A Study of Cross-Cultural Communication among Internationally Educated Taiwanese Nurses in the United States

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A Study of Cross-Cultural Communication among Internationally Educated Taiwanese Nurses in the United States
Ho, Ya-Yu Cloudia
Place of Publication:
[Gainesville, Fla.]
University of Florida
Publication Date:
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1 online resource (243 p.)

Thesis/Dissertation Information

Doctorate ( Ph.D.)
Degree Grantor:
University of Florida
Degree Disciplines:
Curriculum and Instruction (ISC)
Teaching and Learning
Committee Chair:
Coady, Maria R
Committee Members:
Bondy, Elizabeth
Townsend, Jane S
Yoon, Saun-Joo L
Graduation Date:


Subjects / Keywords:
Cross cultural studies ( jstor )
East Asian culture ( jstor )
Health care industry ( jstor )
Hospitals ( jstor )
Intercultural communication ( jstor )
Language ( jstor )
Mandarins ( jstor )
Nurses ( jstor )
Nursing ( jstor )
Registered nurses ( jstor )
Teaching and Learning -- Dissertations, Academic -- UF
education -- enp -- esp -- nurse -- tesol
City of Gainesville ( local )
bibliography ( marcgt )
theses ( marcgt )
government publication (state, provincial, terriorial, dependent) ( marcgt )
born-digital ( sobekcm )
Electronic Thesis or Dissertation
Curriculum and Instruction (ISC) thesis, Ph.D.


The diverse patient population and increasing nursing migration in the United States results in a need to improve the quality of cross-cultural, clinical communication (Andrews, 2003; Hancock, 2008; Sherman, 2007). Cross-cultural communication is necessary but challenging for patients and healthcare practitioners alike. The objective of the study was to construct an understanding of the interrelationship between language needs, cultural differences, educational training, and communication of internationally educated Taiwanese nurses. The research question was, "How do internationally-educated nurses perceive their cross-cultural, clinical communication experiences in the U.S. medical context?" Case study was adopted as the research methodology. The data collection period lasted four months. Purposeful sampling was used to recruit five Taiwanese nursing participants. Primary data collection methods included focus group interviews and individual interviews. Supplementary data consisted of background information surveys, observations, and post-interview reflection journals. The data analysis method was a combination of narrative and thematic analysis. The findings showed that the use of complex/specialized language and cross-cultural differences in clinical settings complicated the five participants' communication experiences. The findings also indicated gaps in language and culture in these nurses' training in the United States. ( en )
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In the series University of Florida Digital Collections.
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Includes vita.
Includes bibliographical references.
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Description based on online resource; title from PDF title page.
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This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Thesis (Ph.D.)--University of Florida, 2012.
Adviser: Coady, Maria R.
Statement of Responsibility:
by Ya-Yu Cloudia Ho.

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Copyright Ho, Ya-Yu Cloudia. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
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864879787 ( OCLC )
LD1780 2012 ( lcc )


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2 2012 Ya Yu Cloudia Ho


3 To m y p arents


4 ACKNOWLEDGMENTS Laugh and the world laugh s with you. Weep, and you weep alone ( Ella Wheeler Wilcox 1883) Purs u ing a PhD degree was a lonely jour ney; however I didn t weep alone. S upport from family, friends professors, colleagues, and students have strengthen ed my belief to overcome challenges overseas. I would like to thank the supervisory committee: Dr. Maria Coady, Dr. Elizabeth Bondy Dr. Jane Townsend, and Dr. Saunjoo Yoon I am grateful for their encouragement and guidance I am deeply indebted to the committee chair, Dr. Maria Coady s dedication and time that she spent on understanding my worry, need, lack, and strength throughout my doctoral journey T his dissertation can t be done without the five Taiwanese nursing contributions. Their voices regarding struggle and success in terms of cross cultural communicati on in the U.S. healthcare context are important resources for international nurses language learning and cultural adjustment I also want to show my appreciation to people who helped me and share d joy and sorrow with me in Florid a : Viven Lee, Cindie Moore Zane Hasan, Mat t Goode Patricia Ant Helen Lin, Chu Chuan Chiu Joan Lin, Hsiao Yu Chang, Ruoxuan Wang Wei Peng, Dr. Shi Fen Yeh Dr. Vivian Wu, Dr. Zhuo Li, Dr. Pinky Chung Dr. Wei Jen Hsu, and Dr. Pei Ying Sarah Chan I am blessed to be cared, loved by people in Taiwan, including (1) my family: parents, Henry Ho and Joyce Ho and brothers Jimmy Ho and Dada Ho ; (2) my friends /colleagues/supervisor : Shya Yu, Carol Hsu, Bu Wang, Ying Chen, Rachel Hsu, Faye Shen, Dr. Marietta Fa Mr. Alien, Director Christine Sun, and Michelle Lee T heir love kept me warm no matter how far apart we were


5 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ .......... 10 LIST OF FIGURES ................................ ................................ ................................ ........ 11 LIST OF ABBREVIATIONS ................................ ................................ ........................... 12 ABSTRACT ................................ ................................ ................................ ................... 14 1 INTRODUCTION ................................ ................................ ................................ .... 16 Overview ................................ ................................ ................................ ................. 16 Diverse Patient Population and Nursing Workforce ................................ .......... 18 Nursing Migration and Pull/Push Factors ................................ ......................... 19 Internationally Educated Nurses ................................ ................................ ....... 21 Visa Credentials Assessment of Internationally Educated Nurses ................... 22 Statement of the Problem ................................ ................................ ....................... 25 Purpose of the Study ................................ ................................ .............................. 25 Research Questions ................................ ................................ ............................... 26 Significance o f the Study ................................ ................................ ........................ 26 Definition of Terms ................................ ................................ ................................ .. 27 Chapter Summary ................................ ................................ ................................ ... 31 2 REVIEW OF LITERATURE ................................ ................................ .................... 32 Overview ................................ ................................ ................................ ................. 32 Review of Literature on Historical Perspectives ................................ ...................... 32 Interrelationship between Culture, Language, Education, and Communication ................................ ................................ ............................. 32 Culture ................................ ................................ ................................ ....... 32 Communication ................................ ................................ .......................... 33 Language ................................ ................................ ................................ ... 35 Education ................................ ................................ ................................ ... 36 Conceptual Framework o f Communicative Competence ................................ ........ 37 Second Language Acquisition ................................ ................................ .......... 38 Components of Communicative Competence ................................ .................. 39 Review of Literature on Contemporary Issues ................................ ........................ 51 Comparative Medical Contexts ................................ ................................ ......... 53 Mandarin Speaking Medical Context ................................ ................................ 53 English Speaking Medical Context ................................ ................................ ... 56 Factors Affecting Cross Cultural Clincial Communication ................................ 59 Context ................................ ................................ ................................ ...... 59 Culture ................................ ................................ ................................ ....... 60 Education ................................ ................................ ................................ ... 62


6 Language ................................ ................................ ................................ ... 64 Chapter Summary ................................ ................................ ................................ ... 68 3 METHODOLOGY ................................ ................................ ................................ ... 69 Overview ................................ ................................ ................................ ................. 69 Theoretical and Epistemo logical Perspectives of the Study ................................ .... 69 Research Design ................................ ................................ ................................ .... 71 Phase I: Pilot Study ................................ ................................ .......................... 73 Phase II: Dissertation Work ................................ ................................ .............. 74 Sett ing ................................ ................................ ................................ ........ 74 Sampling criteria ................................ ................................ ........................ 75 Sampling procedure ................................ ................................ ................... 76 Nursing participants ................................ ................................ ................... 78 Data Collection ................................ ................................ ................................ ....... 81 Informed Consent ................................ ................................ ............................. 82 Background Information Survey ................................ ................................ ....... 83 Interviews ................................ ................................ ................................ ......... 83 Individual interviews ................................ ................................ ................... 85 Focus group interviews ................................ ................................ .............. 86 Observations ................................ ................................ ................................ .... 88 Observing communication in nonmedical settings in hospitals .................. 88 Observing communication in private life and social activities ..................... 89 Transcribing, Summarizing, and Member Checking ................................ ......... 90 Data Analysis ................................ ................................ ................................ .......... 91 Method of Analysis: Narrative and Thematic Analysis ................................ ...... 91 Procedures of Analysis ................................ ................................ ..................... 92 Analyzing primary data: I nterviews ................................ ............................ 92 Analyzing supplemental data: O bservations ................................ .............. 94 Analyzing my own thoughts ................................ ................................ ....... 95 Inter analyzing multiple data ................................ ................................ ...... 95 Member checking ................................ ................................ ....................... 95 Trustworthiness and Triangulation ................................ ................................ .......... 96 Subjectiv ity Statement ................................ ................................ ............................ 99 Research Limitations ................................ ................................ ............................ 100 Chapter Summary ................................ ................................ ................................ 101 4 FINDING S ................................ .......................... 102 Overview ................................ ................................ ................................ ............... 102 Shya ................................ ................................ ................................ ...... 104 Home Family and Culture ................................ ................................ ............... 104 Nurse an d Language Training in Taiwan and the United States .................... 106 Adjustment to the U.S. Healthcare Context ................................ .................... 108 Context Up to Study Period ................................ ................................ ............ 110 ................................ ................................ ................................ .......... 113 Home Family and Cu lture ................................ ................................ ............... 114


7 Nurse and Language Training in Taiwan and the United States .................... 115 Adjustment to the U.S. Healthcare Context ................................ .................... 116 Context Up to Study Period ................................ ................................ ............ 118 Chen ................................ ................................ ................................ ...... 121 Home Family and Culture ................................ ................................ ............... 122 Nurse and Language Training in Taiwan and the United States .................... 123 Adjustment to the U.S. Healthcare Context ................................ .................... 125 Context Up to Study Period ................................ ................................ ............ 127 ................................ ................................ ................................ ........ 129 Home Family and Culture ................................ ................................ ............... 130 Nurse and Language Training in Taiwan and the United States .................... 132 Adjustment to the U.S. Healthcare Context ................................ .................... 133 Context Up to Study Period ................................ ................................ ............ 134 ................................ ................................ ................................ .......... 136 Home Family and Cu lture ................................ ................................ ............... 137 Nurse and Language Training in Taiwan and the United States .................... 13 7 Adjustment to the U.S. Healthcare Context ................................ .................... 139 Context Up to Study Period ................................ ................................ ............ 142 Chap ter Summary ................................ ................................ ................................ 143 5 FINDINGS : MAIN THEMES ................................ ................................ .................. 144 Overview ................................ ................................ ................................ ............... 144 Complex and Specialized Language in Clinical Settings ................................ ................................ ................................ ........... 146 Oral Communication ................................ ................................ ....................... 146 Discriminating non Mandarin sounds ................................ ....................... 147 Jokes, slang and multiple dialects ................................ ............................ 149 Occupation specific vocabulary and hospital register .............................. 152 Written Communication ................................ ................................ .................. 155 Open ended writing in charting ................................ ................................ 155 Reading medical documents ................................ ................................ .... 157 Cultural Differences in Clinical Settings ..... 158 Linguistic and Cultural Diversity of Hospital Personnel and Patients .............. 158 Independent Role of Nurses in U.S. Healthcare ................................ ............. 161 Patient Centered Care ................................ ................................ ................... 163 Identity N egotiation in a New U.S. Environment (being Taiwanese or being American?) ................................ ................................ ................................ ........ 170 Accent: Retaining or Reducing the Taiwanese Accent in English .................. 171 Choices of Speech Registers ................................ ................................ ......... 173 Sweet talk versus professional tone (with patients) ................................ 173 A ssertiveness versus compromise (with patients / hospital personnel) ..... 175 P retentiousness versus h umility (with hospital personnel) ....................... 177 U.S. Nurse Training Gaps: Language and Culture ...... 178 Lecture Oriented Classes: Hospital Orientation ................................ ............. 179 Lack of e ssential l anguage n eeds ................................ ............................ 180


8 Lack of cultural knowledge: Patient backgrounds, hospital subcultu res, hospital policies, and nursing routines ................................ .................. 181 Learning by Doing: Clinical Shadowing ................................ .......................... 184 Chapter Summary ................................ ................................ ................................ 185 6 DISCUSSION AND CONCLUSION ................................ ................................ ...... 187 Over view ................................ ................................ ................................ ............... 187 Cultural Communication Experiences .................... 189 Language Needs in Hospital Settings ................................ ............................ 190 Oral language use ................................ ................................ .................... 190 Written Englis h: Genre specific medical reading and writing ................... 194 Culture in Hospital Settings ................................ ................................ ............ 196 Role of nurses: Patient centered care and independent professional ...... 196 Discourse styles ................................ ................................ ....................... 198 Education and Training: The Need for Specialized, Ongoing Training ........... 200 Pre U.S. training: Language and culture assessment .............................. 201 Early U.S. training: Hospital orientation and mentorships ........................ 202 Application to the Communicative Competence Model ................................ .. 204 More relevant aspects of the model: Grammatical, sociolinguistic, and cultural competence among international nurses ................................ .. 206 Less relevant aspects of the model: Discourse and strategic competence among international nurses ................................ .............. 210 Implications for the Study ................................ ................................ ...................... 211 I in the United States ................................ ........ 211 Communication and cultural mediation ................................ .................... 212 Critical thinking in nursing car e ................................ ................................ 214 Clinical practice ................................ ................................ ........................ 215 Implications f or Researchers: Further Investigations ................................ ...... 216 Conclusion ................................ ................................ ................................ ............ 219 A IRB PROTOCOL ................................ ................................ ................................ ... 223 B RECRUITMENT FLIER ................................ ................................ ......................... 224 C EMAIL SCRI PT OF RECRUITMENT ................................ ................................ .... 225 D INFORMED CONSENT FORM ................................ ................................ ............. 226 E BACKGROUND INFORMATION SHEET ................................ ............................. 228 F INTERVIEW PROTOCOL ................................ ................................ ..................... 229 G CONSENT TO BE AUDIO TAPED ................................ ................................ ....... 231 H EXAMPLE OF NARRATIVE ANALYSIS ................................ ............................... 232 I EXAMPLE OF THEMATIC ANALYSIS ................................ ................................ 233


9 LIST OF REFERENCES ................................ ................................ ............................. 234 BIOGRAPHICAL SKETCH ................................ ................................ .......................... 243


10 LIST OF TABLES Table page 1 1 Passing score of English proficiency examinations for registered nurses .......... 24 2 1 Medical c haracteristics between English s peaking and Mandarin s peaking c ontext ................................ ................................ ................................ ................ 58 2 2 Comparison between Mandarin s peaking and English s peaking n urses ........... 67 3 1 Overview of research taxonomy ................................ ................................ ......... 72 3 2 Background i nformation of p articipants ................................ .............................. 79 3 3 Quantities of d ata c ollection ................................ ................................ ................ 82 3 4 Timeline of d ata c ollection ................................ ................................ .................. 82 4 1 ................................ ................................ .... 103 5 1 Summary of main themes ................................ ................................ ................. 145 6 1 Summary of discussion ................................ ................................ .................... 188


11 LIST OF FIGURES Figure page 2 1 Chronological derivation of communicative ability development ......................... 50 2 2 Components of c ommunicative c ompetence ................................ ...................... 51 6 1 Components of communicative competence for international nurses ............... 205


12 LIST OF ABBREVIATION S BICS Basic Interpersonal Communication Skills CALP Cognitive Academic Language Proficiency CGFNS Commission on Graduates of Foreign Nursing Schools CLD Cultural and Linguistic Diversity or Culturally and Linguistically Diverse CN A C ertified N ursing A ssistant DNR D o N ot R esuscitate E F L English as a Foreign L anguage ENP English for Nursing Purposes ESL English as a Second L anguage ESP English for Specific Purposes IELTS International English Language Testing System IEN Internationally Educated Nurse: A registered nurse who has received nursing training in his/her homeland, grown up with a language other than English in a culture outside o f the U.S., and migrates to the U.S. working as a healthcare professional. L1 First Language L2 Second Language LPN L icensed P ractical N urses NCLEX RN National Council Licensure Examination for Registered Nurses RN Registered Nurses SBAR Situation Backg round Assessment and Recommendation SLA Second Language Acquisition TCM Traditional Chinese Medicine TESOL Teaching English to Speakers of Other Language or Teachers of English to Speakers of Other Languages


13 TOEIC Test of English for International Communication TOEFL Test of English as a Foreign Language TSE Test of Spoken English TWE Test of Written English ZPD Zone of Proximal Development


14 Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy A STUDY OF CROSS CULTURAL COMMUNICAT ION AMONG INTERNATIONALLY EDUCATED TAIWANESE NURSES IN THE UNITED STATES By Ya Yu Cloudia Ho May 2012 Chair: Maria Coady Major: Curriculum and Instruction The d iverse p atient p opulation and increasing nursing migration in the United States results in a need to improve the quality of cross cultural clinical communication ( Andrews, 2003 ; Hancock, 2008 ; Sherman, 2007) C ross cultura l communication is necessary but challenging for patients and healthcare practitioners alike. T he objective of the study was to construct an understanding of the inter relationship between language needs cultural differences educational training, and comm unicati on of internationally educated Taiwanese nurses. The research question was educated nurses perceive their cross cultural Case study was adopted as the r esearch methodology The data collection period lasted four months. Purposeful sampling was used to recruit five Taiwanese nursing participants Primary d ata collection methods included focus group interviews and individual interviews S upplementary data c onsisted of background information surveys, observations and post interview reflection journals. The d ata analysis method was a combination of narrative and thematic analysis.


