in English, which can cause potentially serious problems in communication
In my experience with F2N2, communication was a challenge as he struggled to comprehend what I was saying To address this, I sought assistance from a nurse in charge, who connected me with a cardiology specialist from another team to help prescribe the necessary treatments I found that speaking slowly was essential, as he frequently nodded and responded with 'Yes, yes, yes,' despite not truly understanding my words It became clear that I needed to rephrase my explanations for better clarity.
CS: So is he not a native speaker of English
F2N2: No, he’s not a native speaker
A participant witnessed a miscommunication between a doctor and a patient that led to the patient's anxiety She stepped in to clarify the doctor's intended message and provided translation support for the patient.
Reading
The focus group discussions validated several challenges identified in the tracking study, particularly the use of abbreviations that are unfamiliar to non-UK nurses Additionally, participants expressed difficulties in interpreting notes from doctors and other nurses, highlighting the need for clarification in communication.
And prescriptions you tend to call back and say
Navigating prescription legibility poses significant challenges for newly qualified nurses and those starting in new environments When prescriptions are unclear, it complicates the process of questioning or challenging the prescribed medication, potentially jeopardizing patient safety Effective communication is crucial in these situations, as nurses must feel empowered to express concerns and address discrepancies in prescriptions.
Sometimes you can only tell because of the dose ‘cos it’s like (inaudible) 75 and you just see begins with a
Pharmacists often write the names of medications clearly, sometimes using green ink, which helps ensure accurate prescriptions This practice allows patients to better understand their medications and facilitates communication between pharmacists and healthcare providers.
Writing
Focus Group 2 emphasized the significance of clear and precise writing in documenting patient medical notes Participants highlighted the differences between nurses' personal handover notes and the formal records prepared for patients Additionally, they discussed the level of detail necessary for effective incident reporting.
In our current ward, if we examined each other's handovers, there would be a lack of understanding between us While our official notes are properly documented and legible, they should be clear enough for the next shift to easily comprehend what occurred This ensures effective communication and continuity of care.
Speaking
The general requirements for IELTS speaking outlined by Taylor (2001) are:
Candidates are expected to demonstrate:
1 A wide repertoire of lexis and grammar to enable flexible, appropriate and precise construction of utterances in ‘real time’
To achieve fluent performance in language use, it is essential to have a well-defined set of procedures for pronunciation and lexico-grammar, along with established language chunks These elements facilitate effective communication while minimizing the need for extensive on-line planning and optimizing timing.
The IELTS speaking test is a face-to-face interview with an examiner, which lasts for 11 to 14 minutes
Examiners must adhere to a standardized 'examiner frame' that dictates the phrasing and sequence of questions, ensuring uniformity and fairness for all candidates This structured approach is vital for maintaining equality during the assessment process The test is divided into three parts, which will be analyzed in connection with the nurse communication strategies highlighted in the research.
(The descriptions are from the summary on the
Part 1 – Introduction and interview (4–5 minutes)
In this section, the examiner begins by introducing themselves and verifying the candidate's identity Following this, they engage the candidate with general questions about familiar subjects like home, family, work, studies, and personal interests This part of the assessment evaluates the candidate's ability to express opinions and provide information on everyday topics and common experiences through a variety of questions.
Part 1 focuses on topics relevant for nurses to discuss with patients and colleagues in social settings However, the test format features an asymmetrical interaction, where the examiner leads the conversation.
In day-to-day nursing conversations, nurses must navigate various roles, acting as equals with colleagues and as authoritative figures with patients They gather information, guide patients through hospital procedures, and provide reassurance to those who are anxious Additionally, nurses address issues of non-compliance by collaborating with senior staff and utilize medical terminology, translating it into layman's terms for better patient understanding This requires nurses to skillfully initiate and conclude conversations while effectively introducing and elaborating on pertinent topics.
