health care:

Foreign nurses can slip into communication gap

Baffled by reference to grits, confused about the graveyard shift


Steve Marcus

Nurse Terrie Young, originally of the Philippines, visits with “standardized patient” Nannette Mears during a UNLV nurses training program Friday at Spring Valley Hospital, “Speak for Success” is a research-based program for nurses who speak English as a second language.

Tue, Mar 10, 2009 (2 a.m.)

Speak for Success

Nurse Terrie Young, originally from the Philippines, checks on Launch slideshow »

It’s not politically correct — but it’s a frequent complaint of hospital patients in Las Vegas: “The nurses don’t speak English!”

The complaint is inaccurate. Foreign nurses working in Las Vegas do speak English. All have passed English language competency exams to become licensed in Nevada.

But the complaint also contains an element of truth. More than 15 percent of the Las Vegas nursing workforce is internationally trained, about five times the national average of 3.5 percent, according to an expert at UNLV. Most of these nurses are from Asian countries — the Philippines, India, Japan and Korea. Their English is often heavily accented and they may not understand the nuances of American culture and lingo — which can create challenges for patients and doctors.

Consider the experience of Nancy Menzel, a registered nurse and associate professor of nursing at UNLV. When Menzel was a patient in a Las Vegas hospital, the nurse needed to note every time she urinated, but she had a funny way of asking.

“You go pee pee?” the nurse asked Menzel throughout the night. “You go pee pee?”

“She may have been a wonderful nurse, but it didn’t come across that way,” Menzel said.

The nationwide shortage of nurses is particularly acute in Las Vegas, one of America’s fastest growing cities in the past 20 years. Nevada’s nurse-to-population ratio is among the worst in the country and Las Vegas hospitals have adapted by employing foreign nurses.

Yu “Philip” Xu, a professor at UNLV’s school of nursing who is originally from China, has studied the phenomenon in depth and has developed a unique training program to address the challenges.

Xu’s research has shown that foreign nurses have a difficult transition to the American health care system. A study he conducted on Chinese nurses in the United States found they often felt socially isolated and paralyzed by their communication inadequacies.

Xu recalled his own experience working as a nurse in Alabama. One time he asked a patient how she liked her food and she replied: “It’s as good as grits.”

The woman wasn’t eating grits, and though Xu knew what grits were, he had no idea why the woman was comparing her meal to them.

Debra Scott, executive director of the Nevada Board of Nursing, emphasized that the nurses speak English but may be unfamiliar with cultural idioms. She recalled a foreign nurse who thought she would be working with dead people because she had been assigned to the graveyard shift.

“It can be difficult for people who speak English-only to work with a nurse who has those cultural differences and an accent,” Scott said.

On the flip side, Scott noted that Las Vegas is a diverse city and foreign nurses can enhance care through their language skills and ability to relate to patients who share their heritage.

Foreign nurses are also forced to adjust to differences in the job description in the United States, Xu’s research has shown. Asian nurses are accustomed to family members doing tasks like bathing and feeding the patient, and may feel such jobs are beneath their level of education, one of his studies found.

In addition, many international nurses are not accustomed to the amount of independent judgment and time spent documenting medical care that’s required by the American system, his studies said.

Language and communication problems can have a direct effect on the quality of patient care, and on the perceptions patients have of their care, Xu said. An estimated 100,000 people die every year as the result of medical errors in the United States, and communication problems are believed to be a leading cause. Xu said it’s impossible to know how much internationally trained nurses contribute to medical errors because the area is grossly understudied.

“We are not saying by any stretch that foreign nurses are not providing quality care,” Xu said. “They are providing good care. But they do have challenges — based on the literature and anecdotal evidence and my experience.”

Two local hospitals — Spring Valley Hospital Medical Center and Desert Springs Hospital Medical Center — are positioning themselves as leaders in improving the performance of foreign nurses by participating in a study and training program developed by Xu in partnership with the Nevada Nursing Board.

About 72 nurses are in a program called Speak for Success, which included 10 weeks of training with a speech pathologist to reduce accents and four seminars to increase the understanding of American culture. The participating nurses were pre-tested months ago and then post-tested last week, and the results of the nurses who received the training will be compared to a control group who did not.

Officials from Spring Valley, where about 20 percent of the nursing staff is internationally trained, are sensitive about the program. They emphasized their commitment to help nurses improve their communication skills but were reluctant to admit that poor communication ever poses a problem.

On Medicare surveys, patients have ranked the communication of the nurses at the two hospitals poorly. The percentage of patients who said their nurses “always” communicated well was 46 percent at Desert Springs and 51 percent at Spring Valley, according to the Medicare survey. The Medicare surveys do not report anything regarding the nationality of the nursing staff. Hospital officials said the survey results are at least 9 months old, and that they’ve seen improvements in the survey results since starting Xu’s training program.

Dr. Jim Christensen, head of performance improvement at Spring Valley, said the communication challenges posed by foreign nurses are obvious, but that they are clinically sound. He commended the hospitals for working to improve their performance.

Amy Nassar is the speech pathologist involved in Xu’s study of communication skills. Although the results haven’t been compiled, Nassar said she noticed improvement in the nurses. The pre-testing found a wide range of skill levels, but the post-testing found that nurses who had attended classes were conscious of their pronunciation and careful not to make mistakes, she said.

On Friday, an Spring Valley nurse named Raphi Puthiyaveettil, an Indian nurse who has been in the United States for about three years, conducted his post-test in a role playing exercise with an actress portraying a hospitalized patient. As he conducted his assessment, there were occasions where his accent garbled words or his cadence was mixed-up: “I’m Raphi, I’ll be the nurse assigned to you today morning, for your case.”

But it was also clear that Puthiyaveettil was personable and brought a depth of clinical knowledge to the exam. In the scenario, the patient was diabetic, so he explained her blood sugar levels and the importance of diet and exercise.

He said after the test that the UNLV training program has provided him with a deeper understanding of American culture that will benefit his work at the hospital.

Xu said it’s uncertain when the research results will be published.

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