Empirical evidence reveals that linguistic barriers between nurse and patient can lead to discrimination that compromises care.1 A collaborative communication role-playing activity was created involving freshmen nursing students, in their first professional nursing course, and freshmen international students from the English as a second language (ESL) program. The goal was to create a practical application of communication skills learned in each setting.

International ESL students in this program of study focus on reading, writing, listening, speaking, and conversing for advanced beginner through intermediate levels. The ESL students and their instructors sought opportunities to interact with native English speakers. These ESL students found it challenging to socialize outside the classroom. By isolating themselves, the ESL students were unable to test their communication skills with their English-speaking peers.

Freshmen nursing students have little experience with therapeutic communication at this point in the curriculum. The first nursing course, professional practice in health and illness, is designed for students to learn about themselves as health care providers and gain respect for patients. Nursing students analyze the health care delivery system, gain awareness of cultural differences, and learn about their role as professional caregivers.

Nursing student preparation for this role-playing activity included a lecture and films about therapeutic communication and cultural sensitivity. The nursing students were taught basic therapeutic communication interviewing techniques: asking focused questions, sharing observations, providing information, and using silence to enhance the communication pathway. Several negative techniques were also explored: asking why, failing to listen, giving opinions, relying on stereotyped responses, and showing inappropriate approval or disapproval.

Nursing students learn that body language is important and can affect how a message is interpreted. Traditionally, nursing students have difficulty transforming their communication style from a social interaction to a therapeutic communication. This is especially challenging when the patient is from a different background where cultural and language barriers may exist.2

Carnevale et al1 examined ethical considerations in ESL communication in nursing. They identified 5 norms: (a) respect for the patient as a unique individual, (b) respect for each patient's right to self-determination, (c) respect for patient confidentiality, (d) responsibility for one's own judgment and action, and (e) accepting responsibility to better meet the needs of patients, families, and groups.1

Activity Description

Three role-playing scenarios were created. Each role-playing activity involved 2 nursing students and 1 ESL student. Nursing roles consisted of an interviewer and a process recorder, and students rotated roles within their group. Three role-playing activities were conducted during one 2-hour class; the role-play scenario was conducted twice to ensure that each nursing student participated in each role. Nursing students and ESL students prepared individually before enacting their roles. The ESL students discussed the importance of empathy in nursing, explored the illnesses that they were to portray, practiced each scenario, and were prepared to observe the degree of empathy and patience that the nursing students displayed. Nursing students were expected to apply therapeutic communication skills, use good interviewing techniques such as speaking slowly and clearly to their ESL peers, and use empathy and nonverbal communication skills. When therapeutic communication skills were displayed by a nursing student, the ESL students were encouraged to cooperate. But if the nursing students spoke too quickly or lacked empathy, the ESL students were prepared to state "I do not understand" and refuse to disclose any more assessment information.

Nursing students formally introduced themselves to the ESL student and escorted the ESL student to an interview desk within the classroom setting. This formal introduction process proved effective as an icebreaker for all students.3 Each ESL student was seated with 2 nursing students, 1 as the interviewer and the other as the recorder. The interviewer questioned the ESL student about the chief complaint, whereas the recorder noted the techniques used by the nursing student. Both the ESL student and the nursing students seemed to become more confident as they repeated the interactions.

The nursing students considered this a positive experience: "This was helpful because it will prepare us for real-life situations." Many nursing students acknowledged that nonverbal techniques were helpful when trying to communicate across language barriers, "It is our role to be patient and work with [non-English speakers] in various ways-talking slowly, using hand and face gestures, and staying calm. These are good ways to clarify and communicate effectively with people no matter their background and language."

Discussion

Role-playing was designed to be mutually beneficial for both nursing and ESL students. It was structured to enable both groups to practice communication skills. The ESL students were to improve their English-speaking skills, and the nursing students were to practice therapeutic communication skills while attempting to understand cultural differences. Thus, the activity helped both groups practice their communications skills and understand the importance of cultural awareness in the clinical setting.

In this role-playing activity, nursing and ESL students encountered circumstances that they might someday experience. Nursing students were expected to put into practice therapeutic communication techniques and learn, first hand, how body language might help patients feel more comfortable.4 This role-play activity could help all nursing students with future challenges where cultural and language barriers exist. Failure in this regard could result in misdiagnosis and inadequate patient understanding of treatment plans.1

The language barrier can be viewed as a communication dilemma that nurses may experience when they encounter patients whose culture and speech differ from their own and can often lead to "insufficient information and poor quality nursing care."3 Nursing students should learn about language barriers before they enter their first clinical practicum and should also be taught about diverse cultures within the populations that they will serve.

References