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 Table of Contents  
Year : 2021  |  Volume : 41  |  Issue : 2  |  Page : 58-67

The clinical english communication situations and the requirement of nursing staff on improving their clinical english communication abilities

1 Department of Nursing, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC, Taiwan
2 School of Nursing, National Defense Medical Center, Taipei, Taiwan, ROC, Taiwan
3 Department of Health and Leisure Management, Yuanpei University of Medical Technology, Taipei, Taiwan, ROC, Taiwan
4 Department and Graduate Institute of Biology and Anatomy, National Defense Medical Center, Taipei, Taiwan, ROC, Taiwan
5 Department of Nursing, Songshan Branch, Tri-service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC, Taiwan
6 Department of Nursing, Taoyuan Armed Forces General Hospital; Department of Nursing, Beitou Branch, Tri-service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC, Taiwan

Date of Submission02-Apr-2019
Date of Decision03-Oct-2019
Date of Acceptance22-Oct-2019
Date of Web Publication12-Sep-2020

Correspondence Address:
Ms. Chia-I Hung
RN, Taoyuan Armed Forces General Hospital. No. 168, Zhongxing Road, Longtan District, Taoyuan City; Beitou Branch, Tri-service General Hospital, National Defense Medical Center. No. 60, Xinmin Road, Beitou District, Taipei City
Ms. Pei-Ying Kung
RN, MS, Head Nurse of Songshan Branch, Tri-service General Hospital, National Defense Medical Center. No. 131, Jiankang Road, Songshan District, Taipei City
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmedsci.jmedsci_68_19

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Background: Due to globalization, the frequency to stay in other countries has increased, resulting in more chances to nursing staff to communicate with foreign patients in English. However, English is not the native language in many countries, including Taiwan. Many nurses cannot communicate with foreign patients efficiently. Aim: This study aimed to identify the clinical English Communication Abilities of nurses and their willingness and requirements to improve, negative communication situations, and their influential factors. Methods: A questionnaire to conduct a descriptive, exploratory, cross-sectional survey was applied to 273 clinical nurses at a teaching hospital in Taiwan. Results: Most nurses stated that their English Communication Abilities was insufficient to cope with clinical requirements and were willing to improve this ability. In negative communication situations, the major problems included the nurses felt that they had to spend more time, were more stressed, and were not able to perform at a professional level when interacting with foreign patients, which would reduce interaction with patients. The factors that impact these problems include frequency of self-study and clinical English communicative abilities. English handout containing hygiene instructions was considered the most useful resource to facilitate clinical English conversation. Conclusions: Inadequate English Communication Abilities results in more time spent when communicating with foreign patients. Nurses who have better English Communication Abilities or have set hours for studying English may reduce the frequency of negative situations while communicating in English. Periodical advanced study of English might reduce the negative situation of nurse–patient communicated in English. To provide high-quality international medical service, the hospital managers have to offer appropriate assist strategies to improve nurses' clinical English communication abilities.

Keywords: Communication, globalization, international medical service, quality of care, nurse education, nurse–patient interaction

How to cite this article:
Wu KH, Tzeng WC, Yang PL, Chen YA, Wang YW, Kung PY, Hung CI. The clinical english communication situations and the requirement of nursing staff on improving their clinical english communication abilities. J Med Sci 2021;41:58-67

How to cite this URL:
Wu KH, Tzeng WC, Yang PL, Chen YA, Wang YW, Kung PY, Hung CI. The clinical english communication situations and the requirement of nursing staff on improving their clinical english communication abilities. J Med Sci [serial online] 2021 [cited 2021 Oct 23];41:58-67. Available from: https://www.jmedscindmc.com/text.asp?2021/41/2/58/294946

