Table of Contents
Significance of the Practice Problem
Theory of Transcultural Nursing
Three-Step Model of Change
Synthesis of the Literature
Insufficient Language Proficiency
Effects of Insufficient Language Proficiency
Project Vision, Mission, and Objectives
Project Evaluation Plan
Instrumentation and Data Collection
The purpose of this quantitative project was to examine if the implementation of a mentoring program for Spanish speaking nurses facilitated improvement in communication. This project focused on answering did the improved communication resulting from the mentoring program lead to improved patient interactions and ultimately improved patient satisfaction as evidenced by their Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey results. The project studied 78 nurses randomly selected from the nurses on a Southwest (hospital) telemetry unit. Nurses were then assigned the role of mentor or mentee. To qualify as a mentor, the nurse had to speak fluent English have an above average employment evaluation. The director of the unit approved the mentor mentee assignments. The communication section of the HCAHPS survey was compared from the time frame in 2016 to the exact same time frame in the year previously (2015). A statistical analysis of the data revealed there was no difference in communication by nurses based on the mentor – mentee program outcomes as demonstrated on the HCAHPS survey results. It can be concluded that the mentor program may not be cost and time effective. The study recommends that hospital educators formulate policies that support effective communication of nurses while also considering the efficient use of nurses’ time and institutional financial resources.
El Paso, Texas is fewer than five miles from the United States-Mexico border and 81.2% of its residents identify as Hispanic (U.S. Census Bureau, 2014). Many of these residents speak Spanish as their first language; the same is true for nurses working in the city and its surrounding areas. Approximately 80% of the nurses in a given unit at the Southeastern Hospital speak Spanish and 90% of the patients are English speaking. Patient satisfaction measured by the HCAHPS is low, and for this hospital it appears to result from the number of Spanish speaking nurses that serve patients in these units. Evidence suggests that difficulty communicating with patients is common for Spanish speaking nurses and those that speak other non-English languages (Allan & Larsen, 2003; Lum, Dowedoff, Bradley, Kerekes, & Valeo, 2014; Staples, 2015). The result is a high turnover rate among nurses, as well as poor patient outcomes and satisfaction; these results are consistent with what has been observed at Southeastern Hospital (Kalavana, 2014; Mazurenko & Menachemi, 2015; Moore, Rivera, Grez, & Lawrie, 2013). Solving the communication problem has been difficult. The study examined mentoring for the Spanish speaking nurse, and the correlations of mentor and mentee that allows for improvement in communication (Dunham-Taylor, Lynn, Moore, McDaniel, & Walker, 2004; Hansen & Beaver, 2012; Jacobson & Sherrod, 2012). The ability to communicate clearly with all stakeholders, particularly patients, is needed to promote best practice outcomes (Mazurenko & Menachemi, 2015).
The purpose of this project was to help develop a solution of poor patient communication that leads to decreased patient satisfaction at Southeastern Hospital. This project studied the effectiveness of an English mentor group program on the communication skills of Spanish speaking nurses and their impact on patient satisfaction as measured by patient satisfaction scores on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). The Spanish-speaking nurses participated in an eight-week English mentor group program in teams of three to five members. In these teams, the mentees received support from English speaking and experienced mentor nurses to improve their skills in communicating with patients. Representative samples of the nurses’ patients were surveyed before and after the intervention using the HCAHPS survey (Appendix E). Through these surveys, the project was determined the effectiveness of the mentoring program for the nurses’ communication skills, as measured by patient satisfaction levels reported on the HCAHPS. The remaining sections of this paper discuss the significance of the practice problem, explain the question that guided the project, and synthesize existing literature. Then it outlines the purpose and setting of the project discussing the implementation, outcomes and evaluation of the intervention. The study concludes with the purpose and setting of the project discussing implementation outcomes and evaluation.
Significance of the Practice Problem
The primary problem to patient satisfaction decline at Southeastern Hospital (PHE) is that many Spanish-speaking nurses struggle to communicate effectively with patients as evidenced by the poor HCAHPS results. The result is poor patient satisfaction, low levels of employee morale, and a high rate of attrition among Spanish speaking nurses. The problem at PHE mirrors those encountered in hospitals across the United States and other developed nations (Kalavana, 2014; Mazurenko & Menachemi, 2015; Moore et al., 2013). Specifically, the study indicated that communication is vital to all types of nursing activities, from preventive care and therapy to patient education and health promotion (McCaffrey et al., 2012). Ineffective communication skills negatively influence patient satisfaction as measured by HCAHPS scores (Crawford & Candlin, 2012; Mazurenko & Menachemi, 2015).
