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Improving Intercultural Staff Communication in the Long-Term Care Setting
We speak English too,” a Nigerian certified nursing assistant (CNA) bemoans in a candid conversation about the ongoing communication problems in the nursing facility where she works. “We’re from Africa, where we talk British English,” she says, and cites instances in which coworkers and patients have asked her to “Please speak English” on the floor.
Why is a woman who speaks English having difficulty communicating with her English-speaking coworkers? This incident and many like it were relayed to our research team as part of a study on intercultural communication.1 More than 100 providers participated in a series of focus groups, which included managers, nurses, and CNAs from 10 long-term care nursing facilities across eastern Massachusetts. In Massachusetts and across the country, the demographics of the health care industry are becoming increasingly diverse. Between 2000 and 2020, the percentage of total patient-care hours physicians spend with patients from minority groups will rise from approximately 31% to 40%.2 By 2050, the U.S. minority population age 65 years and over is expected to have increased by almost 20%.3 In addition to changes in the patient population, the health care workforce also will become increasingly diverse.
During the 1990s, immigrant employment grew by 114% in home healthcare, 72% in nursing care facilities, and 32% in hospitals.4 In our study, approximately 46% of the staff were immigrants. The targeting of immigrants for nursing careers may substantially increase as nursing shortages continue to worsen.5 Each immigrant hire brings a new set of customs, languages, and stereotypes into the facility, as well as a new set of integration challenges. The changing demographics raise interesting questions of how well the nursing facilities are operating in the face of growing diversity.6-8 Our study asked managers, nurses, and CNAs about the communication problems at their facilities, and what they believed the precipitating factors to be. All of the facilities had adopted English-only policies that restricted the use of non-English languages to break rooms and other private areas. (Note: The rationale for these policies was to limit the potential confusion that English-speaking residents might experience if their caregivers were speaking a foreign language during their care.) In facilities that are essentially “English-only” zones, what are the remaining communications breakdowns?
SUBTLE COMMUNICATIONS DIFFICULTIES
As expected, there were reports of non-native English speakers struggling to translate their words into English. However, new employees with serious fluency difficulties would have been screened out through either the written application or the interview process. As a result, most current staff members did possess a basic command of the English language, so direct translation was not always the most pressing problem. Instead, our focus groups revealed more subtle communications difficulties that would present interesting staff development challenges. The areas identified were:
Accents: Many staff members complained that thick accents made it difficult for staff to understand each other, even though both speakers may have been speaking English. This was also true for residents. Residents who were ill or hearing-impaired had particular difficulties understanding a staff member with a thick accent. In one discussion group, a nurse reported, “That’s the biggest complaint that we hear from residents and family—that they don’t understand the nursing assistant. They’ll say that the nursing assistants are speaking a different language, when in fact their accent is so thick it does sound like they’re speaking in a different language.”
Tone: Remember the old adage, “It’s not what you say but how you say it.” While most workers know this to be true, many have difficulty following this advice. In a fast-paced, often chaotic healthcare environment, it is easy to fall into the mindset of barking orders. Most workers understand the stress, but that doesn’t mean that tone is overlooked. One CNA complained of the nurse manager who frequently greeted her assistants by yelling, “What!”
Medical Terminology and Technical Jargon: One of the challenges of the healthcare environment is the amount of technical jargon and acronyms that are part of the everyday lexicon. Even native English speakers will struggle to learn the names of medical equipment, diagnostic tests, and paperwork forms. This can be particularly true of new employees who haven’t had enough time to learn the specific terminology.
Body Language: Researchers tell us that 55-70% of communication is conveyed through body language.9 When two people are having difficulty communicating verbally, their reliance on body language may be even greater. However, body language is subject to cultural influence as much as language is. All levels of staff reported that misunderstandings on the floor frequently arose from a misread of body language. For example, eye contact was repeatedly cited as a source of frustration and confusion. In some cultures, direct eye contact is a sign that you respect the speaker; in other cultures, direct eye contact would be considered rude behavior toward the speaker.
Speaking Volume: Related to tone and accents, the volume of a voice can complicate simple communication. Speaking softly can convey respect, but it can also make the deciphering of words difficult. Speaking loudly is easier to hear, but can sometimes come across as rude or aggressive. The norms governing volume of speech can vary by culture.
Jumping to Conclusions: We heard many CNAs complain that their supervisors often assumed that they knew what a CNA was trying to communicate even before the CNA had finished talking. Consequently, the CNAs were often interrupted mid-sentence with the answer to a question that they were not even asking. In these instances, many CNAs felt disrespected by their supervisors and had concerns about the lasting effect on quality of care.
Regional Expressions/Idioms: In some parts of the country, a person drinks “soda,” and in others a person drinks “pop.” For non-native English speakers, the interchange of English expressions adds another layer of confusion. One of the nurse managers interviewed for our study discussed the confusion that arose from a request for “washcloth” versus a “face towel.” The responding CNA had no idea that the two items were the same, and this confusion created a long delay to a relatively easy resident request.