  Introduction Top


Good communication abilities can help nurses to better understand patient feelings and health requirements as well as provide them with better nursing services.[1] Through communication, nursing staff provide care instructions, explain medical procedures and nursing treatments, provide care, and support patients as well as perform professional nursing duties.[2] To communicate effectively, nursing staff are required to use correct grammar and wording and to convey understandable information with appropriate methods and attitudes. Patient satisfaction and perceived quality of care are affected by cultural and linguistic barriers.[3]

Effective language communication can reduce the possibilities of medical conflicts that stem from communication barriers.[4] When health-care providers do not understand patients' exact concerns, they often fail to provide correct treatments and recommendations.[5],[6] Therefore, patients may not accept relevant advice and may even be dissatisfied with health-care services.[7] Failure to smoothly communicate with patients and reach an agreement may also cause nurses to be stressed and frustrated or to show indifferent and negative attitudes; in such cases, professional nursing services may not be performed properly.[8],[9]

Increasing globalization has raised the frequency of people moving to other countries to acquire jobs or education. This increases the chances of hospitals to admit international patients. Therefore, nurses may require adequate foreign language abilities.[10],[11] Taiwan is an international country and plays an active role in the global economy and global health. Moreover, high quality and low costs are the defining characteristics of the national health-care system in Taiwan, which attained 87% satisfaction and attracts overseas patients to Taiwan for medical treatments.[12] English is the most widely used international language. However, nurses in Taiwan often lack clinical English Communication Abilities and have difficulties in communicating with foreign patients.[12] It poses a major challenge in providing internationalized medical care services. Because of the language barrier, it may result in poor nurse–patient relationships, to the extent that patients are at risk, lowering patient satisfaction toward medical care.[3],[12]

A nursing project report performed in Taiwan showed that nurses usually experience the following situations when interacting with foreign patients: an inability to understand what patients mean to say; an inability to correctly express themselves in English; fear of speaking in English or being stressed; using single words or incomplete sentences to communicate; or requiring interpretation help from doctors or patients' families/friends.[13] These situations may cause the nursing staff to visit patients less frequently.[14] Approximately 84% of nurses voiced dissatisfaction with their English-speaking abilities and found it difficult to communicate in English.[15] These reports pointed out that clinical nursing staff in Taiwan do not have adequate proficiency in clinical English.


To provide high-quality medical services for foreign patients, it is necessary for nurses to improve their clinical English communication abilities.[1] Hospital managers and educational institutes have the responsibility to improve nurses' clinical English communication abilities (NCECA). However, we found that for the promotion of policies to improve nurses' English communication abilities, there is a lack of relevant research and information regarding the experiences of the clinical nursing staff with respect to communication barriers. This lack of information motivated us to investigate this subject.


We intended to know nurses' clinical English Communication Abilities and their willingness and requirements to improve as well as the negative communication situations and their influential factors.

Relevant information grabs the attention of hospital managers and nursing educational institutes to better understand the difficulties faced by and requirements of nurses when working with foreign patients. We hope that hospital managers and nursing educational institutes can provide appropriate interventions to improve the clinical English communication abilities of nurses by enabling them to provide foreign patients with complete high-quality nursing services.

  Methods Top


This study is a descriptive, exploratory, cross-sectional survey using a self-administered questionnaire which was given to the clinical nursing staff. The structured questionnaire was designed based on relevant references and clinical experiences, and consisted of the following two sections: “basic information” and NCECA and “NCECA and Communication Situations Assessment (CSA).”


The questionnaires were distributed to the clinical nursing staff at a medical center in Taipei, Taiwan. It is a teaching hospital, with 1700 nursing staff. Approximately % of inpatients and outpatients are international patients from Southeast Asia, Europe, America, Australia, and Africa. English is the main language being used when communicating with foreign patients. There is no customized international ward in this hospital; foreign patients are admitted to wards based on their diagnosis. Therefore, participants were recruited from outpatient departments, emergency rooms, operation rooms, gynecology and obstetrics departments, general wards, and intensive care units.