This problem is particularly significant in light of the number of Spanish speaking and other English as Alternative Language (EAL) nurses working across the United States and in other countries (Health Workforce Australia, 2012; Schumacher, 2011; Xu, 2012). Recognizing this issue, has implemented various systems to ensure that incoming nurses are able to practice nursing effectively. One such system is mandatory English language proficiency testing, such as through the international English language testing system, which administers TOEFL (Xu, 2012). Many hospitals including PHE screen nursing applicants for English language proficiency to ensure that they are able to communicate effectively with patients (Xu, 2012).
However, problems often persist in spite of screening for English proficiency. In particular, tests such as TOEFL do not assess cultural confidence and other communication skills needed to perform well in clinical situations (Lum et al., 2014; Royal College of Nursing, 2014). According to Lum et al. (2014), language skills beyond the ability to read and write in English are critical in the nursing context. Nurses must also possess the social and clinical competency to engage in discussion with patients and colleagues, understand and use culturally-bound idiomatic expressions, and interact successfully with jokes, sarcasm, euphemisms, and even non-verbal communication (Edgecombe, Jennings, & Bowden, 2013; Kawa, 2009; Lum et al., 2014). Spanish speaking nurses at Southeastern Hospital struggle to communicate effectively in these ways. Cultural confidence as demonstrated by the ability to comprehend and comply with expectations is also important, and one study set in the United Kingdom indicated that EAL nurses who passed tests certifying their fluency in English still felt that they did not have the appropriate language skills to work effectively a clinical setting (Stephenson, 2014). This lack of confidence exacerbates difficulties in communication, as nurses who feel unsure of their language abilities seek out fewer professional development opportunities (Terry, Carr, & Williams, 2013).
Because of the need for linguistic competence and confidence not adequately assessed by English language examinations, effective nursing curricula must provide Spanish speaking and other EAL nurses with the opportunity to develop English language fluency in conjunction with the specific communication skills a quality healthcare professional should have (Choi, 2005; Hansen & Beaver, 2012). However, according to Primeau, Champagne, and Lavoie-Tremblay (2014), very few guidelines have been developed concerning the best practices that can help address the linguistic plight of EAL nurses. The intervention proposed in this study offered an opportunity for Spanish speaking nurses at Southeastern Hospital in El Paso, Texas to develop improved patient communication skills under the guidance of a mentor nurse in the interest of improving patient satisfaction via HCAPS scores.
To guide the study, the following Population, Intervention, Comparison, Outcome and Time (PICOT) question is proposed: Does providing an English mentor group for Spanish speaking nurses working in the telemetry unit at the Hospitals of a Southeastern Hospital improve communication with patients as compared to not providing an English mentor group?
The practice problem is that Spanish speaking nurses at Southeastern Hospital often struggle to communicate with patients, resulting in decreases in patient satisfaction as measured by the HCAHPS. This communication problem is common at other hospitals where large percentages of nurses do not speak English as their first language (Allan & Larsen, 2003; Mazurenko & Menachemi, 2015; Moyce, Lash, & de Leon Siantz, 2015; Staples, 2015). These struggles take place in a context of shifting nursing demographics. Developed countries such as the United States witness shortfalls in nursing staff that are being filled by Spanish speaking and other EAL nurses who have emigrated from developing nations (Health Workforce Australia, 2012; Schumacher, 2011). Despite many cases passing tests affirming their proficiency in English (Xu, 2012), the Spanish-speaking nurses struggle to speak clearly with nuanced language abilities (Staples, 2015). A recent study on the relationship between EAL nurses and patient satisfaction indicated that perceived issues with communication are largely responsible for patients’ general dissatisfaction with their hospital care (Mazurenko & Menachemi, 2015). Specifically, four of the six lowest scores correlating with the presence of these nurses involve patients’ satisfaction with communication with nurses and other hospital workers. These scores are particularly low for units at Southeastern Hospital with large percentages of Spanish speaking nurses as indicated on the HCAHP results (Appendix E)
The practice change was an eight-week English mentor group program for Spanish speaking nurses to improve their patient communication skills, with the hopes of increasing patient satisfaction.
1. Population: The population is Spanish-speaking nurses at Southeastern Hospital in El Paso, Texas.
2. Intervention: The intervention is an eight-week English mentor group program for Spanish speaking nurses to improve their patient communication skills in order to increase patient satisfaction scores.
3. Comparison: The comparison is the absence of an eight-week English mentor group program for Spanish speaking nurses to improve their patient communication skills.
4. Outcome: The outcome is that Spanish speaking nurses who participate in the eight-week English mentor group program will communicate more effectively with patients, leading to higher post-intervention levels of patient satisfaction as measured by the HCAHPS. These post-intervention scores will be compared with the baseline scores generated by a pre-intervention administration of the HCAHPS.
