Assessing English language skills of internationally qualified nurses in New Zealand

About the author: Jenny Wraight, RN, BN, MNSc, PGCert ClinEd, is a nursing tutor and clinical educator at Nelson Marlborough Institute of Technology, Nelson, New Zealand. Her correspondence address is [email protected]

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Key words

internationally qualified nurses, clinical communication, English as an additional language, communication assessment

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Aim

Clinical communication assessment guidelines (San Miguel & Rogan, 2015) were developed in Australia to assess nursing students’ English language proficiency. Nurse educators at Nelson Marlborough Institute of Technology adapted these guidelines for New Zealand use, calling them the clinical communication assessment framework (CCAF). The purpose of this framework was to assess the English language proficiency of nurses with English as an additional language (EAL) in the clinical nursing environment. This research reports on an assessment of nurses using this framework, performed before the competency assessment programme (CAP) four-week clinical nursing placement. It describes the first application of this clinical communication assessment tool in New Zealand.

Background

Shifting global demographics are resulting in large numbers of internationally qualified nurses (IQNs) with EAL working in English-speaking countries such as New Zealand (Habermann & Stagge, 2010; Jones & Sherwood, 2014). Out of 49,933 practising registered nurses on the New Zealand register, 27 percent had received their initial training overseas (Nursing Council of New Zealand, 2018). The clinically-focused English language ability of IQNs remains a concern (Bland, Oakley, Earl, & Lichtwark, 2011; Meek, 2015; Olson, 2012; Philip, Manias, & Woodward-Kron, 2015; San Miguel & Rogan, 2015). This concern remains, despite these nurses passing English language competency tests such as the International English language testing system (IELTS) or the Occupational English Test (OET) (O’Neill, Buckendahl, Plake, & Taylor, 2007; Shen et al, 2012). These tests are used internationally and are required by the Nursing Council of New Zealand (Nursing Council) for entry to nursing programmes such as CAP, at NMIT (Nursing Council of New Zealand, 2011).

IELTS assesses the IQN’s basic, generic English language skills, as opposed to comprehensive nursing-focused clinical communication (Ho, 2015; Lu & Maithus, 2012; O’Neill et al., 2007). The Nursing Council requires IQNs to have an OET score of B, or IELTS of 7, over three test sittings. NMIT requires the same level for OET and IELTS; however the IQN candidate must achieve these grades in one sitting (Nelson Marlborough Institute of Technology, 2019). IELTS is more commonly used by IQNs as the entry English test, as it is less expensive, is recognised internationally and is more accessible as it is held more often than OET and is available in IQNs’ countries of origin (Rumsey, Thiessen, Buchan, & Daly, 2016). OET focuses more on simulating the professional context, and is recognised as a language test for overseas-qualified health professionals (Lynch, 2016). However, an OET-IELTS benchmarking report identified discrepancies between the two tests, with some students passing the OET and failing IELTS, and others doing the opposite (Elder, 2007), leading some researchers to question the appropriateness of these English language tests as tools to prepare IQNs for registration (Sedgwick & Garner, 2017).

Clinical educators and nursing assessors at NMIT have reported that CAP students with EAL struggle with communication during clinical placements. This deficiency meant IQNs with EAL needed to be given extra clinical time (Riden, Jacobs, & Marshall, 2014) to ensure they were able to communicate effectively in English in clinical situations (Nursing Council of New Zealand, 2011). No clinical communication assessment tool is used in New Zealand nursing education. NMIT nursing educators developed the CCAF by identifying an Australian tool for assessing clinical English language ability (San Miguel & Rogan, 2015) and adapting it for use in New Zealand. This pilot study was conducted to evaluate the suitability of this new framework for determining IQNs’ communication abilities.

Methods

Ethical approval was obtained from the NMIT research and ethics committee and informed consent obtained from each participant. Inclusion criteria were that the participant:

1) had English as an additional language,
2) was an IQN,
3) had passed IELTS or OET, and
4) was a student on CAP at NMIT.

Before doing CAP clinical placements, participants were assessed by a nursing assessor, using the CCAF, at five objective simulated clinical assessment (OSCA) stations. This assessment involved the participant performing the required clinical assessments while communicating with a “patient” (an OSCA volunteer). Scores – “unsatisfactory” , “needs development” or “satisfactory” – were recorded for spoken English, vocabulary, pronunciation, asking for clarification and demonstrating understanding. An aggregate clinical communication score was calculated.

Findings

Participants, all from the same CAP course, consisted of nurses from the Philippines (n=6) and India (n=4). These nurses had 5.2 ± 0.5 years of experience of nursing in their country of origin, and 1.8 ± 0.4 years of experience using English as a language when nursing (all data are reported average ± SEM – the standard error of the mean). Of these 10 participants, 25 percent scored “unsatisfactory”, 30 percent “needed development” and 45 percent scored a “satisfactory” standard of clinical communication. While no correlation was found between participants’ years of nursing experience and their aggregate clinical communication score (R=.48; P=.16), a significant positive correlation was identified between years of nursing using English and aggregate clinical score (R=.68; P=.032). This finding suggests the first years of nursing in an English-language environment facilitate critical communication growth, allowing IQNs to be effective nurses (Crawford & Candlin, 2013; O’Neill et al, 2007). Students achieving an “unsatisfactory” mark were given additional clinical communication training by the CAP nurse lecturer. The strategies outlined by San Miguel and Rogan (2015) – such as asking students to give a patient hand-over, or to practise talking to patients while carrying out a skill – were used to ensure they received suitable support to improve their clinical communication skills. The CAP students who received additional training were reassessed, and, before placement in the clinical environment, all scored above the “unsatisfactory” level.

Conclusion

English language proficiency is required for IQNs to achieve Nursing Council registration (Nursing Council of New Zealand, 2011). Despite all participants in this study passing IELTS, some required additional English-language training before starting their CAP clinical placement. The CCAF assessment tool, adapted from the San Miguel and Rogan (2015) guideline, allowed easy identification of the specific clinical English-language training needs of IQNs, to ensure their success in the clinical environment, beyond the minimal requirements for registration. This research was conducted as a pilot study in a simulated environment, to assess the usability of the CCAF with IQNs who identify as EAL students in the CAP course. Further research assessing larger numbers of nurses from more diverse language backgrounds will determine the broader applicability of the CCAF to assess IQNs who have English as an additional language.

Recommendations

The CCAF is a promising tool to identify IQNs requiring additional English language training before clinical placement. Due to the initial success of its use, NMIT has integrated this assessment tool into the OSCA and the clinical curriculum for all IQNs who have EAL. This change provides a consistent method of assessing clinical English language proficiency, and efficient use of resources to provide additional training when required to prepare IQNs for clinical placement. Subsequent work will compare the CCAF and clinical communication in greater detail through a larger cohort of approximately 45 IQNs. The CCAF is a practical, efficient and straightforward tool that can be integrated into both simulated and clinical environments to assess the clinical English-language ability of IQNs.

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