15 The findings show ed that the use of complex/s pecialized language and c ross c ultural d ifferences in c linical settings complicated the five participants communication experiences The findings also indicated gaps in l anguage and c ulture in these nurses training in the United States


16 CHAPTER 1 INTRODUCTION Overview Alex ( pseudony m) a 42 year old Brit ish native, was h eavily bandaged around the head fidgety, half coma tose and tossing from side to side. He was a visiting assistant professor, one of my former colleagues teaching English as a Foreign Languag e (EFL) at a Taiwan ese college. He was recovering from an 11 hour brain surgery caused by a serious car accident One week later, he continuously murmured how hurt and frustrated he was in his bed I t is okay. Susan ( pseudony m, o ne of our colleagues ) and I are here to keep an eye out for you. the on duty Taiwanese nurse came to me and complain ed s rudeness and irrational behavior I left my cell phone number and comforted her in Mandarin R u guo you xu yao, kei yi da wo shou ji (If you need any help for interpretation, just call me) One year later, I met a small group of Taiwanese registered nurses (RN) Bette and Fannie ( pseudonyms ), in a community English conversation class Through Bette and Fannie, I met Janet, Zoe, and Yvonne ( pseudonyms ) Some of them were applying for U. S. nursing positions. Some were working with foreign clients in Taiwan For example, Zoe worked in the Anesthesiology Department encountering a high frequency of injured foreign patients She was preparing for the U.S. NCLEX RN examination (National Counci l Licensure Examination for Registered Nurses) and planning to work in the United States Bett e and Janet had passed the NCLEX RN examination H owever, their repeated failures in the English proficiency test IELTS (International English


17 Language Testing Sy stem) impeded them from obtaining a U.S. working visa 1 Yvonne continuously s elf studied English because she looked forward to studying abroad in the near future Compared with other adult learners in the community English conversation class, this group of EFL learners was highly motivated and ambitious in their learning goals. Bettie and Zoe told me how necessary it was for them to be fluent English speaker s Yvonne was embarrassed when she was misunderstood by her foreign patients. Fa nnie complained of the discouragement she and her colleagues felt when language barriers deteriorated their service quality in nursing Janet, Bette, and Zoe explained how urgent it was to pass English proficiency exams to obtain a U.S. working visa. I co in a strange land I also identified with the and eagerness regarding communicating with foreign clients and improving English competence to pursue their American dreams By hear ing the perspectives of both parties, I realized the importance of using English as a communicati on tool in the setting of transcultural nursing. As a former EFL instructor in an occupational oriented College of Technology in Taiwan I saw an opportunity to promote Nursing English education and facilitate cross cultural healthcare communication. E xamin ing international nurses experiences of cross cultural communication in the U .S. medical setting might expand my knowledge of communi cative competence in the nursing profession and contribute to the literature on cross cultural clinical communication 1 R egistered nurses who were born outside of the United States are required to complete a four step visa credentials assessment program in order to receive a working visa, including educational background investigation, licensure validation, English proficiency test (IELTS TOEFL or TOEIC ) and nursing knowledge examination ( CGFNS Qualifying Examination or the National Council Licensure Examination for Registered Nurs es) (CGFNS 2008 ; USCIS 2009)


18 Diverse Patient Population and Nursing Workforce Since 1990, more than half the population growth in the United States has come from immigrants and their children -and many of these immigrants, even if they can get to the hospital and pay for their treatment, may find mainstream health care culturally inaccessible (Fadiman, 1997, p.270) In general, nurses are the initial contact in Globalization has made English one of the most common languages in many cross cultural medical interactions (Grice, 2003; Munoz & Luckmann, 2005). I n an English as a Second Language (ESL) context, such as in the U nited States, New Zealand, Australia, the United Kingdom, and Canada, the growing population of diverse ethnic groups results in the demand for multicultural and multilingual nursing professionals in the healthcare workplace. According to the 2000 U.S. ce nsus, more than 25% of the population in the United States consisted of ethnic minority groups. Meanwhile, approximately one fifth of the population spoke a language other than English at home (U.S. Census Bureau, 2000). In 2004, while 32.6 % of the popula tion was composed of multi ethnic groups, only 12.2 % of registered nurses in the nursing workforce identified themselves as having racially or ethnically diverse backgrounds (U.S. Department of Health and Human Services, 2004). Recently over 100,000 registered nurses departed their home country to work as nursing practitioners in the U nited States (Sherman, 2007). Even though we have observed a growing rate of registered nurses from non European Asian, other Pacific Islander, Hispanic, and Latino backgrounds since 1980 to 2004, the actual numbers of registered nurses with culturally and linguistically diverse (CLD) competence remain low (U.S. Department of Hea lth and Human Services, 2004). Moreover, the U.S. Census Bureau estimated that by the year 2080, ethnic minority


19 groups will amount to 51.1% of the population in the United States (Choi, 2005). The multiethnic population in the United States requires a culturally and linguistically responsive healthcare system to maintain quality me dical services. Therefore, a shortage of CLD nurses and efforts regarding their education, recruitment, employment, and communicative competence has attracted a great deal of attention in the United States (Abriam Yago, Yoder, & Kataoka Yahiro, 1999; Adeni ran, Rich, Gonzalez, Peterson, Jost, & Gabriel, 2008; Bola, Driggers, Dunlap, & Ebersole, 2003; Brown, 2008; Gardner, 2005; Hancock, 2008; Ross, Polsky, & Sochalski, 2005; Sherman, 2007; Xu, Gutierrez, & Kim, 2008; Yoder, 2001). Nursing Migration and Pull/ Push Factors According to Hancock (2008), Kline (2003), and Tshweneagae (2007), t he primary destination countries of international nurses include the United States, Canada, Ireland, the United Kingdom, Australia and New Zealand where English is the domin ant language in the healthcare industry and society at large T he supplying countr ies and regions of foreign nurses are the Philippines South Africa, the United Kingdom, China, South Korea, Japan, Taiwan, Vietnam, Hong Kong India, Mexico, and Puerto Rico. There are various factors pulling and pushing internationally educated nurses to leave home and work in developed English speaking countri es. Coelho (1994) noted that p ull factors are inducement s to attract immigrants or migrants moving t o a host country under their free will Push factors are motivatio n s for local residents to feel pressures or desires to leave the ir original countries In general, factors pushing registered nurses to leave their home countries include unsatisf ying status and involuntary issues, such as low standards of living, work overload, unorganized career promotion, political persecution, oversupply in the nursing market, and risks of


20 o ccupational i njury and d isease (Hancock, 2008; Hawthorne, 2001 ; Kingma, 2001 ; Kline, 2003; Ojo, 1990 ) On the other hand factors pulling registered nurses to move to the United States include the pursuit of professional development, educational opportunities, better income, improved working conditions, higher socioeconomic statu s, self fulfillment, and ambitions of adventure (Hancock, 2008; Kl ine, 2003; Tshweneagae, 2007) In the case of Taiwan registered nurses (RN) and licensed practical n urses (LPN) are both treated independent professional practitioners They implement similar nursing tasks in pract ice Usually, they are not expected to make individual nursing judgment s In general wards, nurses are re sponsible for from eight to12 hospital beds during day shift s 12 to 15 beds during evening shift s and 20 to 40 beds during night shift s, which are particularly demanding. On the contrary, according to the California Boa rd of Registered Nursing ( 20 11 ) U.S. nursing professions are divided into detailed and specific division s of duty, including n urse p ractitioner s (NP), c linical n urse s pecialists (CNS), r egistered n urse s (RN) l icensed p ractical n urse s /licensed vocational nurse s ( LPN / LVN ), certified regi stered nurse anesthetist s (CRNA), certified n urse m idwives (CNM), p ublic h ealth n urse s (PHN), p sychiatric/ m ental h ealth n urse s (PMHN), c ertified n ursing a ssistant s (C N A ), and certified medical assistants (MA). N urses in general wards take care of four to six hospital beds, work based on the t hree shift system or 12 hour work shift, and receive $20 40 payment per hour which is double to triple nurses Taiwan Compared with practicing in the donor countries, the U.S. nursing market obviously provide s better welfare and work environment s for nursing professionals. N evertheless


21 the challenges of fitting into a new country are formidable. The challenges experienced by internationally educated nurses working in the United States are discussed in detail in C hapter 2 With the e xcept ion of the United Kingdom playing the role of both a donor and host country, most int ernationally educated nurses are from non English speaking countries They receive particular nursing training in their home countries. They have unique perspectives on health, diseases, medication life, and death. Additionally, they are accustomed to medical routines dissimilar from the U.S. healthcare environment N urs ing immigration has had tremendous impact upon international nurse s cultural adjustment, professional cultivat ion, transitional training, healthcare delivery models and cross cultur al medic al communication in the United States However, except for the qualification evaluation administere d at the U.S. national level, the contemporar y procedures regarding internationally educated nurses recruitment and on board training are only implemented at the state and institutional level ( Ross Polsky & Sochalski 2005) In the next section, I discus s the definition of internationally educated nurses (IEN) and visa credential procedures for international nurses in the United States. Internationally Educated Nurses According to nursing journals, ESL database s and government documents, several terms a re applie d to discuss education, recruitment, and employment of registered nurses and nurs ing students from diverse ethnicities. Terms are list ed alphabetically as follow: E SL nursing students (Abriam Yago et al. 1999; Bosher & Smalkoski, 2002; Choi, 2005) ethnically diverse nurs ing students (Yoder, 2001) foreign born nurse s (Brown, 2008) foreign educated nurses (Bola et al. 2003 ; CGFNS, 2008 ), foreign nurses (Sherman, 2007) immigrant nurses/s tudent nurses ( Bosher &


22 Smalkoski, 2002; Xu et al., 200 8 ), internationally educated nurses (Adeniran et al., 2008; CGFNS, 2008; Hearnden, 2007; Xu & Kwak, 2005) internationally recruited nurses (Sherman, 2007) and racial and ethnic minority student nurses (Gardner, 2005) Xu and Kwak (2005) state d that internationally educated nurse is operationally defined as a RN (registered nurse) with an active license to practice nursing in the United States who obtained his or her basic nursing education in another country ( p.234) Adeniran et al. (2008) also decl are d that the term internationally educated nurses (IENs) is used to refer to nurses who received their basic nursing education in a country other than the US and who later migrated to the US to practice nursing In this dissertation ESL nurses refer to registered nurses who speak a first language other than English at home or in the community. Yet, they use English as a survival tool to work, live, socialize, and communicate in U.S society. I n the study I use the terms ESL nurses international nurses, and internationally educated nurses (IEN) interchan geably The alternative usage among the three t erms is to emphasize international educationally, culturally, and linguistically diverse backgrounds compared to U.S. dominant white nurses. This study address es the group of registered nurses who have receive d nursing training in their homeland s, grown up with a language and culture other tha n that in which U.S. residents are immersed and migrate d to the U nited States as healthcare profession als Visa Credentials Assessment of International ly Educated Nurses According to the U.S. Citizenship an d Immigration Services (USCIS 2009) and Commission on Graduates of Foreign Nursing Schools (CGFNS 2008), Section 343 of the Illegal Immigration Reform and Immigrant Responsibility Act (IIRIRA) of 1996, registered nurses who were born outside of the United States are required to complete


23 a four step visa credentials assessment program in order to receive a wor king visa, including educational background investigation, licensure validation, English proficiency test, and nursing knowledge examination. The CGFNS Qualifying Examination and the National Council Licensure Examination for Registered Nurses (NCLEX RN ex professional knowled ge in nursing practices. In 2000 census data, residents from Chinese ethnic groups comprised 2,462,585 of the U.S. population (U.S. Census Bureau, 2000). In or der to meet the increasing demand of serving the Mandarin speaking population in the U. S. medical industry, CGFNS open ed t est centers in Taipei, Hong Kong, Beijing, Shanghai, Guangzhou, and Chengdu of the over 50 locations The format of the CGFNS Qualify ing Examination is a paper test. The NCLEX RN examination is a computer adaptive testing (CAT) version. The two nursing knowledge judgment of client needs ( National Council of State Board of Nursing 2007) Johnston ( 2001) conducted language a nd their NCLEX RN scores 184 participants were native English speakers, 31 were bilingual, and 75 nursing graduates spoke a first language other than English. Findings suggest that native English speaking test takers of the NCLEX RN success rate was between 33.3% and 47%. The distinct passing rat io between English native speaking nurses and ESL nurses indicates that language barriers, unfamiliarity with test achievement in the nursing knowledge exam.


24 As to interna internationally educated nurses to demonstrate both oral and written competence in the following examinations, including 1) combination of the Test of English as a Foreign Language (TOEFL) Test of Written English (TWE), and Test of Spoken English (TSE); 2) the four skill TOEFL internet based version (TOEFL iBT); 3) combination of the Test of English for International Communication (TOEIC), TWE, and TSE; or 4) the academic module of Interna tional English Language Testing System (IELTS). The passing score of each test set and its reference to English proficiency level can be seen in Table 1 1. Table 1 1 Passing s core of English p roficiency e xaminations for r egistered n urses Test o ption TOEFL c ombination TOEIC c ombination IELTS a cademic TOEFL iBT Score P aper: 540 TOEIC : 725 Overall: 6.5 iBT : 83 CBT: 207 TWE: 4.0 TWE: 4.0 Speaking: 7.0 Speaking: 26 TSE: 50 TSE: 50 English l evel High i ntermediate Advanced A dvanced High i ntermediate Note. Adapted from CGFNS ( 2008 ) and L CCIBE (2010). On the whole, the evaluation procedure of language tests and nursing knowledge examinations can only attend to basic nursing competencies instead of assessing ESL comprehensive abilities (Bola et al., 2003; Xu et al., 2008) T he language examinations verbal listening, reading, and writing skills in the field of Academic English (e.g., TOEFL, TWE, IELTS), General English (e.g., TSE), and Business English (e. g., TOEIC). However, neither of the above English language tests on in the particular field of nursing. The above issues have turned attention to help ing internationally educated nurses work and communicate compete ntly in the unique U.S. nursing settings, including


25 language proficiency tests, transitional training programs, learning materials, and teacher preparation in the field of Englis h for Nursing Purposes (ENP) S tatement of the Problem How complex is the cross cultural clinical communication between nonnative English speaking nurses and ethnically and linguistically diverse patients? L anguage barriers may be problematic but are generally obvious When a Taiwanese nurse report s mal symptoms under observation by saying to her, (observation) perplexity can be e vident When night shift EFL nurses avoid talking to an Afghan male tumor patient because they are not comfortable speaking English, one c an imagine how upset the patient and his family may f eel Additionally cultural clashes can be surprising and unpleasant. Taiwanese nurses wonder why American, Canadian, and European patients tend to ask for more pain medication than domestic clients do In some Asian areas, a postnatal confinement is important involving complicated diet therapy and care procedures However, h ospitals in the United States provide for example, orange juice for ill and postpartum patient s while hot water is preferred over cold drinks for in Taiwan, Korea, China, and other Asian countries. Predictably, cross cultural communication is confusing for patients and healthcare practitioners alike. Purpose of the Study The U.S. multiethnic population requires a culturally and linguistically responsive healthcare system to maintain quality medical services. Meanwhile efforts regarding international nurses education, recruitment, employment, and cross cultu ral communicati on are noted in the contemporary nursing and ESP ( English for Specific Purposes ) field. I n general two common methods of solving the nurs ing shortage in the


