1. Nursing Across Cultures: The Communicative Needs of Internationally Educated Nurses (IENs) Working With Older Adults Margaret Hearnden PhD (ABD), OISE/UT mhearnden@oise.utoronto.ca

2. Overview Nursing in Canada & elsewhere Language & Health Care Internationally Educated Nurses (IENs) & English for Speakers of Other Languages (ESOL) Research Study Findings

3. Nursing – A Global Shortage “The nursing shortage occurring in health systems around the world is bringing in its wake a serious crisis in terms of adverse impacts on the health and well-being of populations” (International Council of Nurses, 2006)

4. Nursing in Canada An aging population 2001 – population > 65 was 12.64% 2016 – population > 65 estimated at 16% (www.sustreport.org/signals/canpop_age.html)www.sustreport.org/signals/canpop_age.html

5. Nursing in Canada Care of older adults Changing expectations about care of older adults Detrimental effect of ‘elder-speak’ (Williams, Kemper & Hummert, 2003)

6. Language and Health Care  “Language [ ]medicine’s most essential technology” (Jackson, 1998)  Effective communication involves being able to produce contextually appropriate language, as well as the ability to understand the nuances of a given situation (Block, 2003; Ellis, 1994; Lyons, 1996)

7. Language and Health Care How Nurses Communicate Nurses interact:  with clients 56%  with other professionals 34%  with others 10% (Centre for Canadian Language Benchmarks [CCLB], 2002)

8. Language and Health Care How Nurses communicate (adapted from CCLB, 2002)

9. Language and Health Care  Communication difficulties discourage certain populations from accessing health care (Bowen, 2001)  Language barriers negatively affect health care effectiveness and client satisfaction (Buchan & Seccombe, 2004)

10. The IEN in Contemporary Nursing: has an integral role in the provision of nursing across Canada & elsewhere for an aging multicultural client base requires different supports due to differences in language & culture

11. IENs & ESOL Benchmarking English for IENs (CCLB, 2002) IENs experience difficulties with: speaking and listening idiomatic expressions culture

12. IENs & ESOL Barriers…… Language testing is not reflective of the sociolinguistic demands of nursing (CCLB, 2002) Opportunities for ESOL education for professions such as nursing are limited (Munro, 2003)

13. IENs & ESOL Lower pass rates of nursing exams compared to non-IENs (CNO, 2005) Higher attrition rates (Jalili-Grenier & Chase, 1997) Underemployment

14. Research Study: Objectives: To access IEN experiences To motivate a shift in curriculum design

15. Research Study: Research Questions What are the sociolinguistic & sociocultural needs of IENs working with older adults? What are the strengths & weaknesses of educational opportunities for IENs, in terms of the sociolinguistic & socio- cultural needs of nurses working with older adults?

16. Research Study: Recruitment Procedures 9 month collaborative period: 16 care facilities 4 nursing agencies CARE for Nurses, Toronto, ON The Centre for Equity in Health and Society (CEHS), Toronto, ON 1 hospital

17. Research Study: Participants 27 female, 1 male: TOTAL 28 12 countries of origin 9 IENs – 3 years or less in Ontario 7 IENs – 4 years or more in Ontario 3 student IENs 2 Canadian born recent graduates 2 staff educators 4 clients and 1 family member

18. Research Study Data Collection Methods 3 Research sites Individual 20 -30 minute taped interviews Background questionnaires + field notes 4 journal entries over 4 month period from 1 experienced IEN 10 weekly telephone interviews with 1 newly qualified IEN

19. Research Study: Data Analysis Qualitative data analysis using Nvivo Theoretical Framework/Lens -Sociocultural Theory (SCT) -Legitimate Peripheral Participation (LPP)

20. Results Lack of vocabulary Difficulties with pronunciation Limitations in socio-cultural competency Lack of ESOL support & appropriate language testing

21. Lack of vocabulary “they don’t use ‘finger’, they use, er, the word that’s beginning with ‘d’” (Wendy, China) “I feel short in expressing what the real problem is” (Una, Bosnia- Herzegovina) “Like sometimes you’re missing the little words” (Chory, Poland)

22. Difficulties with pronunciation “When we speak [ ] they could hardly understand us” (Marikit, The Philippines) “Probably I’m not pronunciation very good. I say ‘yes, I can’, but she heard it like I refuse” (Wendy, China)

23. Limitations in socio-cultural competency “How do you empathise with a patient? What kind of words do you use? What do you say when someone’s dying? Or if somebody walks in and attacks you verbally, what kind of things you can say?” (Lulu, Hungary)

24. Comparing IEN & Non-IEN participants Communication in nursing Sociocultural education Education for working with older adults

25. Language testing & ESOL support “When I finished the TOEFL test I could understand everything people said, but I couldn’t talk” (Susan, China)

26. Implications IENs need: Greater integration of ESOL into bridging/refresher programs Opportunities for practical experience