5. Time: The time for the intervention is eight weeks.
Studies have indicated that all practicing healthcare providers need to be able to communicate effectively with their colleagues and patients to ensure proper care of their patients (Moore et al., 2013; Trevino & Prigerson, 2014). In particular, better communication between health professionals and patients not only leads to high quality patient outcomes; this also reduces costly and unnecessary tests and services through averting miscommunication and misunderstandings (Kalavana, 2014). Kalavana (2014) claim that nurses’ communication skills can be one of the most significant factors shaping patient satisfaction levels, (Mazurenko & Menachemi, 2015). In addition, studies have indicated that communication is a vital element in all types of nursing activities, including: preventive care, therapy, treatment, rehabilitation, and education and health promotion (McCaffrey et al., 2012; Nørgaard, Kofoed, Ohm Kyvik, & Ammentorp, 2012). Linguistic competence is particularly essential, especially for Spanish speaking and other EAL nurses who seek employment as registered nurses in their host countries. If nurses lack this competence, social misunderstandings and miscommunication may arise, potentially leading to negative patient outcomes not following through with patient education (Crawford & Candlin, 2012).
The theoretical framework for this study consisted of two theories. The first, Leininger’s (1992) theory of transcultural nursing, provided a means for understanding the relationships among language, culture, and effective nursing practice. The second theory was Lewin’s (1947) three-step model of change, which described the process by which a status quo was, is disrupted and transformation occurs.
Theory of Transcultural Nursing
Central to the theory of transcultural nursing is the concept of transcultural nursing itself, and Leininger (1995) defined it as follows:
A substantive area of study and practice focused on comparative cultural care (caring) values, beliefs, and practices of individuals or groups of similar or different cultures with the goal of providing culture-specific and universal nursing care practices in promoting health or well-being or to help people to face unfavorable human conditions, illness, or death in culturally meaningful ways. (p. 75)
In asserting the central importance of culture in nursing care, Leininger’s (1992) theory is premised on several concepts. The most foundational of these ideas is that culture influences all aspects of a person’s life and creates the lenses through which individuals view experiences. As a result, it provides the most important window through which human behavior can be understood. To be effective, nurses must demonstrate cultural competence, or cultural congruency, in their practice (Leininger, 1992). In short, effective nurses understand the cultures of their patients and respond in culturally aligned ways.
This conception of effectiveness presupposes that the primary function of a nurse is to care for patients, and that care finds expression through care modalities (Leininger, 1992). The first of these is preservation and/or maintenance, where the nurse acts without judgment and out of an understanding of the need to preserve the patient’s care beliefs and values, regardless of the culture from which the beliefs and values originate. The second care modality involves cultural care accommodation and negotiation. Using this modality involves acting to encourage patient adaptation to another culture for the purposes of positive health outcomes. Cultural care re-patterning or restructuring characterizes the third modality, and here the nurse acts to effect change in the patient’s culture so as to achieve benefits inaccessible otherwise. In each of these modalities, the aim is a positive outcome for the patient, and the aim is achieved is through decisions and actions guided by care (Leininger, 1992).
Utilizing the theory of transcultural nursing, Spangler (1992) found Filipino American EAL nurses were able to ensure cultural care congruence through the preservation of generic care values and practices, accommodation of the United States culture’s professional values and practices, and the restructuring of less serviceable values. This study made use of Leininger’s theory as a means of understanding the importance of cultural English language ability.
At Southeastern Hospital, Spanish-speaking nurses do not share a culture with many of their patients and they struggle to communicate effectively with them. This lack of cultural congruence and competence makes relating to patients more difficult. Patient satisfaction and health outcomes are compromised (Kalavana, 2014; Moore et al., 2013). Language ability is difficult to measure adequately with existing assessments. Effective communication relies on skills not measured by those examinations: an understanding of culture and the culturally influenced ways, such as sarcasm and euphemism, in which people communicate (Lum et al., 2014; Royal College of Nursing, 2014). As such, EAL nurses who have passed these tests may not possess the cultural knowledge necessary to nurse in culturally aligned ways and to maximize patient outcomes and satisfaction.
Three-Step Model of Change
Lewin’s (1947) three-step model of change comprised another part of the theoretical framework for this change project. According to Lewin (1947), change and the status quo that precedes it necessarily occur in a field, or a reality that is composed of a series of forces. These forces complexly influence individuals and the cultural and institutional groups in which they operate. The first step of the process of change involves a change in this field, or in the equilibrium that leaves the field relatively undisturbed. This change, called unfreezing, often requires a kind of emotional response, or catharsis, to break the shell that maintains the equilibrium (Lewin, 1947). The implication here is that strong forces maintain the status quo, and that powerful feelings are uniquely capable of destroying them. In the second stage, moving occurs, and because the field has been disturbed, the changes involved may be unpredictable and unsustainable (Lewin, 1947). Refreezing characterizes the third and final stage, and as its name suggests, this phase involves the re-establishment of a new equilibrium within the field (Lewin, 1947). Importantly, this refreezing is initially fragile, as the movement of forces elsewhere in the field threatens to disrupt the new equilibrium. As such, changes at the individual level and group level are needed to sustain the new status quo achieved through moving.