26 demands of serving multilingual and multicultural patient population are either recruiting registered nurses from overseas or cultivating domestic student nurses from diverse ethnic groups In the study, I focus on the population of internat ionally educated nurses who are recruited from the Mandarin speaking country Taiwan including discussion of how they communicat e in the United States In other words, t he objective of the study is to construct an understanding of how language, culture, and education background affect the communication experiences of Taiwanese nurses in the United States. Research Questions T he following research question was investigated in the study How do internationally educated Mandarin speaking nurses perceive their cross cultural clinical communication experiences in the U.S. medical context? In order to build an outline of international nurses communicati on experiences, I used three s upporting questions to probe their per ceptions. RQ1: How do internationa l nurses describe language need s for communication in cross cultural medical settings ? R Q2: How do international nurses perceive cultural factors as influencing communication events? RQ3: How do international nurses believe their education and training prepared them for U.S. healthcare communication ? Significance of the Study Transc ultural nursing has become a n important issue both in academic and practical nursing since its foundation in the mid 1960s (Giger & Davidhizar, 2008) The trend of U.S. nursing migration has had significant impact on Asian nursing relevant industries, including immigration agencies and RN test/ English test preparation institutes According to Munoz and Luckmann (2005), the world population of Mandarin


27 speakers is approximately 836 million, which is the most common spoken language in the world. If ESL speakers are included in the global demography, English becomes the second most widely used language with 418 million people. Genera lly, studies of transcultural nursing focus largely on communication between U.S. mainstre am nurses and minority patients such as American nurses with African American or Mexica n American patients However, research examining communicat ion between interna tionally educated nurses and ethnically diverse patients is limited such as studies of Taiwanese nurses with Hispanic patients in California This can be attributed to the minority status of both parties or the complexity of cross cultural communication working experiences (Abriam Yago et al., 1999; Adeniran et al. 2008; Bo l a et al. 2003; Bosher & Smalkoski, 2002; Brown, 2008; Choi, 2005; Gardner, 2005; Hanc ock, 2008; Hearnden, 2007 ; Sherman, 2007; Xu & Kwak 200 5 ; Yoder, 2001) it is challenging to find research aiming at the specific group of Mandarin speaking nurses Therefo re, there is a need to study this subgr oup of inte rnational nurses. Definition of T erms My perspective is situational, meaning here a concern for what one individual can be alive to at a particular moment, this often involving a few other particular individuals and not necessarily restricted to the mutually monitored arena of a face to I must be allowed to proceed by picking my span and level arbitrarily without special justification. (Goffman, 1974, p.8) L anguage is socially constructed, developed, shared, and amended by people. The meaning of language is perceived and interpreted individually according to our cultural frames. The expectation of commu nication is based on our organization of experience ( Goffman, 1974) which is an individual database for people to interpret


28 language in situational use. Everyone has his/her unique schema of experiences which cannot be replaced and mimicked Furthermore t he way we communicate is determined by our intersubjectivity ( Bruner 1990), which is how w e interpret other socially appropriat e manner. The s peech reality is culturally co constructed and no interpretation of another s mind is culture free. The talent of intersubjectivity the way that we mak e sense of meanings and present language, is in relation to our expected roles in family, community workplace, academic field, and society. Therefore, t o minimize readers divergent expectations of the terminology in my study, the following section is to clarify key terms that I interpret and employ in the study A DDRESSIVITY It is a bility to talk to diverse speakers in various culturally specific ways (Bakhtin, 1986). It reflects speech socioeconomic status, and social proximity. C OMMUNICATION E VENTS In this study, i nteractions take place between an international nurse and a non native Mandarin speaker in which he/she experienced enough to recall surprise, discomfort, and misunderstanding or the opposite typical, comfortable, and understanding C OMMUNICATIVE C OMPETENCE It is l anguage ability for people to functionally and meaningfully listen, speak, read, write, and physically interact with others within speech events and written texts ( Hymes, 1971) It includ es knowledge and skills of literacy, linguistic patterns, oral language, non verbal cues, background information of speech events inter sentential relationships in discourse, cultural sensitivity regarding topic relevance, speaker listener relationship, social functions in language use, linguistic register detect ion of communicat ion failures and compensation for miscommunication C OMPREHENSIBLE INPUT It is u nderstandable information generated with contextual support. Language knowledge is absorbed through comprehensible input (Krashen, 1981, 1983) C ROSS CULTURAL COMMUNICATION I n nursing it refers to oral, written, and nonverbal interactions between nurses and patients, patients family and hospital personnel who are from different cultural and linguistic backgrounds. C ULTURE A words discourse patterns social behaviors, and philosophy of life It is transmitted through time and space by


29 language, face to face communication, social activities, generations, and material objects Based on culture, we adopt co constructed percepti ons to predict, explain, and make sense of communication C ULTURAL COMPETENCE A continuous process requir es cultural knowledge, cultural skill s cultural encounters and cultural desire s to practice nursing in multicultural me dical contexts ( Campinha Bacote, 2002) C ULTURAL FACTORS I n terms of transcultural nursing cultural factors include hospital routines, medication, hospital subculture, nursing concepts, patient nurse doctor relationships medical systems, nursing ethics, insurance policies, nursing procedures, communication pragmatics, conversational styles, social topic selection, and social skills. D ISCOURSE It refers to o ral and written texts, such as cross cultural discourse. E DUCA TION It is t he way we are educated and regulated in school It is determined by the mainstream culture (Bruner, 1996). It also dominates our ways of speaking and behaviors in family, community, and workplace Education reinforces our mutual values and cul tivates students to be members in a society. The discussion of education in my study highlights i ing and on the job training E PISTEMOLOGY It is the theory of knowledge. It is how we interpret knowledge and explain what perspectives we adopt to make sense of reality (Hatch, 2002). F OREIGN PATIENT FOREIGN CLIENT INTERNATIONAL PATIEN T and INTERNATIONAL CLIENT A patient comes from a nation other than the host country. F RAMES P rinciples govern subjective consciousness. Frames store cognitive structures and guide human perceptions of a coming speech event ( Goffman 1974) I NTERLOCUTORS It refer s to two people talking to each other. I NTERNATIONALLY E DUCATED N URSE A registered nurse ha s received nursing training in his/her homelands, grown up with a language and culture other than that of the United States and migrate d to the U nited States as a nursing professional. I NTERNATIONAL NURSES and ESL NURSES Nurses work in an English speakin g country other than the home country. L ANGUAGE A system of signs, symbols, sounds, and gestures is arbitrarily created and infinitely creative to express meaning It is collectively constructed and culturally transmitted by human beings. Language change s over time and varies in


30 the essence of structures. It is a conventionally cultural tool to connect human interactions by means of negotiation and thought exchange (Vygotsky, 1978). M ANDARIN SPEAKING NURSE A nurse speaks Mandarin as his/her first language M ETHODOLOGY It represents the research process guiding methods of data collection and data analysis. P ILOT STUDY It is a trial for qualitative investigators to utilize a small scale of study before they carry out a complete research pr oject. R EGISTER A skill discern s social cultural rules of language use in dynamic real life dialogues. Register determines our word choices and ways of speaking when talking to diverse speakers in various situations (Halliday, 1978; Simon Vandenbergen, 1 983). R EGISTERED NURSE A nurse has graduated from nursing programs and passed state board or national nursing examinations to practice in the healthcare setting. S NOWBALL SAMPLING A practical technique help s researchers get started with one or few key names. Then the network begins to roll like a snowball to drag in more and more participants who meet sampling criteria and are capable of providing rich information (Glesne, 2006 ). S TUDENT NURSE and NURSING STUDENT They are alternatively used to describe a student who is enrolled in formal nursing programs in senior high school, vocational school, community college, or university. T HEORETICAL PERSPECTI VE A philosophical assumption direct s research methodology. T RADITIO NAL C HINESE M EDICINE It is t raditional medicine widely applied in East Asian areas. It comprises herbal medicine, cupping, acupuncture massage, and body balance (Galanti, 2008) T RANSCULTURAL NURSING A science focus es on theories and practices on c ulturally relevant nursing care such as a healthcare setting where nurses and patients are from different cultural, ethnic, or linguistic backgrounds. T RIANGULATION An approach validate s the credibility of research findings. It is to use multiple pers pectives to interpret a single set of information ( Guion, 2006 p.3 ). W ESTERN MEDICINE CONTEMPORARY MEDICIN E and MODERN MEDICINE A s cience retain s and restor es human healthiness including two main disc iplines of internal medicine and surgery.


31 C hapter Summary In this chapter, I explored the issues of diverse population, nursing migration, shortage of multi linguistically and multi culturally competent nurses, and procedures of visa credential and E n glish assessment in the United States. I also addressed the purpose and significance of the study. In addition, I defined key terms and posed one research question and three supporting questions in the study. The U.S. multiethnic population requires a culturally and linguistically responsive healthcare system to maintain quality medical services. Meanwhile efforts regarding international nurses education, employment, and cross cultu ral communicat ion should be noted in the contemporary nursing and TESOL field.


32 CHAPTER 2 REVIEW OF LITERATURE Overview The first section of this chapter reviews literature on historical perspectives of the interrelationship between culture, language, education, and communication. An emphasis on the conceptual framework of communicative competence is addressed. In the second part of this chapter, a discussion of empirical research and literature reviewing studies with regard to two issues is included: (a) compar ing medical culture between the Mandarin speaking and the English speaking context s ; and (b) describing f based on literature review Review of Literature on Historical Perspectives Interrelationship between Culture, Language, Education, and Communication The relationship between language, cult ure, education, and communicat ion is intertwined. In the following paragraphs, I review the literature with respect to culture, language, education, and communication Culture Culture is the sum of shared attitudes, values, beliefs, worldview, traditions, customs, and behaviors. It is historically accumulated, revised, and developed by people. It is shared by members of a community in which people are bound together by a common history, religion, occupation, linguistic system, sexual orientation, geographi c location, or socioeconomic status. Therefore, it can be seen as a filter for outsiders to understanding of words and discourse It is also a n integration influencing a nd reflecting


33 the interaction between language and thought (Brown, 200 0 ). Nieto and Bode ( 2007 ) stated that e veryone has culture. People have the ability to create and recreate ideas to affect their world in a variety of ways. Culture is transmitted throug h time and space by generations, material objects, symbols, and physical contact. Overall, the process of cultural construction is unconscious and continuous. Human beings grow up in the cultural environment surrounding them without intentionally noticing it. People develop cultural concepts and modify cultural elements through thinking, observation, participation, and interpersonal activities. Interpreting the substances of culture is socially, culturally, and cognitively determined. Some cultural substan ces do not ev en exist in other communities. Fadiman ( 1997 ) indicates that burying placenta to bless birth seems normal for the Hmong community, but it is not widely acceptable in the U.S. medical context. In some Asian cultures, inviting spiritual treatmen ts into the ward is a tradition and necessity, but it is V ia the insight of culture, people can recognize a variety of communication styles, ethnic traditions, family structures, social distance, interpersonal relationship, social hierarchy, religion, gender sensitivity, and beliefs of health among diverse groups of people (Nieto & Bode, 2007; Peregoy & Boyle, 2008). Communication Communication is interwoven with cultural schemas, family values, and interactive patterns in the environment people are born into. It consists of verbal, written, and nonverbal components. Communication requires language proficiency and cultural knowledge to understand linguistic meanings and pragmatics. Based on culture, speakers and listeners adopt co created perceptions to predict, explain, and make


34 sense of conversations. Furthermore, speakers shift speech styles from c ontext to context People present communicative skills in various ways in relation to their expected roles in society, such as in the family, classroom, workplace, and hospital. The way that speakers and listeners communica te is established by intersubjectivity (Bruner 1990), which is how people interpret others minds in a culturally appropriate manner. I take my own overseas study experiences as an example. As a female international student from Taiwan, I had limited access to diverse ethnic groups before I came to the United States. H owever, the U.S. academic world is filled with multicultural and multiethnic populations. In order to understand the American academic culture, I have observe d o n campus. I also use mass media as supportive data t o acquire social skills, such as watching real life shows, TV dramas, and Hollywood movies. I sometimes consult with friends, classmates, and professors who are from particular ethnic backgrounds about their cultural taboos and communicative politeness. Gr adually, I have overcome my awkward feeling regarding hugging or even kissing cheeks with people for greeting and parting. I try to demonstrate humor and share my thoughts in order to fit into the U.S. academic atmosphere. However, on other occasions, I am careful with word choices and body language to reveal the serious part of me to Asians who are superior to me. Being cautious and speechless is a good skill to employ whenever I am afraid of offending someone. The switch of communication styles between ou tgoing and cautious may be unnecessary and stereotyping, but as an outsider and insider of both cultures, it is how I interpret sociocultural rules of communication in different speech communities.


35 Language Likewise, language is a system of signs, symbols sounds, and gestures which are infinitely creative and arbitrarily created by people. It is collectively built and culturally transmitted from generation to generation. Language refers to a specific civilized product of each era and it changes over times For example, ancient Chinese literature is difficult for contemporary Mandarin speakers to read, write or comprehend. In the subject verb object syntax in Englis h, it is presented by the subject object verb sentence pattern in Korean -Language is a conventionally cultural tool to connect human interactions by means of negotiation and thought exchange (Vygotsky, 1978). Meaning of langu age is perceived individually according to our thinking and cultural knowledge. It facilitates human development and interpersonal communication. Oral language development is a journey of socialization. It requires people s thinking ability, linguistic kno wledge, social skills, cultural sensitivity, and psychological mechanism to encode and decode information. Everyone has an inborn ability to acquire language in which he/she is immersed (Chomsky, 1965) Nonetheless, Everyone also need s opportunities to practice language by interacting with people and environment (Lindfors, 1991; Vygotsky, 1978) In addition to oral interactions, language is correlated with communication in a printed world. Language reflect s the purposes and functions o f conversations and written texts. Literacy begins before school age and continues throughout people s lives. It is not only involved in reading and writing, but also associated with independent


36 thinking and oral language ability. People develop literacy t hrough real life events c ontaining meaningful functions ( Taylor & Dorsey Gaines 1988) Education Education is usually dominated by people who hold superior sociopolitical power in society (Bruner, 1996). It has po on developm ent and cultural cultivation. Everyone brings his/her home habits, family values, and oral traditions into classroom s Education transmits mainstream cultural values to students, including time regulation, behavior models, manners, patriotism, formality an d informality, conversational principles, ideologies, group identities, and attitudes toward economics. ic communication, children from white and black working class communities encounter ed learning difficulties in school settings when compared to students who grew up in town. Trackton African social/communicative skills were not appreciated by the mainstream middle class school values. Their vitality and curiosity toward learning were eradicated by the confusing school routines, class regulations, and time/space concepts. I n Roadville white family traditions, children were accustomed to discretion in word and deed. They ob opinions, and they were taught to make stories only based on truths. Parents had low s family values were quite opposite from the school culture where innovation, independent thinking, self monitoring, and high expectation of school achievement were


37 advocate d. These children from the white working class community in Roadville encountered more and more obstacles in school due to the cultural conflict between family and school. E ducators recognizing ESL (English as a Second Language) and bilingual identities home culture, first language literacy, second language proficiency, communication traditions, and life experiences can affect performance. Escamilla and Coady (2001) argued that some U.S. school teachers exhibited prejudic e against Spanish irrelevance of topic, and misapplying conversational language in English academic writing. H o wever, t hese studen ts were successful interlocutors in Spanish who were capable of transferr ing their L1 literacy skills to English. If ESL teachers first language and neglect how it influences ESL learners second language acquisition teachers may u The relationship between language, culture, education, and communication is intertwined. They are interdependent and mutually constrictive. Like a domino effect, people m otivate changes in communi cati on when their cultural values, educational background, and language immersion have been altered. The next section extends the discussion of the four correlated concepts by reviewing literature of the conceptual framework communicative competence. Conceptual Framework of Communicative Competence Foreign language learning started to be viewed not just as a potential predic t able developmental process but also as the creation of meaning through interactive negotiation among learners. Communicative competence became a household word in SLA, and still stands as an appropriate term to capture current trends in teaching and research