Participants were recruited by using convenience sampling. Clinical nurses with 1-year experience at this hospital were included in the study. The questionnaires with completeness rate <80% were excluded from the study. We analyzed the data of the pilot study by using G-Power 3.1 to determine the sample size. The suggested sample size was 280 (Model: one way ANOVA for F-tests, Effect size f: 0.25, α err probability: 0.05, Power: 0.95, number of variables: 4). Considering the response rate, a total of 300 nurses were recruited.


Basic information

The demographic data included age, gender, years of nursing experience, type of current employer, level of education, and frequency of English study. The clinical data included frequency of English communication with foreign patients, their families, or foreign health-care assistants (HCAs); desired and influential factors; amount of time nurses want to spend studying clinical English dialogs; and resources that nurses want to use to improve NCECA. An 8-item “Resources that nurses want to use to improve NCECA” was used on a Likert 5-point scoring system, with a score of “0” representing “Do not want at all” and “4” representing “Do want very much.”

Nurses' Clinical English Communication Abilities and Communication Situations Assessment

NCECA assessment had an overall total of 20 points, the higher score means better ability. A summation is as follows. (1) Grammar and word usage (8 points): the score in this section is summation of the two scoring items: General English Proficiency Test (GEPT) – full score is 3 points, and NPDT – full score is 5 points. The GEPT is the most popular test in Taiwan and provides institutions or schools with a reference for evaluating the English proficiency levels of their students or staff. That is why we used the GEPT to evaluate grammar and word usage levels for nursing staff. Never having passed the GEPT is a score of 0 point; passing at the elementary level is a score of 1 point; intermediate level is a score of 2 points; and advanced and above is a score of 3 points. However, the GEPT is not focused on clinical medical English, we modified some exercises from a medical English textbook to develop the NPDT. The original scores of NPDT were 0–100, which were converted as follows: 0–5 points (score 0–20à1 point; 21–40à2 points; 41–60à3 points; 61–80à4 points; and 81–100à5 points); (2) English oral speaking (7 points): because a written test does not correspond the English-speaking ability, people with better English-speaking ability can speak fluently and seldom need to rely on body language or ask for interpretation. Therefore, we want to know the main method for nurse–patient communications. The participants decided the main method used when communicating with patients in English. Communicating in fluent English has a score of 4 points; using single words and simple sentences has a score of 3 points; only using single words and body language has a score of 2 points; and asking for interpretation has a score of 1 point. In addition, each of the following option is worth 1 extra point: occasionally or never needing to use body language; occasionally or never need interpretation from colleagues; and occasionally or never using interpretation from patients' families or friends; (3) contextual understanding (5 points): because understanding the meaning expressed by each other is important for effective communication. This section is used to evaluate the intelligibility of communications. Each following option is worth a score of 1 point: (1) patients can always or often understand the meaning expressed by nurses; (2) nurses can always or often understand the meaning expressed by patients; (3) nurses think their English level is always or often good enough to cope with clinical requirements; (4) nurses think their clinical English communication abilities never or occasionally need to be improved; and (5) cultural differences on either side never or occasionally affect communications. The 7-item CSA was used to evaluate the frequencies of negative communication situations and were scored using a 4-point Likert scoring system, in which a score of 1 represents “never” and a score of 4 represents “always.”

Content validity

After the questionnaire design was completed, five experts evaluated its content validity. This group of experts included nursing instructors, experienced clinical nursing experts, and statistics professionals. Based on scores provided by each of the experts, the question would be adopted only if the average score was >3.5 (total score is 4). The average content validity index was 0.87. However, the reliability and validity of them are still unknown.

Pilot study

After some items were amended by experts, thirty clinical nurses were recruited in the pilot study to evaluate the reliability of the questionnaire. The 25-item Cronbach α-coefficient of the questionnaire was 0.86, and the subscales were 0.80, 0.88, and 0.85. The item difficulty of the NPDT was 0.30–0.75, and item discrimination was 0.50–0.90. Item analysis was calculated by SPSS version 22.0 statistics software for Windows (IBM Corp., Armonk, New York, NY, USA).