In Part 2 of the speaking test, candidates receive a card with a specific topic and key points to cover, along with a request to elaborate on one point in detail They have one minute to prepare and can take notes if needed, allowing them to speak for two minutes according to the card's instructions The examiner signals when to start and stop, and may ask follow-up questions This section evaluates candidates' ability to speak fluently and coherently on a topic with minimal preparation, using appropriate language, organizing their ideas logically, and connecting the topic to their personal experiences.
Part 2 of the IELTS speaking test addresses the communicative needs of nurses, emphasizing their role in providing detailed information about facilities, processes, and patient conditions to both patients and the medical team It is crucial for nurses to organize their ideas logically and draw from their experiences during handovers However, the test's structure does not accommodate requests for clarification, which research indicates is a vital component of effective handover communication.
In Part 3, the candidate and examiner engage in a deeper and more abstract discussion of the topics introduced in Part 2 This section evaluates the candidates' skills in articulating their opinions, as well as their ability to analyze, discuss, and speculate on various issues.
Part 3 focuses on the crucial communication between nurses and doctors, highlighting the doctor's role in asking questions to evaluate a patient's condition and provide treatment instructions Additionally, it emphasizes the importance of nurses in sharing their insights, discussing potential treatment options, and proposing actionable solutions.
In the test, communication is predominantly one-way, limiting candidates' chances to showcase their skills in topic management and interaction, as noted by Seedhouse & Harris (2011) Conversely, in a hospital setting, nurses are encouraged to actively engage in decision-making and participate in collaborative discussions with the medical team.
While Part 3 is said to evaluate interaction, the official assessment criteria emphasize fluency and coherence, lexical resource, grammatical range and accuracy, and pronunciation These descriptors suggest a primary focus on delivering a monologue, utilizing connectives and discourse markers, as well as managing language-related hesitation, repetition, and topic development.
Listening
The listening paper consists of four sections, each containing ten questions that follow the sequence of information presented in the recording Candidates have approximately the same amount of time to listen and record their answers.
30 minutes Candidates hear the recordings once only
Different accents, including British, Australian,
New Zealand and North American, are used Candidates are penalised for grammar and spelling mistakes.
Assessing a candidate's ability to understand extended speech presented only once is a more challenging task than the listening skills required in nursing Unlike nurses, who can request repetitions, clarifications, or consult patient records and online resources, candidates must demonstrate comprehension without such aids.
Effective communication involves asking for clarification and repetition to ensure understanding It is important to check if instructions are clear, and if not, provide further explanations This approach enhances comprehension and reinforces the relevance of the information shared.
Participants emphasized the critical importance of attentive listening during handovers, as vital information may not be documented elsewhere The urgency of the situation often necessitates immediate comprehension of what is communicated by medical staff or fellow nurses, as delays can lead to significant repercussions Nurse 2 from Focus Group 1 noted that the skills developed through listening and reading practices serve as excellent preparation for nursing in the UK.
Practicing active listening is crucial when interacting with patients and their families, especially when most training materials feature a British accent After dedicating significant time to honing my listening skills and preparing for exams independently, I have noticed a marked improvement in my listening abilities, which I can effectively apply in real-life situations.
The IELTS listening test uses audio recordings to simulate challenges nurses may encounter, such as understanding information when the speaker is not facing them However, research indicates that nurses in UK hospitals must comprehend a broader variety of English accents than those typically featured in the IELTS, which predominantly includes standard Anglophone accents As one participant from the tracking study remarked, "The English [in the test] is quite clear," highlighting the disparity with real-life situations where patients may have strong accents.
Sections 1 and 2 of the listening paper cover everyday topics commonly encountered in conversations with patients and colleagues In contrast, the paper also includes academic topics that are generally not necessary for nursing practice While some professional development seminars at hospitals may address these topics, attendance is optional Additionally, nurses may need to summarize key points from discussions among medical team members for the benefit of the patient.