38 (Brown, 2000, p.245) The theoretical framework which I adopt for the study is communicative competence. It is the langu age ability that allows people to listen, speak, read, write, and physically interact with others in a functional and meaningful way. The competence of communication has derived from several perspectives. I start the discussion of oral language development from second language acquisition theories, and then connect to Second Language Acquisition 3 ) is a well known theory for second language development First, Krashen distinguished acquisition from learning. Acquisition is an unconscious process to gain linguistic knowledge. It is an effective way to develop second language competence by acquiring language on the basis of real life communica tive purposes. On the other hand, l earning is a formal and deliberate process to recognize and study linguistic rules. Second, in the natural order hypothesis, despite languages having different morphological, phonological, semantic, and syntactic structur es, humans acquire languages in a predic t able order. The progress sequence is universal and applied to most languages in the world. Third, language knowledge is absorbed through comprehensible input. Comprehensible input is understandable information gene rated with contextual support. One example is showing a mobile phone to ESL/EFL students when talking about cell phone devices, which is commonly known as a teaching strategy of using realia/pictures in class. Also, introducing abstract ideas through dail y life activities can facilitate


39 explaining finance management and economic issues via shopping activities. In the imal Development i + in verbal and nonverbal input. Second language learners should receive input slightly higher than their current e to the next proficiency level. Fourth, language acquisition is highly functional in a low anxi ety and less stressful environment, which is identified as affective filter hypothesis. When students learn a second language under pressure and reluctance, t he mechanism of affective filter has built up to hinder them from absorbing language input. Last, Krashen asserted that second language learners have an inherent monitor to regulate their language output in conversations, such as editing, self correcting, and clarifying what they have said. Like the innate mechanism of first language acquisition, second language ability is developed in a natural, unconscious and predic t able way. Second language learners nput. They also monitor their verbal performance and are aware of language errors. Components of Communicative Competence One needs fresh kinds of data, one needs to investigate directly the use of language in contexts of situation, so as to discern patte rns proper to speech activity, patterns that escape separate studies of grammar, of personality, of social structure, religion, and the like, each abstracting from the patterning of speech activity into some other frame of reference (Hymes, 1974, pp.3 4) The concept of communicative competence was initially introduced by Hymes ( 1971, 1972, 1974 ) a sociolinguistic advocat e of ethnography of communication. According to Hymes, when we refer to communication, it is not merely about linguistic


40 components, suc h as grammar, vocabulary, pronunciation, and spelling. Communication is an ethnographic phenomenon. It is correlated with cultural values, roles and identities, conventions and formality, communicative channels, geography, ecology, and history of a communi ty. Culture and context confine our interpretations of conversations within particular speech events. Sentences and purposes can be displayed in various ways. Hymes declared that communication is based on dynamic cooperation between speakers and listeners In order to functionally and interactively exchange thoughts and express voices, we require linguistic knowledge, nonverbal cues, background knowledge of topics, and social information of participants. Schiffrin mpetence as a combination of (p.140). Brown (200 0 ) to The dynamic concept of communication is also discussed by Bakhtin (1986). He distinguished utterance from sentence. S entence is a unit of combined linguistic features, including se mantics, phonology, morphology, and syntax. Sentence reflect s the literal structure of language instead of the reality of speech discourse. In contrast, an u tterance is a unit of communication R eal life dialogue is based on the understanding of implicati ons beyond sentences. We comprehend meanings by interpreting utterances in situated meanings Utterance is unrepeatable and lively. It is guided by speakers intention s and speech situations Utterance s also confine responses. For example, a competent ESL speaker is able to discover a literate


41 functioning diversely in multiple situations She/he evaluates the response based on the participant, tim e place, and condition such as replying with G ood t hanks 1980 development also contributes to the concept of communicative competence. Cummins proposed that academic language and social language require different capabilities: Cognitive Academic Language Proficiency (CALP) and Basic Interpersonal rmance. CALP is about demonstrating language skills in cognitively demanding and context reduced situations. It usually involves abstract concepts and complicated speech tasks, such as giving a presentation about U.S. geology in class. BICS regards communi cating with people in daily life conversations. Social language is less cognitively challenging and offers more contextual clues within conversations. For example, chatting with friends in sp eaking attitudes and facial expressions. Nonetheless some contextually reduced social events demand higher BICS, such as making a medical appointment via phone conversation. Many ESL/EFL speakers may agree that talking to someone face to face is easier th an talking theory, combined with cognition and contextual influences, has turned a new page for second language education since the late 1970s and early 1980s. Canale and S wain (1980) and Canale (1983) adapted the concept of communicative competence and defined it as four dimensions: grammatical


42 competence, discourse competence, sociolinguistic competence, and strategic competence. A successful communicat ive participant has ( 1) grammatical competence: knowledge of language verbal and nonverbal codes, including words, grammar, and sounds ; ( 2) discourse competence: knowledge of inter sentential relationships in texts, such as cohesion and coherence of conversations ; ( 3) socioli nguistic competence: cultural sensitivity regarding language use, such as topic relevance social functions and speaker listener relationship; for instance, to address interlocutors in an appropriate manner, and ( 4) strategic competence: ability to detect failures, make repairs for miscommunication, and facilitate communication efficiency, such as asking a participant to clarify what he/she has just said. Bachman (1990) elaborated on Canale and Swain (1983) concept of communicative competence through a language testing perspective. He designed a theoretical framework of Communicative Language the capacity for implemen ting, or executing that competence in appropriate, knowledge of language, knowledge of the world, knowledge of speech situation, and strategic competence. Knowledge of the world constructs a conceptual foundation for people to make sense of interpersonal interactions. Knowledge of speech situation provides information for us to know who, what, why, when, and where concerning conversations. Strategic competence is a monitori ng system to determine final speaking options generated by language knowledge It enables us to identify speech situations, determine which competencies should apply, and form an entire plan for implementing


43 competence is concerned with ability of conversational compensation in language, Bachman Bachman (1990) named knowledge of language as language competence. L anguage competence enables us to control language forms (organizational competence) and functions (pragmatic competence) in s poken and written texts. Under the umbrella of organizational competence separated a bilities between grammar (grammatical competence) and discourse (textual competence). Grammatical competence, is concerned with language rules at the sentence level: an ability to correctly master lexicon, spelling, syntactic rules, morphemes, phonemes, an d other linguistics features. Textual competence involves rhetorical organization in inter sentential level: a skill to make discourse logically sequential, coherent, and cohesive. In the dimension of pragmatic competence, Bachman emphasized functional an d cultural aspects of language use. Pragmatic competence regulates language functions in sociocultural use, including illocutionary competence and sociolinguistic competence. According to Halliday (197 3, 1975 ), huma ns are capable of implementing multif aceted language functions to communicate meaningfully. For example, p eople use language as a means to get things done (instrumental function ), to invite others to conversations and interactions (int eractional function), to ask questions (heuristic function ), to make up situations (imaginative function ), and to convey a message to others (representational function)


44 Illocutionary competence is the ability to manipulate language functions (e.g., complaining, questioning, and criticizing) and to discover implications beyond indirect speech acts. human language: how to accomplish actions by speakin g. Examples of speech acts are apologizing, showing appreciation, and making suggestions. Austin divided utterances into locutionary act, illocutionary act, and perlocutionary act. Locutionary acts include sounds, words, and literal meaning of a sentence, instance; the illocutionary act is requesti ng the host to turn on the air conditioning. Perlocutionary act is the effect on thoughts or actions by noting in this example. Searle (19 6 9) further defined speech acts into five classes: representatives, commissives, expressive, directives, and declarations. Representative is an act to B achman 1975 ) language function theory all emphasize the significance of manipulating the multifunction of language within communicative competence.


45 sociocultural knowledge of language use. It allows us to implement language functions appropriately in specific speech events. For example, people show politeness to the elderly in ceremonies and use formal language in business meetings. It requires people s awareness of dialectal variations and ability to reflect diversity. Linguistic register (Halliday, 1978 ; Simon Vandenbergen, 1983) is related to the strategic competence which Canale (1983) proposed and the sociolinguistic competence that Bachman (1990) stated. It is a skill to discern social cultural rules of language use in dynamic real life dialogues. Register determines our word choices and ways of speaking when talking to diverse speakers in various situations. Brown (2000) defined register a s a variety of words, pronunciation, phrases, and expressions which imply that speakers are from certain occupational groups or social class. Nonetheless, withi n systematic functional linguistic viewpoints, register is not restricted to occupational or soc ioeconomic distinction. It is applied in a wider aspect that any single language speaker can make multiple linguistic choices within any social activity ( Burns Joyce, & Gollin, 1996 ). For instance, we naturally talk formally in front of people who are sup erior to us and talk casually to our intimate friends. We nickname our family members but carefully address new acquaintances by their highest socioeconomic achievement, such as Miss Chan, Professor Jackson, Dr. Yeh or President Ma We form and shift regi sters based on the contextual variables: field, tenor, and mode ( Halliday, 1978 cited in Burns Joyce, & Gollin, 1996 ). Field is concerned with what the social communication related to, such as a dinner invitation. Tenor is about participants involved in the conversation, including social


46 relationship, power, and identity of the speaker listen er, such as student professor, daughter father, and husband wife. Mode refers to how communication occurs, such as talking on the phone or writing in emails. Dimensio ns of register are varied across languages because every speech community has its own cultural values in terms of how to speak politely. The complexity of cultural influences in register explains the challenge facing second language speakers to perform Eng lish in a conventionally appropriate way in diverse speech situations. Pragmatics is also an important concept when discussing competence of communication. It is a study of meaning and context of communication. It examines how we use language within a part icular context and why we use it in a specific way. The following examples explain pragmatics in conversation Example 1: Student Mei A (Taiwanese) is initia t ing small talk with her English teacher, Shane (Amer ican) : Mei A : The traffic is terrible. Shane: Yeah, right. You can say that again. Mei A : Oh, the traffic is ter rible [ answering Shane perplexedly ] Shane: [ silence Example 2: James (American) is talking to his big sister, Michelle (American) : James: The traffic is terrible. Michelle: Yeah, right. You can say that again. James: The traffic is terrible [ teasing Michelle with a naughty smile ] Michelle: [ silence ]


47 E xample one, above, displays a lack of pragmatic skills leading to illogical dialogue. For the second language speaker Mei A it is difficult to interpret specific idioms utilized in particular contexts. E xample two provides the same literal sentences but a totally different atmosphere. English native speaker, James, is pretending that he means. The most well known pragmatics theorist is Grice (1975), who stated that communication should be built on cooperative principles between speaking participants. Gricean pragmatics maxims comprise four principles: quantity, quality, rel evance and manner. Quantity is concerned with how we make information adequate and not excessive when speaking. Quality is about telling truths. Rel evance is regarding appropriate/clear topic connections and talking in relevance to participants. Manner is the skill t literal meanings of a sentence (locutionary act) in discourse, but instead, we interpret e conclusions of meanings. Implicatures are inferences helping us make sense of conversations through words, background knowledge of topics, and maxims of cooperative principles. If we go back to the example 2 with Michelle and James, Michelle is aware of with her. As a native English speaker immersed in American English culture, she cooperative principles. T


48 conversation. Communication is an ethnographic phenomenon which represents a particular (Schiffrin, 1994). However, Gricean pragmatics maxims of quantity, quality, relation, and manner do not take nonver bal elements of communication into account. Like written and spoken language, nonverbal communication is one of the cultural products created by civilization. The way we act approach, smile, nod, shake head, bow, step backward, wrinkle eyes, or shrink sho ulders is highly associated with culture. cause spirit loss. Even clothes and dressing play a role in interpersonal interactions considered aggressive when a female guest elaborately dresses up in white to disrupt a wedding. In Taiwanese culture, wearing red i blessings to the newly married couple. Nevertheless there is no white clothing taboo. Guests can dress in any color except for black at a wedding. In funerals, Taiwanese wear black clothes a nd cautiously avoid red dress Ariza, Morales Jones, Yahya, and Zainuddin (2007) describ ed the importance of cross cultural pragmatics for ESL learners. Having correct knowledge of English grammar is not enough for fluent ESL speakers. They should also understand how language is spec ifically used and expected in the U.S. mainstream culture. For instance,


49 Referring to my experiences as an international student in Australia and the modesty is highly promoted based on the re gulations of Confucianism. I always feel I know the call ing attention to cultural and contextual influences in communication has shifted the emphasis of grammatical teaching toward the trend of a communicative approach pedagogy and assessment in ESL and EFL education over the last 30 years (Baleghizadeh, 2007; Chen, 2006). The concepts of the above conceptual framework are also synthesized in two figures provided in th e end of this section. Figure 2 1 establishes a chronological trace of language develop ment in communicati ve co mpetence Figure 2 2 illustrates the components of communicative competence.


50 Figure 2 1 Chronological d erivation of c ommunicative a bility d evelopment ( Note: s ynthesized from Austin 1962; Bachman 1990 ; Bakhtin, 1986; Canale 1983; Canale & Swain 1980 ; Cummins, 1979 1980; Grice 1975 ; Halliday 1973 1975, & 1978; Hymes 1971, 1972 ; Searle 1969 )


51 Figure 2 2 Components of c ommunicative c ompetence ( Note: s ynthesized and adapted from Ariza et al., 2007 ; Austin 1962 ; Bachman 1990 ; Canale 1983; Canale & Swain 1980 ; Chomsky 1959 ; Grice 1975 ; Halliday 1973 1975, & 1978 ; Hymes 1972 ; Searle 1969 ) Review of Literature on Contemporary Issues cal experiences and therefore competence can vary from culture to culture, country to country, or even region to region. Despite these constraints, nurse migration continues to be fuelled by (Hancock, 2008, p.261) E very community has its specific behavior patterns mannersims of speech attitudes toward education and values of health which also affect how we make sense of the world. M edicine is interpreted differently by people from diverse background s U nfortunately the reality is that people usually expect internationally educated nurses to act exactly as mainstream nurses do in the host community International nurses are capable of being sensitive to multicultural patient s. Their bilingual and bicultu ral


52 competencies contribut e considerably to the ethnically diverse society of the United States N onetheless the challenges faced by international nurses working in a host country are culturally, linguistically, educationally, communicatively emotionally socially, physically, and politically extensive Hearnden (2007) conducted a qualitative research on communicative needs for internationally educated nurses in Canada. The study revealed that in order to work in an English speaking country, international nurses deal t with stressful and extensive challenges, including immigration screening, cultural adjustment, communicative obstacles, financial burden, family responsibilities and relationship disconnection with the original country. Xu and Kwak (200 5 ) adopted a secondary analysis method to examine from the 2000 National Sample Survey of Registered Nurses in the United States Co ntrasting with U.S. mainstream nurses, international ly educated nurses were inclined to be single and young They were assigned heavier duty and longer working hours. Moreover, Gardner (2005), Sherman (2007), and Xu et al. (2008) s uggested that i nternational ly educated nurses ran high risks of suffering isolation, homesickness, depression, injustice racism, and discrimination. For instance, t hey left home alone and had limited social circles and family contacts to support them in t he new community Their responsibilities were great but their pay was small. They received less job promotion chances compar ed with white nurses. Sometimes, their accents were ridiculed by mainstream nursing peers. Furthermore, their nursing competence was frequently questioned by patients and healthcare colleagues simply owing to their skin color or accents rather than their professional training and nursing qualifications.


53 Comparative Medical Contexts Contemporary medicine also known as western medicine and modern medicine is the science of retaining and restoring human healthiness by prevention and treatment of mental and physical illnesses. It includes two main disciplines, which are internal medicine and surgery. Weste rn medicine rule s the current U.S. medical industry. In Mandarin speaking countries, such as China and Taiwan, it is common to see a mixture of Traditional Chinese Medicine (TCM) and modern medicine ( D'Avanzo, 2008 ) Traditional Chinese Medicine comprises herbal medicine, cupping, acupuncture message and body balance. According to contemporary medicine, diseases are caused by germs. However, based on TCM perspectives, the upset of body balance is the key cause of illness (Galanti, 2008) While western med icine is defined as an invasive intervention to human body, Chinese medicine is well known by its natural and moderate treatment towards health. Mandarin Speaking Medical Context In Mandarin speaking medical co ntexts such as China and Taiwan, the entire h ealthcare system and atmosphere is doctor centered. Physicians are images of authority and expertise who have superior medical knowledge. N urses are usually females who serve supplementary roles to assist doctors. They are inclined to follow doctors medical orders and accomplish task oriented nursing jobs (Sherman, 2007; Xu et al., 2008) Nurses have a heavy workload and rush in and out in the stressful working environment. In China, the ratio between nurses and patients is 1 nurse per 1,000 people ( D 'Avanzo 2008) In Taiwan, registered nurses and licensed practice nurses in general wards are in charge of eight or more hospital beds per shift which is twice the U.S. nurses working burden.