Ethical considerations

Prior to distribution, the survey was approved by the Tri-Service General Hospital's ethical review board (TSGHIRB-100-05-165). Informed consents were acquired from all the participants. Participants' documents were securely stored in locked locations.

Data collection

The data were collected from November 2012 to August 2013. The researchers explained the purpose of this survey and dispatched questionnaires to voluntary participants in the handover meeting. Participants had 1 week to finish the questionnaire. We prepared two envelopes for every participant. Participants returned informed consent and completed the questionnaire in separately sealed envelopes, which de-linked identifying information to their responses, and placed them in the return box. The researchers then collected the return box 2 weeks later.

Data analysis

The information collected from the questionnaire was entered into a computer and analyzed using SPSS version 22.0 statistics software for Windows (IBM Corp., Armonk, New York, NY, USA). Based on the level of measurements, “Basic information” and the “NCECA and CSA” were analyzed using descriptive statistical analysis. The influential factors of CSA were analyzed by inferential statistical analysis using one-way ANOVA, Scheffe's post hoc analysis, and the Kruskal–Wallis test.

  Results Top

In this study, a total of 300 nurses were approached, 294 questionnaire samples were returned with a response rate of 98%, and 273 valid samples were analyzed after questionnaires with exclusion of several omissions.

Basic information

Most of the participants were female (96.7%) and between the ages of 21 and 35 years (77.7%). The frequency that nurses communicate with foreign patients, families, and HCAs is usually “once per year” or “once per season.” Most nurses (72.%) reported that they do want to use resources provided by the hospital to improve NCECA. [Table 1] shows the detailed data of basic information.
Table 1: Nurses' basic information (n=273)

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The most wanted resources to improve NCECA of nursing staff is a handout of hygiene instructions in English (2.84 ± 1.00, mean score ± standard deviation). The next is getting note cards with common clinical English dialog phrases for reference or assistance when nurses communicate with foreign patients (2.79 ± 0.88). [Table 2] summarizes the other data.
Table 2: Resources that nurses want to use to improve Nurses' Clinical English Communication Abilities

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Nurses' Clinical English Communication Abilities

In the “English grammar and word usage” section, most nurses reported that they had never passed the GEPT (84.6%), with the second most common response being that they had passed the elementary level of the GEPT (8.1%). The average score on the NPDT was 58.3 ± 24.4. After integrating the results of the abovementioned survey items, we revealed that the average score of the section on NCECA was 11.41 ± 2.81 (total is 20 points), skewness is 0.16, and kurtosis is 0.61, which is within normal distribution. Among NCECA, the section with the highest scoring rate was “English oral speaking” (77.3%) and the section with the next highest scoring rate was “contextual understanding” (54.6%), whereas the “Grammar and word usage” section had the lowest scoring rate (40.9%) [Table 3].
Table 3: Statistics distribution of nurses' Clinical English Communication Abilities

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The frequencies of negative communication situations

The average score of each item was listed as follows: “Spend more time when communicating with foreign patients/families/HCAs” was 2.65 ± 0.79; “Feel stressed when facing foreign patients/families/HCAs” was 2.36 ± 0.91; “May not perform complete professional services because of poor English communication abilities” was 2.25 ± 0.86; “Reduce interaction with foreign patients/families/HCAs because of fear of using English” was 2.24 ± 0.88; “May not want to be assigned to care for English-speaking patients” was 1.97 ± 0.96; “May not promptly resolve patients' issues because of poor communication abilities” was 1.82 ± 0.73; and “Cause unhappiness among foreign patients/families/HCAs because of poor communication abilities” was 1.58 ± 0.75 [Table 4].
Table 4: Nurses' clinical English negative communication situations

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Influential factors of the frequencies of negative communication situations