The listening test uses a range of response formats:
2 matching information from the recording to an option on the list
4 form/note/table/flow chart/summary completion
Response formats 3-6 require concise answers of two words or a number, essential for nurses completing forms, charts, and checklists These formats encompass various listening activities, including detailed understanding of specific points and general comprehension of main ideas They emphasize the importance of listening for detailed and specific information, particularly during patient admissions and colleague handovers.
When preparing a patient for surgery, it is crucial to thoroughly inquire about their medical and surgical history, as this information is vital for ensuring a safe and effective operation.
Preparing a patient for surgery involves a meticulous checklist that must be accurately completed It is essential to fill in any blanks with the correct information after consulting the patient If there are discrepancies, the surgical team will verify the details again in the operating room to ensure no critical information has been overlooked This thorough process is vital for patient safety and care.
To ensure a comprehensive understanding during interviews, candidates should focus on enhancing their listening skills This approach allows them to grasp the complete context of the conversation and respond accurately to questions, rather than making assumptions Ultimately, fully understanding what is being communicated is essential to meet the expectations set for them.
Reading
This article features three sections, each containing a reading text sourced from various materials such as books, journals, magazines, newspapers, and online resources, all tailored for a general audience.
According to the Cambridge English website, the topics covered are relevant to both undergraduate and postgraduate students, showcasing various rhetorical functions such as narrative, descriptive, discursive, and argumentative styles Each text includes at least one comprehensive logical argument and may feature diagrams, graphs, or illustrations Additionally, any technical vocabulary is accompanied by straightforward dictionary definitions for clarity.
The test does not evaluate the specific reading skills necessary for nursing, which include recognizing words and phrases and understanding simple syntax within extended narratives Nurses engage with various materials such as medical notes, handover sheets, and medicine labels, which often utilize a restricted code with headings, bullet points, abbreviations, and concise notes In contrast, IELTS texts demand a comprehension of coherence and cohesion in longer passages, as well as the ability to interpret both implicit and explicit meanings and to parse simple and complex sentences.
The current study identifies that the primary nursing-related texts are protocols and policy statements Protocols tend to be formulaic and predictable, while policy statements, though important for nurses to read, are rarely encountered in their daily responsibilities.
Obviously, on a daily basis, sometimes you don’t have time to read a lot of things, for example, even certain specific things like a lot of trust policies they
…need to work according to – you need to read them
…And they’re available on the Internet…You have to read things like this…obviously [the trust policies] are more technical content-wise (Interview 4)
Two participants acknowledged reading journal articles, highlighting that while the ability to comprehend academic texts is beneficial, it is more of a personal preference than a requirement for their daily tasks.
The duration of the test is one hour, including time allowed to transfer responses to an answer sheet
As with the listening paper, the reading paper in IELTS uses a range of response formats:
2 identifying information (true/false/not given)
3 identifying writer’s views/claims (yes/no/ not given)
5 matching headings to paragraphs or sections in a text
6 matching a set of statements or pieces of information to a list of options
7 complete sentences based on information in the text by selecting from a range of possible endings
8 sentence completion choosing one or two words and/or a number from the text
9 summary/note/table/flow chart completion using words from the text, or from a list of options
The article consists of 40 questions, which are arranged in the same sequence as the corresponding answers found in the text Candidates will incur penalties for any spelling and grammar mistakes.
The questions assess a range of capacities on the part of candidates, such as to:
! understand specific points in detail
! identify the overarching topic of a paragraph (or section)
! recognise the difference between the main idea and a supporting idea
! recognise the function of various elements (example, reason, description, comparison, summary, explanation, etc.)
! differentiate factual information from opinions, theories or ideas
! recognise relationships and connections between elements in the text
! skim and scan the text to find the information quickly so that part can be read more carefully for detail
! interpret a detailed description and relate it to information given in a diagram
Nurses must possess key reading skills to effectively skim and scan texts for quick information retrieval, essential for their role in healthcare These abilities enable them to accurately relate medical notes to diagrams and charts in patient records, as well as identify critical details like quantities and expiry dates on medicine labels.