54 In Asian and Mandarin speaking contexts, p atients tend to be given little information about doctors diagnos es treatments and medications (Geissler, 1998; D'Avanzo, 2008 ) Similar situations can also be found in Taiwan By and large, medical diagnoses and medical documents are written in English vocabulary and phra ses instead Mandarin. T aiwanese p atients usually have limited access to their health conditions and are discouraged to ask questions Furthermore, Giger and Davidhizar (2008) also declared that Asian patients tend to wards acting like subordinates to healthcare professionals Although East Asian patients are confused regarding prescription they may hesitate to ask for clarification They are inclined to be less opinionative and mak e fewer requests during medical visits. Com par ed with patients from European and U.S. backgrounds, Asian patients are also more reluctant to express their feeling s of pain To some extent, Asian people interpret health, illness and treatment differently from mainstream American viewpoints. For in stance, Asian people believe that human s neutrally co exist with nature rather than control nature (Galanti, 2008). The core value of Traditional Chinese Medicine keeps the human body balanced rather than radically chang ing body conditions. The neutral per ception also affects patients acceptance of invasive treatments. Additionally, influenced by Taoism Buddhism and Confucian ism valu es regarding the past, Asians seem to cherish the memory of the past and respect for the elderly (Munoz & Luckmann 2005). They are dutiful for personally taking care of any elderly family member who is sick rather than leav ing him/her alone with healthcare professionals. Lipson and Steiger (1996) argue that it can be more challenging to


55 persuade people who care about the past than who are present orientated or future oriented to change current behaviors in order to prevent illnesses Taiwan, the country where I grew up, has its specific medical system, hospital regulation and nursing culture. The Taiwanese population is composed of five linguistic and ethnic groups including Holo, Hakka, aborigine, mainland Chinese, and a host of immigrants (Perng, Lin, & Chuang, 2007). Mandarin is the official and popularize d language in healthcare communication We are accustomed t o using Celsius for temperature, centimeter for height and kilogram for weight Taiwanese government establishes a national health insurance for citizens and foreign visitors who have legally resided in Taiwan beyond four months. Even though our medical c ulture encourages an appointment system, a walk in policy is conventionally acceptable in many private clinics and regional hospitals. In the outpatient department, p atients are usually gathered in a waiting lobby before seeing a doctor When a physician gives medical consultation, we probably share the same clinic room with one and two more patients during the consultation. C onsequently patients confidentiality may not be completely concealed When the physician keeps staying in one room throughout his/her clinical hours, outpatients are frequently asked to move from room to room in order to complete examination and treatment procedure s Generally, outpatients in Taiwan benefit from high clinical efficiency. Patients are able to complete the entire m edical procedures with one time medical visit s including seeing a doctor, making examinations, receiving medical treatment s, picking up prescriptions and paying medical bills at the clinic and hospital.


56 English Speaking Medical C ontext Broadly speaking, U.S. medical service is more patient centered and privacy oriented Physicians are not the only actors/actresses who enjoy the spotlight in the medical setting. Healthcare professionals distribute the burdens of medical care. U.S. registered nurses are tr eated as nursing practitioners who are capable of thinking critical ly and manag ing cases independently Compared with nurses from overseas U S registered nurses benefit from a more flexible working schedule a lighter workload better welfare and higher socioeconomic status (Hancock, 2008; Hawthorne, 2001 ; Kingma, 2001 ; Kline, 2003) On average, American culture values autonomy independence, freedom, privacy, capitalism heal th, and fitness (Galanti, 2008), which implies Americans medical in teractions. Americans are characterized by an adventurous spirit and a willingness to challenge nature by embracing the future and are open to new medicine and in vasive interventions (Munoz & Luckmann, 2005). Mostly, families expect the hospital team to ad dress patients inpatient care, such as feeding, bathing and sputum suctioning In addition, it is easy for p atients to acquire health information from TV commercials, health magazines, medical consultations, or other channels U.S. patients are able to fo rm their own opinions about interventions which is probably ascribed to the advocacy of individualism and critical thinking in the U.S. culture. T he U S patient structure comprises a c ulturally and linguistically diverse population. Americans use Fahren heit inch and pound for health m easurement Patients are covered under private health insurance policies or hold a non insured status. Except for particular emergency clinics and walk in clinics patients are usually expected to make an appointment s consultation Out patients


57 are usually assigned an individual room during the consultation. C ontrast ing with patients in Mandarin speaking contexts, they enjoy better privacy and confidentiality (Xu et al., 2008). Patients are al lowed to physically stay in one room alone while doctors and nurses are in and out of the room to provide medical services. N onetheless sometimes finishing a whole set of medical procedures for patients is time consuming Patients are expected to schedule multiple appointments to get cured. They may spend one day in doctor s consultation, other day for examination, and another day for treatment. P atients usually go to pharmacies outside the hospital to pick up prescription Instead of paying fees right aft er the medical visit, patients wait for medical bills sent from health insurance companies to make a payment. The above paragraphs provide readers an introduction to Mandarin speaking and English speaking healthcare environment s However categorizing med ical culture into Weste rn and Asian English speaking and Mandarin speaking, or U.S. and Taiwan context runs the risk of overgeneralization Pointing out the characteristics of the comparative medical world constructs a foundation of understand ing essentia l differences and build ing on similarities of the two medical communities for readers It is important to understand intra ethnic individual variables and avoid stereotyping healthcare practitioners and patients from certain ethnic groups. The characteristics of the comparative medical contexts are also presented in Table 2 1.


58 Table 2 1 Medical c haracteristics between English s peaking and Mandarin s peaking c ontext Characteristics English s peaking c ontext ( i.e., United States) Mandarin s peaking c ontext ( i.e., Taiwan) Science of Medicine Western medicine (also known as contemporary medicine and modern medicine) Modern medicine and Traditional Chinese Medicine Diseases caused by germs Illnesses caused by upset body balance Radical and invasive medical intervention Neutral towards body and health Population Culturally and linguistically diverse patients Five linguistic and ethnic groups: Holo, Hakka, aborigine, mainland Chinese, and various immigrants Dominant Language English Mandarin Health Insurance Private health insurances National health insurance Measurement Fahrenheit, inch and pound Centigrade, centimeter and kilogram Medical Atmosphere Patient centered Doctor centered Time Orientation Future oriented (prevention is more acceptable) Past oriented (changing behaviors for future prevention is less acceptable) Human and Nature Challenging with nature (radical treatment is more acceptable) Neutrally co exist with nature (invasive treatment is less acceptable) Role of Doctor Shares duties with healthcare professionals Image of authority and expertise of medical knowledge Role of Nurse Independent nursing practitioner Critical thinking and independent judgment Following task oriented nursing care In charge of 4 6 hospital beds per shift ( general wards) In charge of 8 or more hospital beds per shift ( general wards) Role of Patient Privacy and confidentiality protected Less privacy protected Aware of health related issues and opinionative about medicine, treatment and intervention Less informed about medical treatment Role of Family Reliant on hospital team to accomplish inpatient care Responsible for family Note. Synthesized from D'Av anzo ( 2008 ), Galanti ( 2008 ), Geissle r ( 1998 ), Giger and Davidhizar ( 2008 ), Lipson and Steiger ( 1996 ), Munoz and Luckmann ( 2005 ), Perng, Lin and Chuang ( 2007 ), S herman ( 2007 ), and Xu et al. ( 2008 )


59 F actors Affecting Cross Cultural Clinical Communication T he nature of trans cultural nursing communication is intricate and complex. Internationally educated nurses communication experiences are influenced by how people use language, how they interact physically, how they interpret culture how they speak rhetorically and how they apply conversational patterns. Context Contexts (also refer to environments) communicati on experiences The ethnicity and age population of p vary among nations Also, every country has it particular common illnesses (Bola et al., 2003) For example, U.S. large proportion of obesity and hypertensive i s not common ly seen in other countries. Furthermore the U.S. culturally and linguistically diverse population increases the complexity of communication for ESL nurses. Providing healthcare service s in the U.S. demands international nurses competen cy both in language and cultur e W ithout sound accommodation and tran sitional training i t is im practical to expect mono ethnic nurses to demonstrate high communicative competence when they are in charge of ethnically diverse clients. The U.S. healthcare context has its specific nursing care and discourse patterns distinct from international home experiences Asian nurses seem used to a task oriented and doctor centered e nvironment They experience cultural confrontations when working in the patient centered environment in the United States highlighting nurses auto nomy and critical thinking ( Sherman, 2007) A ddition ally different medical systems, health insurance policies, and staff patterns lead to contradictory expectations of nursing jobs between patients and nurses It is possible that internationally educated


60 nurses encounter a communicati on situation that never occurred to them when they worked in the home country Culture C ulture confine s our interpretations of medical conversations We all possess our own perception s toward medicine. C ulture influences our basic concepts and cognitions in many aspects which leads to different expectations of medical interactions. Cultural barriers build even higher blockage than second language deficiency A second language speaker or a medical interpreter who is unfamilia r with the beliefs of communities can still encounter communication failures. M lack of cultural knowledge, cultural awareness and cultural skills may result in miscommunication or even worse fatal damage to patients. Fadiman (1997) analyzed a cross cultural medic al case of a Hmong family in the United States. Through studying the Hmong s culture, history, philosophy of health, refugee status, and spiritual life Fadiman concluded that the U.S. ignorance of the Hmong English barriers and self sufficiency traditions caused misinterpretation of their resistance toward medical interventions For example, common medical routines, such as t aking blood samples and giving injections could result in severe communicat ion conflict s because the two concept s ha d never existed in Hmong traditions In addition, t he illiterate background of the Hmong family increase d the difficulties of reading measurements and administering medication. In Hmong community, the perception of time was not regulated by 24 hours as in modern society. The disease of epilepsy was rationalized as a spirit coercing the patient to make him/her fall down. Cross cultural communication was frustrating for the medical team and the


61 Hmong family. The Hmong family just d id not fit the interactive patterns that doctors and registered nurses ha d been trained to deal with Culture also restrains our perspectives of d iseases Depending on the culture, illnesses may be attributed to spiritual loss, spiritual damage, germs or body imbalance Galanti (2008) argued that s ome Asian culture s view human s as parts of nature rather than control ler s of nature It influences people s perceptions whether medicine is invasive or noninvasive to health. W hile middle class American s tend to be future oriented about time, progress, and change, Asian values seem to request people to remain in state. Nurses also require cultural competence to comfort patients and families about dying and death based o n their cultural and religious backgrounds. Another example is how cultural customs conflict with hygiene Some Indonesian patients refuse to use chopsticks and insist on using their bare hands to eat hospital meals ( Chien & Tsao, 2009) The variety of cul tural beliefs can result in diverse expectations of medical communication between doctors, patients and international nurses. In some culture s m edical communication relies more on nonverbal cues than oral conversations. L ack of c ultural knowledge in language use may also cause international nurse miscommunication and social isolation. Bola et al. (2003) indicated that i n the United States communication largely depends on oral utterances Relatively, i n Japan and Korea, communic ation relies to a great degree on nonverbal cues to show emotions, personal distance, and social relationship, such as nodding, bowing, or standing behind or beside the speaker to show attention Moreover the intricacy of nonverbal cues also challenges ES L nurses cross cultural communication For example international


62 nurses should know that when native Alaska patients raise eyebrows it represent s yes and when wrinkle nose it signif ies no (Nieto & Bode, 2007) Also, international nurses should be awar e of gender and social distances in different cultural and religious regulations when they physically assist patients. Education School literacy is usually established by the people who have superiority in ethnic ity or socioeconomic status. The way we are educated and regulated in school is determined by the mainstream culture which also dominates our ways of speaking and behaviors in family, commun ity, and workplace (Heath, 1983 ; Bruner, 1996). Education reinforces mutual values and cultivates students to be members in a society. In Taiwan, education is highly valued and emphasized. From individual, family to the whole country, nearly everyone is judged by the philosophy of Confucianism. Our lives, learning, career, politics, relationships, and social behaviors are largely guided by humaneness ( ren ) ritual ( li ), loyalty ( zhong ), and filial piety ( xiao ). In my generation (1980s), we are taught to obey customs, respect the elderly, appreciate what we have, be filial to parents, be kind to people, and be loyal to authorities. N onetheless there are always exceptions. Individual differences and impacts brought by globalization gradually shift some traditional values toward the West, such as the nuclear family structure an d Americanized social skills. With regard to nursing education, Peng and Hsu (2005) adapted argument about the Western Chinese nursing training While science, law and religion tend to form the basis of Western school culture Chine se schooling is founded on humanism and sensibility. School ing in English speaking countries is more scientifically oriented and devoted to finding the omnipresent truth. In Taiwan, humanistic education


63 is valued. N urs ing students develop both humanism and professional knowledge in nursing programs. They are taught to be kindhearted to people [ virtues ( de )], to tell right from wrong [ wisdom ( zi )], to keep a healthy condition [ body ( ti )] and to be cooperative with patients, colleagues, supervisors, and social members [ public relation ( qun )] In general, a test oriented curriculum is common in Taiwan There is a tendency for students to choose a field of study determined by their scores on the national college entrance exam (Yen & Stevens, 2004) L ack of options in choosing majors may lead to lack of devotion to the nursing profession after graduation. choices of major based on their personal interests. Wang, Singh Bird and Ives (2008) semi structured interviews and thematic content analysis. Findings indicate d that participants ha d issues transitioning from teacher centered and lect uring oriented classes to seminar and tutorial based classes. Success in the Australian curriculum relie d on a large proportion of oral presentation, independent learning, and critical thinking. N evertheless from a n Asian communicati on tradition in which listening is a virtue, the Taiwanese nursing students encounter ed academic obstacles caused by cultural clashes rather than English language deficiency or intelligence disability M oreover, participants in Wang et al. (2008) research claimed that in additi on to language barriers and cultural conflicts, the unique Australian nursing regulations attitudes toward health, approaches to nursing, and medical systems also impede d the m from succeeding academically and clinically.


64 Xu Gutierrez and Kim (2 008) condu cted a phenomenological study examining nine immigrant Mandarin speaking nurses working experiences in the United States. Seven informants were from Mainland China and two came from Taiwan In the in depth interviews, p articipants declared that hierarchy was valued in their home countries T hey were offended when the U.S. subordinates rejected their orders. A ddition ally education influence s distinguishing from English speakers. Overall, Asian speakers tend to be caref ul regarding what they say They are used to speak ing in an indirect manner and allowing t he listener to save face. On the contrary, American speakers are used to direct expressions ( Escamilla & Coady, 2001; Kaplan, 1996) Gardner (2005) investigated 15 et hnic minority students experiences studying in a white dominate nursing program in California. By means of analyzing in depth semi structured interview, Gardner indicated that racial minority students were concerned about discu ssion styles and argumentative attitudes in and out of classrooms. Bosher and Smalkoski ( 2002 ) and Sherman ( 2007 ) also stated that one of the common difficult ies facing ESL nurses and nursing students was showing assertiveness Language Language is one of the main factors that influence nurses communication experiences First, t he diversity of written and speech texts for medical purposes increases the complexity of cross cultural communication for internationally educated nurses Accord ing to Lee ( 1998 ) and Lee ( 2005 ), nursing involves a variety of tasks, such as dictati ng listening to chief complaints and symptoms and reading diagnosis reports. Beside s encountering discourses relevant to health issues, it is common for ESL/EFL nurses to face small talks with a variety of speakers


65 Studies show that ESL nurses are requested to be competent in showing assertiveness to patients, communicating via telephone, pronouncing appropriate stress and intonation, ask ing patients and supervisors for clarification, and talking about social topics beyond healthcare issues (Bosher & Smalkoski, 2002; Sherman, 2007; Xu et al., 2008) Participants of i nternational nurses in Hearnden s (2007) research also stated that talking on the phone was quite a challenge for them even in daily life situations, no t to mention difficulties inherent in call ing doctors for medical orders. Second, chang ing speaking styles when taking to different speaker s is complex Addressivity is the abili ty to talk to diverse speakers in various culturally specific ways (Bakhtin, 1986). It reflects speakers and social proximity. As beginning English speakers, EFL/ESL nurses ha ve difficulties in switching talking to a prior study (Ho, 2008 ), the participant EFL nurses utte red fragments or incomprehensi ble sentences to foreign instead of going to put you rather than and in place of ESL /EFL nurses use their existing knowledge of medical terms and abbreviations to cope with cross cultural communication. N onethe less insufficient knowledge of grammar and register leads to potential risks for mis understanding Selecting suitable words and comprehending f speakers or registers r esult in particular communication styles and speech patterns in patients and families.