Clinical English communication abilities

The scores of NCECA were divided into three levels: elementary (0–7), intermediate (8–15), and advanced (16–20). The correlation between the frequencies of the negative communication situations and NCECA was analyzed using one-way ANOVA. Six of seven items in the negative communication situations had a significant difference. The left side of [Table 5] shows the F value and post hoc comparison using the Scheffe's test of each item. Nursing staff who belong to the advanced level had significantly lower frequencies of negative communication situations than those who belonged to the elementary and intermediate levels.
Table 5: The correlation between clinical English communication abilities/frequency of self-study and negative communication situations

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Frequency of English self-study

The Kruskal–Wallis test was used to analyze the correlation between the frequency of self-study and negative communication situations, and the results were statistically significant. The right side of [Table 5] shows the detailed data and Chi-square values. Nurses engaged in higher English self-study frequency had significantly lower frequencies of negative communication situations.

  Discussion Top

The results of this study show that most nurses want to use the resources provided by the hospital to improve NCECA, though communicating with foreign patients in English, which is not a high frequency of occurrence. Most nurses believed that their English abilities are inadequate for meeting clinical requirements and they should improve their clinical English abilities. This result is similar to that reported by Lyu et al., which showed that 67% of nurses were willing to participate in language training courses.[15] In our study, up to half of the nurses reported that they think patients were unable to understand what they mean and were unable to understand what patients mean. This result showed that their education and training did not prepare them well in English health-care communication, which was consistent with the results of Ho's report.[3] Therefore, we suggest that hospital managers should provide English learning resources to help them improve the quality of care, communicate with foreign patients and caregivers, and keep abreast of medical/nursing research and new treatments.

A total of 38.9% of nurses reported “Feel stressed when facing foreign patients/families/HCAs” and 35.9% of nurses reported “Reduce interaction with foreign patients/families/HCAs because of fear of using English.” Gao et al. disclosed that 55.6% of nurses reported feeling stressed when caring for foreign patients and 44.4% of the nurses reduced the number of times they visited foreign patients.[13] Although these two situations were reported less frequently in our study, these situations may still cause mental stress for nurses who are already under intense pressure while working and may affect the nursing care quality.[16] Improving nurses' language ability is a solution to this situation; however, it takes time. Establishing an English-friendly environment in hospitals is a strategy to get instant results, such as bilingual indications in the hospital environment, multilanguage patient education handouts, and on-site interpreting services, among others.

Nurses rarely report that they “May not want to be assigned to care for English-speaking patients,” “Cause unhappiness among foreign patients/families/HCAs because of poor communication abilities,” and “May not promptly resolve patients' issues because of poor communication abilities,” which demonstrates that most nurses currently do not reject caring for foreign patients. Although their English communication abilities may be lacking, nurses still felt that they could help foreign patients and did not feel that foreign patients were dissatisfied with their nursing services. However, this study only investigated from the nurses' perspective; the results do not reflect patient perceptions regarding the quality of nursing care. Previously, the Taiwanese Department of Health conducted a survey among foreigners in Taiwan regarding their level of satisfaction with the domestic English living environment. The results showed that foreign patients' satisfaction with health-care services was only 40.1%. In 2009, Lyu et al. interviewed fifty foreign patients and found that only 32% of them were satisfied with their health care, with poor communication being the main factor.[15] Another study from the patients' perspective showed that two-thirds of patients were unable to understand treatment instructions because of language barriers, and they believed that nurses were unable to understand what they meant.[17] In addition, half of the patients felt that nurses avoided speaking with them; 70% of patients thought that they were unable to completely express their primary complaints and their requirements were ignored because nurses ended the conversations early.[17] From the patient's point of view, the biggest obstacle to communication is the language difference between patient and nurse.[18] However, there was no significant difference in overall satisfaction with nursing services, which is probably because of compromises by patients coupled with an inability to change the current situation.[17]

The results of inferential statistical tests showed that nurses who have better NCECA or have set hours for studying English may reduce the frequency of negative situations while communicating in English. A project report demonstrated the main causes of the difficulty in English communications between nurses and patients as a lack of relevant learning courses and teaching materials and low English levels among the nurses themselves.[15] Therefore, it is necessary to improve clinical English abilities among nursing staff to provide high-quality nursing care for foreign patients. In terms of nursing education institutions, it is common for nursing graduates to lack sufficient English abilities, especially in listening and oral speaking abilities.