Response formats 8-11, which limit answers to two words or a number, reflect the documentation requirements for nurses Accurate information transfer is crucial, especially under time constraints However, the IELTS reading test fails to evaluate nurses' comprehension of the specific written language they encounter in their professional roles.
While academic reading is valuable, it may not be essential for nursing professionals Nurses primarily rely on notes from doctors and consultants, which are readily accessible through computer systems Additionally, local policies and procedures provide the necessary information for effective practice.
When in doubt, we can always seek clarification by reviewing the material If someone lacks the necessary skills, reaching out to the supervising nurse for guidance is essential The knowledge we gain in nursing is directly applicable to our practice.
So we can understand, yes (N2, Interview 4)
Writing
Task achievement/response
Task 1 is highly relevant for nurses, as it evaluates their ability to provide a structured overview of visual data such as graphs, tables, charts, or diagrams, while using language that is suitable for the intended audience and context.
Candidates are evaluated based on their ability to organize and present data, describe processes or events, and explain how things work In contrast, Task 2 focuses on assessing the candidate's skills in expressing and justifying opinions, discussing topics, summarizing details, outlining problems, identifying solutions, and supporting their arguments with relevant examples in an extended essay format.
Coherence and cohesion
The IELTS scoring criteria for both tasks highlight the significance of logical progression and the effective use of cohesive devices, particularly in Task 2, where paragraphing is crucial In the context of nurse record-keeping, maintaining a chronological sequence is essential, making logical progression unavoidable However, the use of cohesive devices and proper paragraphing holds less importance in nurses' writing due to the limitations of space in forms, charts, and tables, which restricts extended writing.
Lexical resource
As candidates advance through the IELTS bands, they must expand their vocabulary, enhance precision, and demonstrate an understanding of style and collocation While these criteria focus on general vocabulary, nurses operate within a medical register that relies heavily on technical language Precision in nursing communication is achieved through the effective use of common formulaic phrases, medical terminology, and numerical data.
Grammatical range and accuracy
Candidates aiming for higher band scores are required to exhibit more complex syntax and greater accuracy, particularly in punctuation At band score 7, they should utilize a range of complex structures, consistently produce error-free sentences, and demonstrate strong grammar and punctuation control, although minor errors may still occur.
Nurses' writing skills focus on brevity and precision, emphasizing accurate reporting of events, medication names, and patient conditions When reviewing written records, nurses prioritize identifying lexical or numerical errors over punctuation or syntax issues.
Language requirements for overseas nursing practitioners
Nurses play a crucial role in the communication network of patient care, regularly interacting with patients and serving as a liaison between them, their families, and healthcare professionals They must skillfully navigate both lay and medical language, especially in high-stress situations, and know when to employ indirect communication to prevent conflicts Additionally, nurses need to understand the appropriate conventions for turn-taking in conversations to ensure effective communication.
Nurses play a crucial role in patient care within hospitals, requiring proficiency in English to gather essential information about patients' medical histories They must navigate checklists and forms while considering the cultural and linguistic backgrounds of patients Additionally, nurses are responsible for orienting patients to hospital procedures, assessing their conditions, building trust, and providing reassurance They also need to effectively manage situations involving agitated or abusive patients.
Effective communication in healthcare involves using suitable language to request, inform, and engage with patients, while addressing their responses and concerns It is essential to employ indirectness to soften statements and facilitate social interaction, particularly when language barriers exist between interlocutors.
Nurses play a crucial role in navigating the hospital hierarchy, often acting as patient advocates by seeking clarification and repetition from medical staff, which can sometimes be perceived as confrontational To ensure positive patient outcomes, they must balance challenging authority with conflict avoidance while collaborating effectively with the medical team on treatment discussions Additionally, nurses engage in co-constructive communication with colleagues to verify information and procedures, assist patients in mobilizing, and negotiate responsibilities They also provide guidance to healthcare assistants and agency staff, all while fostering a supportive work environment through relaxation, conversation, and culturally appropriate humor.