66 Third h ow nurses pe rceive the speech event and construct meaning is restrained by prior experiences According to Goffman (1974), the principles of governing subjective consciousness are frames. Frames store cognitive structures and guide human perceptions of a coming speech event For instance, when a nurse is informing family members about a patient s death (speech event), she is activating her preoccupied frame of dying and death (cognitive structure) However, frames are flexible and uncertain. We unconsciously adopt and adjust our frames based on particular occasions, participants, time, and communicative patterns of discourse C ommunicative competence requires the ability to choos e the appropriate frame. International nurses need to be familiar w ith various ways of talking about one topic with different people in various settings For instance, they switch styles when talking about body care and death with Islamic people Christian s or Buddhist s in daily life conversation or in nursing discourse Fo u rth, diverse medical literacy also result s in communication chaos. Take Taiwan and U.S. for example. W hen a patient has respiratory collapse, Taiwanese medical emergency team instead of which is regularly adopted by the U.S. medical industry Taiwanese I n addition h ospitals in Taiwan and U.S. rely on different technology to manipulate medical equipments. T he above examples imply that inter nationally educated nurses may easily misapply their homeland experiences to U.S. nursing practices and lead s to unpredictable medical miscommunication. I synthesize the above arguments and present them in the Table 2 2. The intention is to provide a comparative perspective to readers about characteristics between


67 English speaking and Mandarin speaking nurses rather than reinforcing any stereotypes of the two speech community. Table 2 2 C omparison between Mandarin s peaking and English s peaking n urses Mandarin s peaking n urses English s peaking n urses Cultural Values Harmony, hierarchy, and obedience Argumentative and challenging Conformity and collectivism Uniqueness, individualism, and competition Education Humanism and arts; Sensibility oriented education Science, law and religion; Science oriented education Choice of field of study is determined by scores of the national college entrance exam Flexible application system in educational system to more dir choosing fields Structured, teacher centered, lecturing oriented learning environment Independent learning, critical thinking, presentation, assessment, seminar and tutorial learning environment Communication Indirect, beatin g around the bush, low occurrence of assertiveness Direct, linear, assertive C ommunication relies on a great degree of nonverbal cues C ommunication mostly depends on verbal utterances Listening is stressed Expression and speaking out are stressed Nursing Practices Nursing care is more task oriented Nursing care is more independent with clinical judgment Nurses serve in roles as Nurses practice individual works, higher socioeconomic status Doctor centered atmosphere Pat ient centered healthcare philosophy Note. Synthesized from Adeniran et al. ( 2008 ), Bola et al. ( 2003 ), Choi ( 2005 ), D'Avanzo ( 2008 ), Gardner ( 2005 ), Geissler ( 1998 ), Munoz and Luckmann ( 2005 ), Peng and Hsu ( 2005 ), Perng et al. ( 2007 ), Sherman ( 2007 ), Wan g et al. ( 2008 ), and Xu et al. ( 2008 )


68 C hapter Summary To conclude, this chapter reviewed literature on culture, language, education communication second language development, and communicative competence In the second part, this chapter compared medical culture and described factors affecting international nurses communication experiences I nternationally cross cultural communication experiences are influenced by the interrelationship between environment, language, cult ure, education, and speech situations they encounter. C onflicting professional values, medical relationships, nursing philosophies, and expectations of nursing roles can communicati on experiences. M oreover the d if ferences in hospital subculture and medical literacy may also impede their communication The unfamiliarity with the U.S. healthcare delivery system, management of pain, nursing assessment nursing procedures, medication administration, medical technology, and working with multicultural populations all increase the difficulties of their adapti on to the U.S. healthcare context (Adeniran et al., 2008; Bola et al., 2003; Sherman 2007).


69 CHAPTER 3 METHODOLOGY O verview This study was based on the theoretical perspective of constructivism embedded in the epistemology of constructionism. Qualitative c ase studies were employed in order to gain a better understanding of internationally educated nurse s perspectives, experiences, values, and beliefs of cross cultural communicati on events. I used purposeful sampling to recruit five Taiwanese nurses to participate in the one semester research period The primary data included individual interviews and focus group interviews. The supplementary data w ere com posed of background information derived from surveys, observations, and post interview reflection journals. A combination of narrative analysis and thematic analysis was used as an analytic tool to examine the data. In th is chapter, I describe the research design including the data collection method s and data analysis I also discuss trustworthiness, triangulation researcher subjectivity, and research limitations Theoretical and Epistemological Perspectives of the Study Meanings are constructed by human beings as they engage with the world they are interpreting. Before there were consciousnesses on earth capable of interpreting the world, the world held no meaning at all. (Crotty, 2003, p.43) This study investigated h ow internat ionally educated nurses perceived their cross cultural communication experiences in the U.S. medical context In social science, epistemology is the theory of knowledge. It shows the relationship between the knower and what is known (Hatch, 2002). It inclu des how people interpret knowledge and explains what perspectives are adopt ed to make sense of reality. Epistemology is viewed as a philosophical base for qualitative studies because it guides the theoretical


70 perspective and research design. The theory of knowledge in this study is constructionism. According to constructionists ( Berger & Luckmann 1967 ; Crotty, 2003), knowledge is not discovered. R eality is neither instinctively determined nor neutral, as it cannot exist without human interpretations. On th e contrary, human s construct k nowledge through interactions with objects, other human beings and the world around them Constructionists posit that reality is based on what humans believe it to be. T heoretical perspective is a philosophical assumption di rect ing the research methodology. The perspective adopted in this study is constructivism Constructivists emphasize how individuals value their worlds through their own meaning making ( Crotty 2003). In this perspective, multiple realities can co exist because people use personal experiences and cultural frames to construct meaning. Meaning in communication depends on how the speaker and listener make sense of the encountered speech events. Further, within this perspective, knowledge neither exists arbi trarily, nor is it subjectively de termine d. People experience communication behaviors, phenomena and social events to identify their feelings via interaction s between their surroundings and consciousness Constructivists also posit that there is no absol ute truth. Everyone s meaning making is unique and valid. Human s simply use different perspectives to legitimize what they believe. Hadjistavropoulos qualitative research seeks to understand and articulate the meanings of p eople s experiences rather than formulate general laws of behavior (p. 163 ). Q ualitative inquiry aims to investigate people s experiences in natural situations. It describes how people perceive their world. Wh ile quantitative research involves designing, deciding, predicting, and inferring data ( Agresti


71 & Finlay, 2008) to find general rules or average results of specific phenomena by using statistics and numbers, qualitative research ers use d etailed and thick descriptions to present findings. C ommunication is a dynamic social phenomenon Cross cultural communication involves complex elements of language thought, culture, context, speech topics, speech members, and social relationships. This study sought to understand international nurses exper iences i n their own terms. A final statistic al number c ould not have descriptively and comprehensive ly answered my research questions. In order to have an insightful understanding of Taiwanese nurses values and experiences of cross cultural communication, I therefore chose to conduct a qualitative study to collect in depth data from nursing participants Research Design Methodology represents the guiding methods for data collection and data analysis in the research process. Baxter and Jack ( 2008 ) noted that the tradition of case study is research that explores a contemporary phenomenon with specific people within a particular context. The boundar ies of the study are clear which helps the researcher to focus on the interrelationship between parti cipants phenomen a, and contexts. Case stud ies incorporate various data collection methods to gather deep and rich data from sources such as interviews, observation s documentation, artifacts, and field notes. In this study, I endeavored to discover how in ternationally educated nurses ( the participants ) describe d their experiences in communication ( the phenomenon ), and how they ma de sense of their feelings and perspectives associated with the unique U.S. healthcare setting ( the context). A s a result I chos e a case study design to answer my research questions. T a ble 3 1 provides an overview of the research taxonomy of the study.


72 Table 3 1. Overview of r esearch t axonomy Epistemology Constructionism : Knowledge is constructed by people through interactions with objects, human beings, and the world around us. Understanding that reality is based on what we agree it to be. Theoretical p erspectives Constructivism: The way that people see the world is a subject object interwoven product. We experience communication behaviors, phenomena and social events to declare feelings via the reciprocal interaction between the surroundings and consciousness. Conceptual f ramework C ommunicative c ompetence: This concept encompasses the language ability to functionally and mean ingfully listen, speak, read, write, and physically interact with others within speech events and written texts. Methodology Case s tudy: This methodology is a research tradition that helps researchers focus on the interrelationship among participants, phe nomena, and contexts. Sampling Criteria of the five p selection: Speak ing Mandarin as the first language P ossessing intermediate or higher level of English Receive d nursing education and professional training in the home country (Taiwan) Currently work ing in the U S healthcare context D ata c ollection Primary d ata: Individual interviews and focus group interviews Secondary d ata: Background Information surveys, observations and field notes, and post interview reflection journals Data a nal ysis A combination of narrative and thematic a nalysis : This method emphasiz es the analysis of stories told by participants regarding their experiences in personal events. Patterns were identified as they emerged from the data


73 This research design ha d two phases : a pilot study and the main data collection period with the five participating nurses An approved IRB protocol is located in Appendix A Phase I: Pilot Study Pilot work is a trial for qualitativ e investigators to implement a small scale study before they carry out a complete research project. Sampson (2004) noted that pilot studies help researchers become prepared and better prepared (p.392). I conducted pilot work to examine whether the interview questions were robust enough to capture the data that I needed to conduct a larger scale study. The methods used included interviews with an internationally educated Mandarin speaking nurse and observ ation of cross cultural, clinical communicati on among the international nurse, U.S. patients, and U.S. healthcare staff. I began the first pilot study under an approved, b ehavioral/ n on m edical IRB in May, 2009. However, a fter realization that the observation s in clinical settings required additional c onsents from patients, families, and hospital staff under the medical IRB approval, which I was not authorized to collect, I revised the pilot study by reapplying for permission The revised pilot study sought to collect data from one international nurse v ia interview and non medical observation s The study was subsequently implemented a second time in March, 2010. Results from the pilot study indicated that I needed to narrow my interview questions by targeting rather than work experiences For example, I revised the questions Can you describe the difficulties at work? to Can you describe the difficulties you face when you communicate with people at work? I also edited the questions using field specific ( TES OL ) terminology


74 which caused my nursing participant some confusion For example, I replaced the question, What components of competence are needed when you work to In what situations do you use (oral and written) English at work? ; In terms of listening speaking reading, and writing, what skills do you use frequently at work? ; and What skills are you good and not good at? I n addition, I revise d an item on the background information sheet by adding home country professional background I learned that international nurses f ormer working experiences could be an influential element to guide their cross cultural communication experiences in the United States. Phase II: Dissertation Work The current study began in December of 2010 following supervisory committee approval to conduct the study in California The following paragraphs introduce the setting sampling criteria, sampling procedure s participants, data collection methods and data analysis. S etting The research goal was to investigate international ly ed ucated Mandarin speaking cross cultural communication experiences in the United States. The setting of the study was the U.S. healthcare context. It is commonly known that Taiwanese and Chinese immigrants reside prin cipally in California or New York more than in any other state. Due to the limited population of Mandarin speaking nurses in Florida I sent fliers and emails to potential participants across the country (see details in sampling procedure section) in order to recruit the first Taiwanese nursing participant, Shya ( pseudonym ) in California Next, I adopted snowball sampling to rely on Shya as a connection to recruit four additional Taiwanese nursing participants who were all internationally educated, Mandari n speakers working in southern California


75 Sampling criteria According to Xu and Kwak (2005) females dominate the U.S. nursing human resource field in the modern medical setting. While 93.8% of internationally educated nurses are women, 94.2% of U.S. nurses are females. G enerally, social interaction, communication patterns, and politeness strategies are influenced by gender ( Boxer, 2002) and may further influence c ross cultural, clinical communication. N onetheless I remained open minded regarding the variability of gender when selecting the participants, as the research communication in clinical settings rather than to focus on gender issues. I utilized purposeful sampling procedures The recommend ation from the first participant Shya, enabled me to recruit four additional Mandarin speaking nursing participants in addition to her self. As a result, all were acquaintances of each other and were Taiwanese females. As noted above, I used four criteri a to meet sampling requirements for the study. If a participant failed to meet one of the four criteria during the recruitment period, he/she was not invited to participate. The four selection criteria include d: 1. a nurse who sp oke Mandarin as his/her first language; 2. a nurse who possess ed intermediate or higher level of English proficiency; 3. a nurse who received nursing education or professional training in a home countr y (Taiwan); 4. a nurse who was currently working in a U.S. healthcare setting The first criterion, the requirement to be a Mandarin speaker, meant that the participants were native Mandarin speakers. Second, t heoretically international nurses should have achieved high intermediate or advanced English proficiency before


76 obtaining a U.S. worki ng visa The proficiency criterion was based on VisaScreen requirement s such as TOEFL ( Test of English as a Foreign Language ) and IELTS ( International English Language Testing System ) exam scores. Therefore, the participants had intermediate level or higher abilities in English. As to the third criterion, home cultural background and schooling experiences were distinct from those in the United States The final criterion, nurses current work in clinical practice was intended to ensure that the participants communicati on reflections based on recent experiences. Sampling procedure T echnically due to my non nursing background, my restricted access to nursing circles, and the limited populatio n of Mandarin speaking nurses in Florida, it was initially challenging to recruit internationally educated Mandarin speaking nurses who were willing to voluntarily participate in the study, an experience similar to other scholars ( Hearnden 2007) To overc ome th is dilemma I use d purposeful sampling to select participants. Unlike quantitative work aiming at discerning general patterns, qualitative research studies information rich cases. Patton (2002) stated that intentionally selecting information rich par ticipants who specifically match the purpose of qualitative research contributes to a rich and deep outline of research findings. P urposeful sampling can include many sampling techniques. In my case, I employed snowball sampling (Glesne, 2006 ) to identify five participants Snowball sampling is a practical technique to help researchers get started with one or only a few key informants before rolling like a snowball to identify additional participants who meet sampling criteria and are capable of providing rich information To locate potential participants I posted fliers e mailed and talked to Asian ethnic


77 associations, international student clubs, Mandarin speaking religious institutions (e.g., Tzu Chi and Christian churches), Chinese communities, Chine se Sunday schools, U.S. hospitals, nursing academia, and university faculty involved in the nursing field. The recruitment flier and email script can be found in Appendi ces B and C. Internet search was also applied to expand my sampling network. During th e recruitment period, I received Shya s responses via email. She told me that her nursing professor had forwarded my recruitment invitation email to her. She found my research topic interesting and felt that it had been rarely discussed by others. She want ed to help shed light on the situation to benefit future Taiwanese nurses who plan ned to work overseas. Through several phone conversations and email correspondences we realized that Shya was one of my nursing friends classmates They enrolled in the same nursing program and attended one course together at university in southern Taiwan. We became friends because of this connection, and this helped build our rapport even though we did not have a chance to physically meet before I began data collection After I made contact with the first participant Shya, I asked her to recommend other nurses who might be interested in my work. Shya referred me to Bu and Chen ( pseudonym s). A fterwards Bu introduced me to Wei and Co ( pseudonym s). Shya, Bu, We i, Chen, and Co were five Taiwanese nurses who worked in U.S. hospitals in urban cities in southern California. They were all Mandarin speakers. Their English proficiency test results were assessed as high intermediate to advanced level. They all received nursing education in Taiwan before they moved to the United States. Before I physically met with the five participants, I spoke with them on the phone and/or via the In ternet. I