Differences in Assertiveness: In our conversations with nurse managers, we frequently heard expectations that staff would “speak up” if there were a problem in the workplace. Consequently, managers assumed that if they didn’t hear complaints from their staff, the staff was happy. Yet we learned in our follow-up conversations with their staff that this was not always the case. Whether or not staff members felt comfortable voicing their complaints or standing up for themselves varied greatly by culture. Many CNAs came from a culture of silence in which it was unacceptable or even dangerous to speak out against a problem. As one CNA reported about her teammates, “Nobody [is] going to say anything because nobody wants to get fired. Everybody wants to keep their job.” As a consequence of this, we found CNAs who had endured systematic verbal and physical abuse from residents without ever bringing the incidents to management’s attention.
POTENTIAL STRATEGIES FOR IMPROVEMENT
These reports to our research staff revealed that improving intercultural communication is a tremendous staff development challenge. As the healthcare workforce and resident population continues to diversify, staff will increasingly require long-term improvement strategies. We asked managers, nurses, and CNAs about communications strategies that had worked for them in the past or that they thought might work in the future. The conversations revealed that there were lots of strategies being tried at both facility and individual levels. While our study design could not evaluate the success of each suggestion, we did collect information about a number of strategies that warrant further consideration:
ESL Classes: ESL classes were already offered in all of the facilities we interviewed. Although ESL participation will not solve all intercultural communication problems, the classes are a good option for employees who need to improve basic English-language skills. When combined with additional communications strategies, their effect may be even greater. Staff developers may want to spend time searching for ESL classes that have been specialized for workers in medical facilities. Such classes offer students the opportunity to practice general communication skills, as well as using medical terminology, or “medspeak.”
Cultural Competence Training: The goal of a cultural competency program is to make the participants aware of their own cultural assumptions and to generate awareness of the cultural assumptions of others. An effective training can aid communication by targeting issues related to cultural customs and practices, the use of body language, and the cultural norms pertaining to conflict resolution.
Visual Aids: Many facilities have visual aids available to communicate with residents who are hearing-impaired or whose primary language is not English. For example, many facilities used index cards with pictorial representations of common objects and daily procedures. The pictures may also have contained captions translated into several languages. These same types of materials could be used or modified to help communicate with a diverse staff.
Translation of Written Materials: Several staff members reported in our focus groups that forms, memorandums, and written instructions were some of their biggest communication challenges. Does your facility have the resources to translate some of these materials into other languages? Facilities may already have translators available in-house who would appreciate the opportunity to assist their colleagues from their native country.
Pairing with Mentors: Identify the staff members who are strong communicators and are fluent in foreign languages. These staff members are a great internal resource for facilities and could assist in training new employees. The benefits of mentoring are twofold. Mentors are recognized for their contributions to the organization and are provided a leadership role. New employees may be more comfortable having a mentor from a similar culture orient them to the facility.
Making a Group Time Commitment: Employees need to make a significant time commitment to improve communication with their peers. This can be formally managed by scheduling (and keeping!) meetings to share ideas, to problem-solve, or just to commiserate with teammates. Informal meetings over lunch or a coffee break can also be effective ways to connect with coworkers.
Making an Individual Time Commitment: Beyond group meetings, staff need to make efforts on an individual level. Managers should spend the extra time it takes listening to coworkers from start to finish. In our focus groups, managers admitted to frequently interrupting their staff when they could not follow the employee’s chain of logic. Instead of cutting off an employee to save time, investing the additional seconds it takes to let the employee finish likely will be more productive. Another suggestion from managers was to spend extra time repeating instructions, and then having the employee repeat them as well. Managers found that they actually saved time by talking slowly, repeating their directions, and then having the employee say the directions in his/her own words to reinforce them. The extra seconds spent up front went a long way in reducing the subsequent time spent on correcting communications problems. These options offer nursing facilities strategies to begin the long-term process of improving organizational intercultural communication. We expect that the list will continue to grow as more facilities are faced with the challenges of a diversifying workforce and patient population. None of the solutions described can solve all of the communications problems we encountered in our study; rather, several tactics need to be coordinated in a comprehensive problem-solving response.
A UNIVERSAL CHALLENGE
If there was one common theme throughout all of our conversations it is that all of the nursing facilities were facing the same challenges. Given this, facilities may want to join together to innovate and implement solutions. Lessons learned in one facility may benefit another facility. Trainings and classes can be made more affordable if the costs are shared across facilities. For example, several facilities in the same geographic region had pooled resources for shared professional development activities. As a consortium, they partnered with a local community college for assistance with CNA training. In a final bit of irony, improved communication across facilities may be a key contributor to improving communication within a facility.
This research reported in this article was supported by the Better Jobs, Better Care grants program with funding by The Robert Wood Johnson Foundation and The Atlantic Philanthropies.