Effective communication becomes increasingly challenging in situations with multiple participants, such as when nurses interact with patients and their families who may be overhearing medical discussions, or when they include patients in conversations with both medical and non-medical staff.
This requires the sensitivity to know what information to select, how to structure the talk to be comprehensible to both parties, and the appropriate register to use
Nurses must effectively communicate with patients, doctors, and fellow nurses who may have limited English proficiency This requires them to be culturally and linguistically sensitive, recognizing potential misunderstandings and proactively using repair strategies to ensure clear communication In cases where patients speak little or no English, nurses should utilize available institutional resources and create their own strategies to enhance communication, ultimately prioritizing patient safety.
Effective listening is vital in nursing interactions, as emphasized by Morse and Piland (1981) During handover, while written records provide essential medical information, they may lack critical verbal details important for the incoming nurse Therefore, nurses must listen attentively and identify relevant information, ensuring they also confirm their understanding when communicating with both medical staff and patients.
Apker et al (2006) emphasized the significance of active listening among healthcare team members, which is crucial for effectively addressing both direct and indirect patient requests Additionally, it is essential for healthcare professionals to assess a patient's mood and condition through their conversations.
Although much more limited in scope than larger studies aimed at gathering data for language tests such as O’Hagan, Manias et al (2013) and Epp and Stawychny
In 2002, nurses provided detailed local accounts of their daily routines and incidents, highlighting important practices such as crosschecking and challenging the actions of doctors and fellow nurses They also addressed the complexities of emotionally charged situations involving patients and their families.
Listening effectively in nursing is complex due to various factors, including diverse accents, patients with speech difficulties from medications or physical challenges, and medical staff whose faces may be obscured while reading from texts or screens Additionally, communication over the phone can be particularly challenging as it often involves indirectness when discussing emotionally sensitive topics with patients, relatives, and friends.
Nurses face varying reading requirements in their daily roles, often needing to engage with more complex materials for re-registration and professional development Their reading skills must encompass understanding figures, medical terminology, abbreviations, and notes, while also being adept at searching for specific drug or procedure information using both paper references and online resources Additionally, nurses must be proficient in reading both handwritten and digital records, navigating cultural differences in abbreviations with the help of colleagues, online resources, or hospital-provided glossaries.
More challenging reading, e.g of journal articles appears to be optional However, according to The Prep
Handbook (Nursing and Midwifery Council 2011), which is the post-registration education and practice guide for all nurses and midwives, they are expected to engage in
To maintain registration, a total of 35 hours of learning activities must be completed within the three years leading up to the renewal The upcoming revalidation of the Prep, set for October 2015, emphasizes a commitment to more stringent verification of Prep requirements.
In order to fulfil these requirements for professional development, nurses may need to read relevant research publications
Writing in nursing should be clear, concise, and accurate, as it involves transferring information between various formats, such as tables, checklists, and digital records.
They have to record their actions in patient records, but this must be in brief notes, or connected narrative
More demanding is the incident report, which would be ‘knowledge telling’, rather than ‘knowledge transforming’ required for academic writing (Bereiter
& Scardamalia 1987) McNamara (1996) identified the limited demands on written communication compared with listening and speaking for health professionals
Epp and Stawychny (2002) made the same observation with regard to reading and writing for nurses
Nurse communication poses significant challenges, particularly for those from diverse cultural and linguistic backgrounds Reports from nurses highlight the social and political pressures within hospital environments, where time constraints necessitate brevity and clarity, often relying on checklists and abbreviations Accountability is paramount, reflected in the emphasis on thorough record-keeping and the need for clarification and confirmation in communications Effective communication spans various skill areas, encompassing both therapeutic and medical routines that, while essential, can be relatively straightforward to learn.
Social chat is crucial for therapy and enhancing calmness and well-being in nursing, but it can be challenging for nurses from cultures that prioritize a task-based approach to patient care.