Communication ability is important in the nursing profession and the nurse–patient relationship. However, English communication abilities may not be improved in one stride. In addition, improvements in the environment of English conversation are necessary to improve and maintain English ability for nurses. The frequency of nurses communicating with foreign patients is obviously insufficient to enhance or maintain English ability. Systematically using professional interpreters could be an effective solution; however, the cost concerns and scheduling difficulties would be factors that obstruct the fulfillment of this policy.[19] In addition to providing reinforcement training and a reward system, hospitals should develop more multilanguage handouts to help foreign patients and create note cards with common clinical English dialog phrases for health-care professionals. Nowadays, various portable electronic devices (such as smartphones and tablet computers) are popular; patients can type their primary complaints into those devices and use translation software (such as Google Translator). Similarly, nurses can use these same devices to translate Chinese into English to convey important messages to patients.[20]

Improving clinical nurses' English communication abilities demands immediate attention in Taiwan and other countries due to globalization and the increasing chances of international medical services. The findings of this study can be used in designing health and nursing policies. Considering the safety and care quality of foreign patients, the government should mandate hospital managers to offer appropriate assistance strategies, such as on-site interpreters, developing various patient education handouts, and providing in-service courses associated with clinical English to facilitate communications between foreign patients and nurses. Foreign language training courses should be included as a part in continuing education and license renewal requirements. These strategies could also be applied to other medical personnel, who also have opportunities to serve foreign patients, such as dietitians, radiation technologists, medical technologists, pharmacists, respiratory therapists, and physical therapists.

The Ministry of Education should impose a policy that all nursing education institutes provide appropriate intervention to improve NCECA. For undergraduate nursing schools, it should be mandatory to include clinical English classes as a compulsory subject, which will ensure language competency among nursing students. In addition to holding English-associated courses, meeting graduation thresholds of English competence should also be considered. Like other advanced nursing roles, establishing a certification system for clinical English abilities could be an incentive to study English. Correct and effective communication not only ensures patients' safety but also care quality.

Study limitations

In our study, the survey results regarding the frequency of English communications between nurses and patients/families/HCAs were based on individual memories, which may not reflect the actual frequency of occurrence. Moreover, the information in this survey regarding nurses' CSA was only collected from nursing staff and did not include any patient opinions; therefore, the results may not reflect the true feelings of patients, which is really the biggest limitation of the present study.

  Conclusions And Recommendations Top

Based on our results, we conclude that most nurses think that they should improve their clinical English abilities. Inadequate English-communicating ability results in more time spent when communicating with foreign patients. Nurses who have better English-communicating abilities or have set hours for studying English may reduce the frequency of negative situations while communicating in English.

We recommend that hospital managers be carefully consider incorporating courses associated with clinical English dialogs for in-service education curriculum, with course materials focusing on common clinical dialogs to familiarize nurses with nurse–patient dialogs. In addition, nursing education institutions should offer nursing English courses and prioritize English listening and speaking abilities' training. For immediately overcoming language barriers, nurse staff can use electronic devices with translating functions to help with understand patient demands.


We appreciate the Nursing Department of Tri-Service General Hospital for questionnaire distribution and Chia-Hui Liu for collecting and inputting of data. The authors thank Crimson Interactive Pvt. Ltd. (Ulatus) – www.ulatus.tw – for their assistance in English editing.

Financial support and sponsorship

This research was supported by grants from the Tri-Service General Hospital (TSGH-C101-157), and Taoyuan Armed Forces General Hospital (104-34), Taiwan.

Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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