78 explained the informed consent form (Appendix D) as well as the purposes, meth ods, risks, and benefits of participating in the study. Each expressed her willingness to participate. In mid December of 201 0 I fl ew from Florida to a domestic airport in southern California. I stayed there for four months to conduct face to face focus group interviews, individual interviews, and observations. Shya was not only a research participant s he was also my landlord who subleased a room for me to stay in in California throughout the data collection period In addition to utilizing formal data collection tools, such as interviews and observations, I studied Shya s cross cultural communication experiences through living with, interacting with, and shadowing her. I also used the accommodation s offered in southern California as an advantage to investigate the other four international nurses perceptions of communication To build rapport with the participants, I observ ed and engag ed in their communication events during daily life, leisure time, social activities, and accessibl e working hours. The total number of observation hours for all five participants in the study was 112 Nursing participants The five participants had some background similarities as well as differences. I expand upon these in Chapter 4. An overview of the background s of the five participants is seen in Table 3 2


79 Table 3 2 Background i nformation of p articipants Name Age Educatio n English l evel S pecialty W ork years Shya 30 BSN Advanced : IELTS 6.5 Medical intensive care 5 years Bu 35 BHM ASN Advanced : IELTS 6.5 Surgical intensive care 4 years Co 47 BSN Intermediate : TOEFL 4 5 0 Surgical intensive care 7 years Wei 45 BSN Advanced Orthopedic s 7 years Chen 27 BSN Advanced : IELTS 6.5 Labor and delivery 3 years Note. B H M: Bachelor of Healthcare Management; BSN: Bachelor of Science in Nursing; ASN: Associate of Science in Nursing; IELTS: International English Language Testing System; TOEFL: Test of English as a Foreign Language Shya was a 30 year old Taiwanese woman She was a registered nurse (RN) in the medical intensive care unit ( M ICU) at the university hospital in southern California. Sh e owned a house and live d with her Taiwanese American fianc at the time of the study The house was located in a predominately American domina nt community where the Chinese population wa s a minority. Shya ha d a b achelor s degree in s cience in n ursing from southern Taiwan; however, she did not gain practical nursing experiences in Taiwan except for having a one year internship there She moved to the United States in 2005 and started working as a MICU nurse about three years prior to the study She passed the U.S. VisaScreen requirement identif ying her as being at an advanced English level according to her IELTS results. Bu was a 35 year old female Taiwanese nurse who work ed in a surgical intensive care unit (SICU) as a registered nurse in a university hospital in southern California. She came to kn o w Shya through the Taiwanese RN agency five years prior to the study. Bu lived with h er boyfriend, a Leban ese American doctor in a townhouse she had recently purchased Bu obtained two degrees in Taiwan including degree in s cience in n ursing and a b in healthcare m anagement She


80 ha d nearly ten year s of clinical experience as a t horacic s urgical nurse in Taiwan before she worked in California. In 2006, she fl ew to the United States and started working in a hospital beginning in 2007. Bu also achieved high English proficiency scores gaining the status of a n advanced English speaker based on her IELTS scores Chen was the youngest nursing participant in the study. She was 27 years old at the time of the study and ha s worked as a labor and delivery nurse in a U.S. community hospital for one year. Chen was acq uainted with Shya and Bu because they took the RN preparation courses together in Taiwan. Chen settled down in southern California two years prior to the study She lived with her Cantonese American husband Kevin ( pseudonym ) in a mix ed ethnic community. She obtained a b s degree in s cience in n ursing from a highly reputed medical university in Taiwan. She worked as a labor and delivery nurse in southern Taiwan for seven to eight months before she left for the United States. She achieved high IELTS scores in reading, listening, and writing but struggled with speaking scores. N evertheless her overall English test results categorized her as being at an advanced English level Co was a 47 year old female Taiwanese nurse who has immigrated to the United States in 2004. Co was Bu s SICU colleague at the university hospital. Co was a religious Christian who ha d been married to her Taiwanese American husband for six years. Co and her husband, niece and in law s live d together in an urban city in southern California at the time of the study When Co was in Taiwan, she graduated from a nursing high school and then enrolled in a nursing university. She received a s degree in n ursing after four year s of study. Co ha d a more abundant work h istory than the other four participants. Before she immigrated to the United States, she


81 worked as an ICU (intensive care unit) nurse and as an a nesthesia nurse for two years and twenty years respectively Her English proficiency level was intermediate b ased on her TOEFL results. Wei was in her mid 40 live d with her 17 year old son James and 11 year old son Jack (both pseudonym s) in an upper class white dominant community in southern California. Wei wa s a previous charge nurse who was in charge of the unit in the community hospital where Bu had worked Wei ha d been living in the United States for 17 years at the time of the study She had been work ing as an orthopedic nurse in U.S. hospitals for six and half years. Among the five pa rticipant s, Wei was the one who had been involved with U.S. healthcare for the longest period of time. She graduated with a b achelor s degree in nursing from Taiwan. Before she moved to the United States, she worked in a surgical unit for five years in Tai pei. Her English level identifi ed her as an advanced speaker. Data Collection The data collection period spanned from December 2010 un t il the end of April 2011. The participants were asked to voluntarily participate in a study to shar e their communication stories in the U.S. healthcare context. The data collection methods included background information surveys, interviews (focus group interview s individual interviews, interview notes, and post interview reflection journals), and nonmedical observations (w ith field notes). These multifaceted collection tools contributed to gathering content rich and focused data The notes and reflection journals also helped record my reflection s The q uantities of the d ata collected are noted in Table 3 3 The timeline for the data collection i s in Table 3 4


82 Table 3 3 Quantities of d ata c ollection Methods Numbers Background surveys 5 surveys (one each) Focus group interviews 5 Individual interviews 15 Casual conversations U ncountable Interview notes 20 pages Observation field notes 26 pages Post interview reflection journals 20 journals entries Table 3 4 Timeline of d ata c ollection Date Collected data December 2010 Individual interview s : Shya Focus group interview s : Bu and Shya O bservation s : Shya Bu, Wei January 2011 Individual interview s : Shya Co, Wei, Bu Focus group interview s : Chen, Wei, Bu and Shya O bservation s : Shya Bu, Wei, Co, and Chen February 2011 Individual interview s : Chen, Bu, and Co O bservation s : Shya Bu, Wei, Co, and Chen March 2011 Individual interview s : Shya and Chen Focus group interview s : Co, Chen, Wei, Bu and Shya O bservation s : Bu, Wei, and Chen April 2011 Individual interview s : Co O bservation s : Bu, Wei, and Shya Informed Consent Before I gathered data from the five Taiwanese nursing participa nts, I explained the details of the informed consent form with them face to face, including the purpose of the study, the level of participants involvement potential risks and benefits of th e study compensation, participants confidentiality, their right to withdraw from the study, and the persons whom they could contact for further inquiries regarding the research Then, each participant signed the informed consent document and I proceeded with the interview s and nonmedical observation s The informed consent form is in Appendix D.


83 B ackground Information Survey Questionnaires and surveys are tools for obtaining background information on the and values from a target population ( Marshall & Rossman, 2006) In this study, I administered a background information survey to gather the basic information including language status, e ducation al background home country p rofessional experi ence s, and U.S. p rofessional practices. The background information survey facilitate d the sampling selection and kept records of individual participant s linguistic, cultural, and educational information. The survey form can be found in Appendix E. Interv iews interviewing provides a way of generating empirical data about the social world by asking people to talk about their lives all interviews are interactional (p.3). To explore how international nurses view their cross cultural communication experiences I conducted two types of interviews : focus group interviews and individual interviews. I adapted Hearnden s (2007) interview questions to develop my own interview protocol (Appendix F). I probed issues regarding th eir communication motivation, preparation, job orientation social networking, and work training in the United States. During the interviews, I took notes o n the conversations and observe d behavior s body language, facial expressions, and attitude s toward the interviewer and other participants. After each interview, I maintained a post interview reflection journal to keep track of my feelings and thoughts regarding the process and discern primary themes from the data. Writing notes and keep ing post interview journals accounted for supplementary data resources in order to help triangulate my research findings.


84 I conducted individual interviews and focus group interviews primarily in Mandarin, the and my first language Sometim es the participants switched among Mandarin, Taiwanese, and English. Mandarin is the national, official language in Taiwan while Taiwanese is the second most popular dialect of Chinese in Taiwan. I transcribed the interviews and kept my post interview ref lection journals both in Mandarin. I translated documents and data from Mandarin to English for the purposes of this study. The original data collection design was to use an initial focus group interview as a warm up event to help me and the five partic ipants build familiarity. By means of the first group interview, I intended to ask Shya to share her communication stories to break the ice. I also intended to elicit reactions from the other four nursing participants so that they would express their thoug hts. Th e aim was to help me build rapport with the unfamiliar participants through sharing their stories and experiences However, the outcome of the sampling revealed that the five participant s were already acquainted with each other before they were invited to participate in the study. Because of Shya s referr al the other four Taiwanese nursing participants quickly treated me as a friend This shortened the gap between us and facilitated a sense of rapport. More impo rtant ly due to their distinct work schedules and private plans, it was extremely difficult to arrange the focus group interviews regularly during the data collection period. Therefore, I initiated the data collection by first conducting an individual inte rview with each participant, and then held focus group interviews and second, third, or fourth individual interviews intermittently throughout the data collection period. The long individual and focus group interviews helped me not only investigate partici pants communication


85 experiences on a deeper level, but throughout our intensive interactions I also began to understand their feelings and perceptions about nursing in the U nited States. Individual interviews There were fifteen individual interview sessio ns. E ach participant attended two to four interview meetings depending on her availability Individual interviews were held at a place and time designated by the participants, including their h omes coffee shops, and /or restaurants. The duration of individ ual interviews ranged from 47 minutes to one hour and sixteen minutes. The length was determined by how much information the participants share d about their experiences Mandarin was the dominant language used in the interviews. All interview c onversations were recorded with a digital recorder. The consent form for audio taping can be found in Appendix G. During the interviews, I took notes o n the conversations After each interview, I maintained a post interview reflection journal to keep track of my reflections. The format of individual meetings was semi structured. The interviews emphasized eliciting participants stor ies in order to investigate their inner th oughts and receive more natural data through detailed descriptions of communication events they ha d encountered. No personal health information was collected, discussed, or reve a led in the interviews. Interview questions focused on international nurses st ories of communication events, immigration history, daily work, English language experiences, cultural encounters, and educational comparisons (i.e., hospital orientation, nursing degree training and courses of English for Nursing Purposes) At the begin ning of each interview, I asked questions relevant to their experiences to start the conversation, such as Please describe a typical work day. What kinds of nursing tasks are you involved with? I also


86 asked them to share stories describing specific communication events that occurred during their work hours. Grbich (2007) noted that eliciting stories of personal experiences contributes to gathering more natural data than administering formal interviews. Within indivi dual interviews, I used open ended questions in order to elicit responses. I also allowed the flexibility of topic shift to maintain a flowing conversation Additionally, I created a comfortable conversational atmosphere by using language familiar to the n ursing participants. For instance, I investigate d international nurses perceptions of cross cultural communication events by asking w hom /why/what do you rather than what kinds of communicative competence do you think are required for international nurses? I used pre determined questions but remained open to their responses Focus group interviews There were a total of five focus group interviews. The focus group interviews were composed of two participant groups, three participant groups, and a single group of five participants based on the nurses schedules and availability Focus group interviews were held at a place and time designated by the participants, including the houses of Shya, Bu, and Wei. I prepared food, beverages snacks, and fruit for the group interview meetings. The five participants focus group meetings were conducted during or after meals depending on the atmosphere and how much time was provided for the get together The duration of focus group interviews ranged from one hour and 18 minutes to one hour and 43 minutes. The length was determined by how much the participants shared about their experiences Mandarin was used to conduct the interviews, and the int erviews were recorded using a digital recorder. I took notes o n the interview conversations. After each interview, I kept after interview reflection journals.


87 The format of the five focus group interviews was semi structured. These interviews emphasized es tablishing a comfortable atmosphere to encourage participant experience sharing. S haring and discussions with nursing peers could elicit participants to echo each other, as well as to engage in storytelling. Participants were asked to exclude any personal ident ifiable information, employment status, and health information during the interview s In the first group interview, I asked Shya to share her communication stories to help break the ice. This facilitated me, the interviewer, to build rapport with the other four participants in order to elicit discussion and encourage them to express their thoughts via stories and experience exchanges. As time went by, the participants gradually became familiar with the group interview template. Therefore, Shya, Bu, We i, Chen, and Co felt more free and relaxed when launch ing into storytelling during the second to the fi fth interview meetings. Each focus group interview had one to two pre determined, specific themes, including 1) daily work and communication events ; 2) personal history and communication events ; 3) nursing education and communication events ; 4) English language and communication events ; 5) work comparison and communication events ; and 6) h ospital training and communication events. Similar to the individua l interview techniques I used open ended questions to elicit responses. I also provided flexibility for topic shifts and temporary digressions Typically I did not interrupt the flow of conversation. Nonetheless when the turn taking was apparently uneven, I would intentionally invite particular participant s to share their thoughts, such as do you think, Chen? What is your opinion regarding this experience?


88 Observations Initially my study was restricted by the research review board in terms of the observ ation of authentic clinic al communication of the nursing participants In the end I was permitted to observe international nurses communication events regarding their nonmedical interactions as the supplemental data, such as in daily life a nd social network ing Emerson, Fretz, and Shaw (2001) indicated, observation establishing a place in some natural setting on a relatively long term basis in order to investigate, experience, and represent the social life and social processes that occur in that setting comprises one core activity in ethnographic fieldwork (p.352). In order to gather rich er and deep er data with respect to nursing participants experiences of cross cultural communication I used observation s and the field notes as a supplemental data collection method. O bservation s and field notes totaled 112 hours and 26 pages. Each participant was observed three to seven times depending on her availability Sometimes participants gathered together and other times they were observed individually Each time, the observation period lasted from three to eleven hours. The two main observation categories were communication in nonmedical settings in hospitals and communication in private life and social activities. Observing communication i n nonmedical settings in hospitals Since IRB 01 limit ed my access to the dynamic nurse patient and nurse nurse conversations in U.S. clinical settings, I studied the social talk in caf s, lounge rooms, lobbies, and other nonmedical settings i n side hospitals. I observed their cross cultural communication with colleagues and non patient related people in their workplaces. Observing nursing participants during their work ing hours when they were not involved with medical cases filled the research gap caused by the limitations of


89 confidentiality and the IRB restriction. The nonmedical hospital observation s collected totaled 12. Each participant was observed two to three times. During each observation I spent three to five hours in the nonclinical a reas in the hospitals. O bserving communication in private life and social activities During the research period, I encounter ed a variety of opportunities to interact with Shya, Bu, Wei, Chen, and Co in addition to the pre p lanned formal interview meetings. It was mentioned that I shared a home with one of the participant s, Shya. Shya, Bu, and Chen were friends. Bu, Wei, and Co were all acquainted with each other. They were used to keep ing in touch with each other and spend ing time together prior to the commencement of the study. I became familiar with their p ersonal li v e s and social network s by observ ing them, learning from them, eating with them, hanging out with them, living with them, and chatting with them with the aim of collec t ing data. The observational data were gathered from shopping, BBQ events, beach activities a New Year celebration party, dining, afternoon tea meetings, church Chinese Sunday school, friends home visit s and a family reunion. As a result, I was sociall y involved with the five participants when I was in southern California After I asked for permission to shadow them to observe how they live d and communicated in their personal life, casual conversations occurred. Casual conversations could sometimes con tribute significant and insightful information with regard to reflections on communication It was important to observe whom they frequently talked to or wrote to and how they interacted and communicate d. For example, i n addition to communi ca tion difficulties at work, participants experienced communication conflicts in their daily li v e s Furthermore, since the participants spent quite a lot of time together many opportunities arose for me to observe their casual