Nurses whose primary language is not English can find it difficult to establish a professional identity, and make small talk to put patients at ease (O’Neill 2011; Deegan
The pragmatics of small talk in nursing practice is culturally related (O’Neill 2011)
IELTS and the language needs of practising nurses
Speaking
The speaking test evaluates essential communication skills for nurses, including discussing everyday topics relevant to interactions with patients and staff, as well as organizing information from notes related to patient medical history, treatments, and current conditions It also assesses their ability to respond to inquiries from other medical team members However, research indicates that several critical aspects of nurse communication are not included in the test, highlighting the need for a more comprehensive evaluation of their competencies.
! elicit personal information from someone in a formal situation, using prompts and requests for clarification, and, possibly, other more indirect means
! reassure someone who is anxious
! request action from a superior, a peer, or someone in their care, and deal with refusal
! challenge the actions of a superior
! participate in team decision-making
! translate lay talk into a specialist register and vice versa
! use language collaboratively with a peer, to negotiate responsibilities, issue instructions, and check information
In the IELTS speaking test, communication is asymmetrical, with the examiner controlling the flow of conversation, as evidenced by Ducasse and Brown's (2011) study showing candidates do not initiate or change topics This contrasts sharply with nurses’ interactions with patients, where nurses often hold more power in the dialogue Furthermore, the test format does not allow candidates to showcase their ability to adapt their communication style for different social contexts or engage with multiple interlocutors, skills that are essential for nursing practice.
Effective communication in the IELTS exam primarily involves responding to questions and prompts from the examiner, limiting candidates' ability to showcase essential skills like using face-saving language to refuse requests or manage conflicts with authority figures Additionally, the exam does not assess the ability to engage in spontaneous social interactions, such as eliciting responses, providing comments, back-channeling, managing topics, turn-taking, and confirming understanding—key components of effective communication in nursing.
The absence of many important features of social conversation in the IELTS speaking test was noted by
Listening
The listening paper evaluates crucial aspects of nurse communication, focusing on listening for detail, general understanding, and specific information It employs various response formats, including labeling diagrams and completing forms, notes, tables, and summaries, to reflect the diverse listening tasks nurses encounter in their practice.
The test assesses the ability to listen and comprehend communication from multiple sources, which is crucial for nurses They must understand instructions during handovers and interactions with colleagues, as well as engage in social conversations with patients and their families Additionally, nurses need to effectively participate in formal discussions with medical team members.
The IELTS test evaluates an essential listening skill for nurses by requiring them to comprehend spoken English in real time, as candidates only hear the material once However, it does not assess the crucial skill of seeking clarification or confirmation of important information, which is vital for effective communication in nursing This gap is especially significant for overseas-trained nurses who may be unfamiliar with the diverse range of accents in the UK, extending beyond the various Anglophone accents.
The IELTS test aims to evaluate candidates' communicative competence, particularly for nurses, by assessing their ability to understand and respond to diverse speech patterns While including all non-standard English varieties in a listening test is impractical, it is essential for the assessment to focus on candidates' skills in interpreting speech that may not be immediately clear.
In summary, IELTS tests much of the listening that nurses engage in, but it does not include the participative listening that is an essential part of their workplace communication.
Reading
Nurses encounter shorter and more fragmented texts at work compared to the reading materials required by the IELTS, which often lack the structural and cohesive devices emphasized in the test The language and syntax used in nursing texts are generally simpler However, essential reading processes such as skimming, scanning, and completing tables, charts, notes, and diagrams based on the information read are skills that nurses also need to master, similar to those assessed in the IELTS exam.
Academic reading skills are crucial for nursing, particularly in the Overseas Nursing Program (ONP), which is essential for internationally-trained non-EEA nurses seeking to register in the UK As part of the ONP, these nurses must complete 20 days of protected learning, which includes a university-based course where candidates are required to read articles on nursing practices.