Lewin’s (1947) change model guided this project, which involved the implementation of an English mentor group program for Spanish speaking nurses working in the 30-bed cardiac telemetry unit at a Southeastern Hospital for eight weeks. The problem motivating the study was that patient satisfaction rates are negatively correlated with the presence of Spanish speaking nurses at Southeastern Hospital. This problem of poor patient satisfaction is common in situations where cultural incongruence results from language differences (Mazurenko & Menachemi, 2015). The purpose of the intervention was is to help the Spanish speaking mentee nurses at Southeastern Hospital communicate more effectively with their patients, ideally increasing patient satisfaction measured by the HCAHPS. The three steps of unfreezing, moving, and refreezing was created by the intervention, which aimed to effect lasting change in nurse communication and patient satisfaction.
Synthesis of the Literature
A large and increasing percentage of nurses at Southeastern Hospital speak Spanish as their first language, and this trend mirrors one in the rest of the United States. For instance, in 2008, internationally educated nurses, many of whom speak Spanish primarily, comprised approximately 13% of nurses receiving licensure (Schumacher, 2011). This increase results from a general shortage of nurses across the developed world, which has intensified in recent years and appears likely to continue (Health Workforce Australia, 2012; Schumacher, 2011). In Australia, it is projected that 109,000 more nurses will be needed than are available by 2025, and the result is an influx of nurses educated in China (Health Workforce Australia, 2012). At Southeastern Hospital, nurses who speak Spanish have filled the shortage. Unfortunately, the tests currently used to assess nurses’ language ability do not sufficiently measure all the nuances of effective communication in English (Lum et al., 2014; Royal College of Nursing, 2012). However, effective communication is necessary for positive patient outcomes and satisfaction, both directly and through rapport with colleagues (Crawford & Candlin, 2012; Kalavana, 2014).
Because of the very clear need for effective language education for Spanish speaking and other EAL nurses, many transitional educational programs are offered by host countries in the developed world (Xu, 2012). However, many of these programs do not utilize evidence-based approaches and are generally understudied in terms of their effectiveness (Allan & Larsen, 2003). This situation persists despite research on effective pedagogy for nurses learning English for use in clinical settings (Hansen & Beaver, 2012). In a review of the literature, Hansen and Beaver (2012) used existing research to recommend a number of effective practices, including the use of checklists to organize patient information, role-playing, and the utilization of peer mentors who speak English for modeling, support, and feedback.
Insufficient Language Proficiency
Moyce et al. (2015) conducted a systematic review of the literature focusing on the migration- and acculturation-related lived experiences of 44 internationally educated nurses, many of whom speak English as an alternative language. The researchers found that one of the most significant problems that nurses face in their host country is the language barrier. However, language education alone may not be enough. O’Neill (2011) has argued that developing language proficiency in the classroom is not sufficient to ensure that nurses are effective in clinical settings, particularly as they must make complicated linguistic, cultural and social choices to be successful.
Many EAL nurses are not able to negotiate the transition to English communication on their own, and the result is considerable difficulty in interacting with colleagues and patients (Staples, 2015). For instance, a group of 52 EAL nurses in one study used language marked by significantly less frequent use of English lexico-grammatical features, including past tense and several stance features. The lack of precision that results from difficulties signifying time and likelihood or obligation can cause significant problems in discussing sensitive or nuanced issues with patients (Staples, 2015).
These documented language difficulties are mirrored by perceptions by EAL nurses, their colleagues, and patients that communication is at times difficult. A study of EAL nurses in the UK revealed that they struggled with colloquialisms and felt that they could not communicate effectively as a result (Allan & Larsen, 2003). A similar problem attends accents, even when nurses do exhibit greater mastery over the nuances of expression in English. A recent and large-scale study conducted by Wagner, Brush, Castle, Eaton, and Capezuti (2015) sampled 1,629 nurses across 98 nursing homes in five different states in the United States. Results indicated EAL nurses, English speaking nurses, physicians, patients, and their family members to cause difficulties in communication perceived accent differences. Thoughtfully then, did this lead to decreased patient satisfaction, decreased learning, and poor communication?
Communication difficulties stem from a lack of language proficiency and differing accents, and one of the results of this problem involves the jobs that EAL nurses are able to access (Salami & Nelson, 2014). Specifically, rather than seeking and gaining employment commensurate with their education, many nurses work as healthcare assistants, since this position is seen as more practical (Salami & Nelson, 2014; Stephenson, 2014). However, being relegated by choice or necessity to these positions limits the mobility of EAL nurses.