The Overseas Nurses Program (ONP) in the UK requires candidates to provide reflective spoken and written responses as part of their assessment, which is crucial for registration This evaluation of academic reading and writing skills is essential for determining candidates' readiness for pre-registration training However, the ONP is being phased out in favor of a computer-based multiple-choice test conducted in the candidate's home country, along with a practical exam in the UK, although details regarding this transition were not available during the research period.
Continuing professional development (CPD) plays a vital role in healthcare, with many hospitals offering regular seminars that encourage discussions on pre-read journal articles Some healthcare professionals also engage with relevant research journals through hospital subscriptions While these activities are beneficial for maintaining professional competence and re-registration, they are not significantly highlighted in the current study, which primarily examines daily practices of nurses rather than their self-improvement efforts outside of work.
In general, therefore, the academically-oriented reading skills that are tested in the IELTS are only marginally relevant for nurses.
Writing
Nurses' writing in their daily responsibilities significantly differs from the writing assessed by the IELTS The NMC guidelines emphasize that nurses must document all assessments and reviews conducted, ensuring clear evidence of the care arrangements made for ongoing treatment Additionally, it is essential to include information provided regarding care and treatment.
Nurses are expected, however, to be selective with regard to these details:
You should use your professional judgment to decide what is relevant and what should be recorded
The data from the research indicate that nurses need to be competent in writing in short texts, rather than in extended and cohesive texts
Participants emphasized the importance of brevity and succinctness in their writing, focusing on capturing essential information Their notes typically consist of single words, brief collocations, numbers, and unconnected sequences marked by time indicators, rather than complete sentences The content is often predetermined, as much of their writing involves filling out forms and charts Nurses do not require proficiency in punctuation, paragraph construction, or the use of cohesive devices, which are criteria for achieving an IELTS writing Band 7.
The NMC guidelines emphasize the necessity for writing to be easily comprehensible for patients under a nurse's care Research participants highlighted that records must be factual, avoiding unnecessary abbreviations, jargon, meaningless phrases, and irrelevant speculation.
(2007, p 5) Limited vocabulary and simple syntax are essential, by contrast with the ‘less common lexical items’ and ‘a variety of complex structures’ stipulated for
Achieving a Band 7 in IELTS writing requires the use of less common lexical items, which does not necessarily refer to specialized technical terms like those used in the medical field It emphasizes the importance of incorporating a diverse vocabulary to enhance communication effectively.
Some apparent correspondences between the language of the IELTS criteria and that of statements by the NMC with respect to writing should not be taken at face value
While the IELTS criteria for Task 2 emphasize the use of 'factual information', it differs from the factual details central to nursing documentation, as highlighted in this report Similarly, IELTS Writing Task 1 mandates candidates to provide 'a clear overview of main trends, differences, or stages' and to 'maintain a clear position throughout the response', which are also vital elements of nurses’ reports on patient progress.
There is a crucial difference, however, in that the IELTS criterion relates to expository writing, whereas nurses write in narrative form
Consequently, the concept of ‘errors’ in nurses’ writing is very different from that of the IELTS assessment criteria
Inaccurate information and misuse of technical terms can lead to imprecision in nursing documentation To maintain accuracy, nurses should implement thorough checking procedures when recording and transferring information across different formats or mediums Additionally, grammatical errors and the incorrect use of non-technical vocabulary can contribute to misunderstandings in communication.
In conclusion, there is a significant gap between the writing skills that nurses must exhibit on the IELTS writing exam and their actual writing practices in their professional roles.
Summary
The research indicates that the IELTS test evaluates key components of English language proficiency, particularly in listening, which are essential for effective communication in nursing.
Achieving an IELTS Band 7 involves various skills that may not directly reflect the English competence needed for overseas-trained nurses to practice in the UK Notably, certain essential language skills and strategies vital for nursing, especially in speaking, are not adequately assessed by the IELTS exam.
Recommendations
Two options are recommended, both of which would require further, more extensive research into nurse communications in the UK
To enhance the IELTS assessment for nursing professionals, it is proposed to introduce an alternative module in the speaking test that evaluates communicative competence specific to nursing practice Additionally, it is recommended to consider accepting lower band scores in reading and writing for nurses to better accommodate their language proficiency needs.
2 To develop a test for non-native English speaking health professionals, who apply to register for practice in the UK, similar to the Occupational English Test in Australia
If an English language requirement were to be stipulated for EEA nurses, a test specifically for nurses would be desirable, given the escalation in demand for nurses in the UK
This study acknowledges its limitations, focusing on the communication practices of a small group of nurses in specific contexts over a brief timeframe Due to its narrow scope, the research did not secure permissions for direct hospital observations or for gathering a wider array of documentation, which could have facilitated a more comprehensive triangulation of the nurses' accounts.
The data collected provides valuable insights into nurse communications, which are crucial for evaluating the adequacy of the IELTS test as an English language requirement for non-EEA internationally-trained nurses This study is the first of its kind in the UK and aligns with similar findings regarding nurse communications found in the literature on the Occupational English Test in Australia and the Canadian English Language Benchmark Assessment for Nurses.
In conclusion, although the IELTS listening test is deemed suitable, nurses need a broader proficiency in spoken English that extends beyond what is evaluated in the IELTS speaking test.
Proficiency in pragmatics is essential for effective communication in medical and healthcare contexts, enabling individuals to engage with diverse interlocutors on various topics Mastering different registers and functions of language is crucial for successful social interactions in everyday situations.
The IELTS speaking test minimally evaluates essential skills for nurses, while the writing assessment lacks direct relevance to their professional duties Although certain reading test requirements are applicable, they often exceed the practical reading demands that nurses encounter in their daily work.
The current study focuses on the actions of nurses to assess test requirements, rather than comparing these actions to established assessment criteria (O’Neill et al 2007; Epp & Stawychny).
The current IELTS test focuses on assessing knowledge for practical use, overlooking important pragmatic aspects of communication These aspects include the ability to initiate conversations, take turns, and collaborate effectively with others in dialogue.
According to McNamara (1996), effective communication is crucial for nurses, and IELTS scores play a significant role in evaluating a candidate's language proficiency in nursing contexts However, this study reveals that the IELTS does not sufficiently assess the social and pragmatic language skills necessary for successful communication in the nursing profession.
This study recommends specific assessments to enhance nurses' spoken and written communication skills It identifies several areas where the IELTS test falls short in evaluating nurses' linguistic readiness for practice, particularly in terms of pragmatic and social language use.
Wette (2012) suggests that New Zealand should accept lower IELTS scores or, ideally, the OET (Occupational English Test) for health professionals This approach would enable qualified nurses to enter the country and acquire the necessary cultural language skills for effective practice in the local context.
While local support for language development in practice is ideal, it is uncertain in the UK, especially amid the NHS's current financial challenges Recent changes to registration requirements for non-EEA nurses trained outside the UK have replaced the support previously offered through protected learning in the Overseas Nursing program.
Program and supervised practice with a multiple-choice test of knowledge in the country of origin and an OSCE
(a practical examination of their nursing skills) in the
UK, on successful completion of which nurses are expected to be ready with minimal linguistic skills required for practice
In light of recent changes, it is essential for international nurses to demonstrate their communication skills before practicing in the UK A framework has been established to assist internationally educated health professionals, including those in nursing, midwifery, and medicine, in London However, this framework has not yet been recognized as a statutory requirement.
Revising the current assessment requires a comprehensive study and collaboration with health practitioners, similar to the approaches used in the CELBAN (Epp & Stawychny 2002) and the recent re-validation of the OET (Elder et al 2013) It is essential to incorporate the viewpoints of various stakeholders, including patients and managers Balancing the efficiency, practicality, and accessibility of an assessment with its adequacy and appropriateness presents a significant challenge.
Language assessment, as noted by McNamara, is inherently social and political To ensure patient safety and support the wellbeing of non-native speaker nurses trained outside the UK, it is essential that these professionals possess at least a minimum level of linguistic readiness for their practice.
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