90 conversations. I also took fie ld notes of casual conversations during those social events with the participants consent. Transcribing, Summarizing, and Member Checking During the data collection period in southern California, I transcribed the group and individual interviews verbatim after each meeting. Poland (2003) noted the significance of transcription quality, so I transcribed the details as precisely as I could, including intonation, interruptions, silence, turn taking, and overlaps. The language that the participants used in th e interviews was their first language, Mandarin. In order to keep their original voices to the most extent, I transcribed the interviews in Mandarin verbatim I finish ed each transcription no longer than one week after each interview to ensure that I still had a fresh impression of the conversation. I transcribe d the interview sound files in my private room to ensure that nobody was present at that time I listened to the digital sound files multiple times in order to immerse myself in the data as fully as I could. Whenever I completed each verbatim transcript ion and the accompanying observation field notes I utilized preliminary analysis to summarize key points. I listed questions generated from the interview transcript s, interview notes, post interview reflection journals, and observation field notes which needed to be clarif ied by the participants. S ubsequently I printed out the summaries and questions and showed them to Shya, Wei, Chen, Co, and Bu when we met next ti me. I spent ten to twenty minutes asking them whether the summaries of the interviews and observations objectively re presented their shared experiences and observed behaviors. The participants clarified the meaning when I misunderstood th eir expressions a nd actions This method is known as member checking ( Glesne 2006 ;


91 Hatch, 2002). By going back to the participants to clarify and verify, I was able to confirm whether the collected data and the interpretation represented what the participant was trying to express Member checking acted as an essential data collection step particularly for me as a n outsider to the nursing field, who could have possibly misinterpreted their clinical communication experiences Data Analysis Method of Analysis: Narrative and Thematic Analysis The data analysis method employed in the study was a combination of narrative and thematic analys e s. I adopted Grbich s (2007) descriptions of narrative sociolinguistic and sociocultural approach, and Bernard s and Ryan s (2010) and Gibson s and Brown s (2009) techniques of thematic analysis to interpret the interviews and observation data. In my study, narrative analysis served to analyze the structure, sequence, content, and context of stories What the participants re ally mean t hidden in the communication stories was examine d. Grbich (2007) stated that eliciting narratives of personal experiences is seen as a more natural form of communication than face to face interviews (p.124). I listened closely to the five inter nationally educated nursing discuss ion with their particular experiences and I encouraged them to share communication stories that they encountered in the U.S. healthcare context. Qualitative work does not seek absolute truths or general patterns of human experiences In contrast, qualitative r esearchers attempt to transfer inner thoughts into a more tangible form for the purpose of analysis Narrative analysis is a n approach used for interdisciplinary purp oses in social science, such as linguistics, education, anthropology sociology, and political science. It attempts to understand


92 experiences of particular incidents. Analysis of narratives investigates the sociolinguistic aspect of stories, including plots and structures. Furthermore, it also examines the sociocultural aspect of narratives, such as the social and cultural frameworks that participants apply to make meaning of their personal events. Sands (2004) claimed that stories are constr uctions created through interpersonal, socio cultural and historical processes (p.49). When I interpreted the five participants stories, I also inferred and referred to the sociocultural meanings behind or beyond their narratives, rather than simply pres enting the plots in stories. I used narrative analysis as an analytic tool to interpret the experienced reality of cross cultural communication events via investigating their personal stories. In addition, I applied thematic analysis to anal yze the multiple set of data, including interview transcripts, interview notes, observation field notes, and post interview reflection journals. During the coding process, I found codes and inter analyze d the codes to identify patterns, and eventually to f ind themes emerged from the data. Procedures of Analysis According to Grbich (2007), Bernard and Ryan (2010), and Gibson and Brown (2009), the analysis process consisted of the following steps. Analyzing primary data: I nterviews The primary data of the study consisted of individual interviews and focus group interviews. There were three major stages to analyz e the interview data. Within the major stages, several analysis steps and techniques were repetitively taken. In the first stage, I examined each i ndividual s single story. In the second stage, I inter analyzed the same s multiple stories to identify codes. After I completed the


93 individuals analysis, in the last stage, I compared the five Taiwanese nurses stories to find cor responding codes and generate themes that emerged from across the data During the i nitial stage of individuals narrative analysis I examined the participants narratives. I focused on the structures and plots of their stories in the interview transcript s. I divided the stories into several sections, including abstract, orientation, complicating action, evaluation, resolution, and coda (see examples in A ppendix H). Grbich (2007) and Labov (1972) noted that understanding the structures of stories can help researchers have a close insight into the key points (e.g., summary), sequential ordering (e.g., time and place), transformation (i.e., direction change), relationship of characters and results and influences brought by the events. In the next step, I moved to a broader analytic level. I looked at the clues which represented the political, social, and cultural context of the stories. The contextual information could help me interpret the way that the participants made sense of their communication experi ences Moreover through the exploration of sociocultural backgrounds of their stories, I was able to interpret the participants emotions and feelings within the communication events. Bernard and Ryan (2010) declared that rich narratives contain informa tion on themes that characterize the experiences of informants (p.62). Therefore, within the narrative analysis process es, I also used thematic analysis to examine the data. To code is to categorize the interview transcripts in order to portray a general feature of data. To begin with, I looked for apriori codes (Gibson & Brown, 2009). Apriori codes exist before the exploration of data. They are pre defined based on motivations, research interests, research questions, and theoretical relevance In the


94 study, I reviewed the research questions and read the data while paying attention to look ing for codes relevant to the questions. To be specific, the apriori codes were related to language needs, cultural factors, and educational training affectin g the communication experiences Afterwards t he analysis focused on the empirical codes of the interview data to find commonalities, relationships and differences across a data set (Gibson & Brown, 2009, p.127). I examined information which was repeated, emphasized, agree d to contradicted, similar, different, and missing among the participants I re read the transcripts and found distinct codes presenting the same patterns. I collected th ese codes representing the same features together to form a larger body of information, code family. For instance, I found in Shya s data, the individual codes of independence, honesty, confidence, and hospitality could be gathered together under a broader code family of home family experiences The definition of the code included: the role of Shya s family background and culture in shaping her attitudes, belief patterns, and experiences in communication As a second example, in Chen s data analysis, the c odes of discomfort, frustration, and low motivation were collected to form an upper code family of English level The definition included Chen s descriptions of herself (as a self evaluation ), test results of her English level, and how the level functi oned in the cross cultural, clinical communication events. I also created thematic figures to move the selected codes into the same body of information (see examples in A ppendix I). Analyzing supplemental data: O bservations The secondary source of data in this study consisted of observation notes. I followed the thematic analytic procedures (Bernard & Ryan, 2010; Gibson & Brown, 2009) illustrated above to examine the field notes


95 Analyzing my own thoughts During the research process, it was inevitable to include my own ideas when recording and interpreting the data. It was i mpossible to remove my personal perspectives in the study. Instead of eliminating my perspectives, I used reflections to review them and I used my subjectivity as a contribution to the study. I maintained post interview reflection journals to record my own thoughts and ideas. Afterwards, I used thematic analysis to examine my role and voice in the interviews, reflection journals and interpretation. I followed the same analysis techniqu es and verified new themes appearing from the interpretation process Later, I summarized the interpretation and showed it to the participants for member checking. Inter analyzing multiple data Within this step, I inter analyzed the multiple forms of coll ected data (interviews, observations, and reflection journals) to correlate the information with in each set of data with codes. I went back to the transcripts and field notes to compare meaning. I verified cross data themes and organized them together. Aft er th e themes emerging from the whole database were finalized, I started constructing an outline for the finding chapters. Member checking As mentioned in the prior section, during the data collection period in southern California, I initiated primary analysis after each interview and observation event, and then I summarized the analysis descriptions and showed them to participants for primary member checking I n the data analysis stage, this member checking was also used to increase research trustwort hiness After I completed the inter data analysis and created the description outlines of Chapter 4 and Chapter 5 about the findings, I sent the outlines to the participants. I asked for their comments and for them to consider


96 whether these descriptions ac curately represented their meanings and experiences The participants and I exchanged ideas and after thoughts via online communication tools. Through the process of double checking with participants via member checking, I was able to verify whether the tr anscripts, interview notes, observation field notes, and my interpretations objectively represented what they said. Trustworthiness and T riangulation In order to increase the validity of the study I was cautious with data collection methods, data analysi s techniques, my rapport with the participants, the breadth and depth of my engagement, and the trustworthiness of data interpretations. The first point is related to rapport building with the participants and the breadth and depth of my engagement. Lincoln and Guba (1985) stated that long term immersion in the research site and rapport building with informants is beneficial for obtaining credible data. From December 2010 to April 2011, the intensive interviews and observa tions with the five nursing participants contributed to the depth of my understanding of international nurses communication experiences Through sharing a house with Shya and t aking part in the Taiwanese nurses social circles, I engaged with my participa nts deeply during the data collection period. In addition, I managed to avoid the pitfalls due to the close relationship between th e researcher and participants. T o collect information as much as possible I almost kept notes of everything I saw, every word I heard from the participants such as their personal lives, social and family relationship, and other concerns irrelevant to the study. However, when I started analyzing the data, I realized that the deep involvement with the participants could put the study at risk of presenting subjective findings To avoid


97 this situation, I made decisions to exclude these personal data unrelated to the study purposes during analysis. The s econd issue regards the data collection methods. The research des ign of the study was based on the t heoretical perspective of constructivism. According to constructivism the understanding of conversations is co constructed by the interviewer and interviewees. Meaning do es not naturally exist; instead, it is mutually in terpreted by the researcher and the respondents. As a c onstructivist interviewer, I was aware of my obligation as a conversational partner to co construct the interview events with the participants. To build sound interviewer interviewee relationships and collect trustworthy data, Rubin and Rubin (2005) and Seidman (1991) provided practical interview techniques for qualitative researchers. I followed their suggestions to conduct the 20 interviews in a more trustworthy way, including listening actively, avoiding leading questions, clarifying oversimplified responses respect ing interviewees voices, and pa ying attention to the flow of conversations. Furthermore, t riangulation is an approach used to validate the trustworthiness of the findings. It is to u se multiple perspectives to interpret a single set of information ( Guion, 2006 p.3 ). In this study, in addition to collecting the primary data by listening to the five international nurses expressions through interviews, I gathered an additional four su pplementary sources of data to facilitate triangula tion of the data, including a background information survey, interview notes, observations and field notes, and my post interview reflection journals. Collecting data by observing participants communicati on behavior in different circumstances helped me to examine the manifold aspects of international nurses cross cultural communication from different angles.


98 Recording my own perceptions and feelings during the process of research, such as notes and reflec tion journals functioned to verify my interpretations S haring the summary and primary analysis of interview transcripts and observation notes with the nursing participants, confirmed whether my interpretations truthfully presented their communication experiences The t hird point is with respect to the trustworth iness of the data analysis method. Gee (2005) emphasizes two concepts to assure analysis validity, including agreement and linguistic details. Agreement is similar to the member checking mechani sm which allows participants to review the inter pretation of their narratives. Bernard and Ryan (2010) also advocated that agreement of the data can help increase confidence in the validity of the emerged themes. In general, the more accurat e ly linguistic details of data are collected, the more valid the analysis will be. In this study, I transcribed the interviews verbatim in the original language, Mandarin, to record the stories in detail T o maintain most of the linguistic fe atures and avoid meaning loss resulting from translation, I also used Mandarin to code the interview transcripts, which enhanced the credibility of the analysis. After the patterns of these codes were identified I translated these Mandarin codes to Englis h and define d them in English. I am an ESL speaker with no n ative American English speaking background I have a Mandarin English translation certificate from a n institute of higher education in Taiwan. I use d my own translation skills and my perceptions o f the two languages to interpret the data. Moreover writing deep, rich, and detail ed descriptions of the data was helpful to increase the validity of my representation o f the world of meaning making.


99 That is why I used Chapter 4 to introduce participants backgrounds and C hapter 5 to present their perceptions of communication experiences categorized in to main themes. Furthermore, being aware of my speaking, actions, and relationships with participants during the interview facilit ate s my ability to reflect upon research validity. Subjectiv ity Statement Qualitative research is a process of discovery and description intended to transfer participants inner mind s to external literal interpretations In this study, c onstruct ing intern ational nurses reality of cross cultural communication required both the participants and my reciprocal cooperation in making sense of meaning. Crotty (2003) and Hatch (2002) mentioned the unfeasibility of vacuum ing out constructivist researchers person al perception s to become totally objective during data description, analysis, and interpretation. It is inevitable that my subjectivity w ould be involved throughout the research journey. Alt hough I might not be able to directly relate to what the internationally educated Taiwanese nurses experience d during cross cultural, clinical communication, I am a Taiwanese female, an international student, an ESL speaker, a part time employee, and a minority in the United States just like them I am a researc her coming from a similar cultural/linguistic background and overseas experiences as the participants I might see m yself in them rather than to see them as distinguished individuals. Therefore, it was probable that I un intentionally attach ed personal bias when interpret ing the data. It was also likely that I might hav e had difficulty identifying their culture because I was like a fish in the water. The possibility exists that I transferred my own cultural background, cross cultural communicati on experience s emotions expectations and assumptions to the data.

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100 Glesne ( 2006 ) suggested that researchers should be aware of their own reflections and treat the ir subjectivity as strengths rather than as disadvantage s Therefore, in the study, I was conscious of m y personal reactions. I used them as gatekeeper s to monitor the trustworthiness of the study. To make my subjectivity concordant to other s, I kept track of my feelings by maintaining reflection journals throughout the research period Research Limitations There are four limitations of my study To begin with Boxer ( 2002 ) and Burns, Joyce, and Gollin ( 1996) claimed that gathering authentic conversational data is the primary method for collecting data especially when studying communication experiences in q ualitative research H owever, due to issues of patient confidentiality, it was challenging to find research sites and recruit participants for clinical observation. Second, although the participants all came from Taiwan, they carried diverse characteristic s. They had received different nursing training (i.e., high school nursing and college nursing), had particular nursing specialties and grew up in different family conditions. Their individuality affected their attitudes toward communication. Overlooking their distinctiveness could deteriorate the validity of the research Third my non nursing background and subjective understanding of the data posed potential risk s for prejudiced discussion. The findings from intensive interviews a nd observations were based on my individual interpretations of how international ly educated nurses describe d what they had perceived. The multiple layers of my actually increase d the complexity of data analysis.

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101 Finally, the study adopte d case study, a qualitative method to investigate internationally educated nurses cross cultural communication. I discovered how the five international nurses ( participants ) described their experiences in communication ( phenomenon ), and how they made sens e of their feelings and perspectives associated with the unique U.S. healthcare setting (context). These details made the study specific to the five nursing participants. Unlike quantitative work which result s in general principles of average behaviors, t hese findings can neither be duplicated nor generalized. I do not imply that the study results can be transferred or applied to others without adjustment. Chapter Summary This chapter discussed the epistemology, theoretica l perspectives, methodology, the s etting sampling procedure and criteria participant s, methods of data collection, and analytical tool of the data interpretation. I also discussed the research trustworthiness and my subjectivity as the researcher The research design was aimed at answeri ng the research questions. I did not seek to find absolute truths, indisputable explanations, or general patterns of human experiences On the contrary I sought to interpret nursing experiences of cross cultural communication and to convey their inner thoughts

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102 CHAPTER 4 FINDING S : PARTICIPANTS PORTRAITS Overview This study investigated how internationally educated Mandarin speaking nurses perceived cross cultural, clinical communication experiences in the U.S. medical context. The three subquestions of this study included: (a) how participants described language n eeds for communication in those settings; (b) how they perceived cultural factors as influencing communication events; and (c) how they believe d that their education and training prepared them for U.S. healthcare communication. In this chapter, I provide a description and background for each of the five internationally educated Taiwanese nurse participants: Shya, Bu, Co, Wei, and Chen (all pseudon yms). The primary language of the interviews was Mandarin. I translated the interview data from Mandarin to English for the purposes of this study. The stories depicted in this chapter illustrate respect to language use; her nursing and language training programs in Taiwan and the United States ; and her immigration experiences and adjustment to the U.S. healthcare context. The their cross cult ural 4 1.

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103 Table 4 1 Summary of participants p ortraits Shya Bu Chen Wei Co Home family and culture N urturing style the result of home family : sincere, r esponsible and hospitable C onviction to learning the outcome of home family and cultural influences : enthusiastic and diligent Aptitude led by father: modest, easygoing, and gracious Parents as role model s : n o wants, no compromise V alues and attitudes toward communicati on influenced by parents : humble, helpful, and responsible Nursing training TW: BSN ; US RN agency US: N urse staffing service s company ; hospital orientation and continu ing education TW: BHM and ASN ; US RN agency US: N urse staffing service s company ; hospital orientation and continu ing education TW: BSN ; US RN agency US: Community ESL classes; hospital orientation and continu ing education TW: BSN US: Private tutor; hospital orientation and continu ing education TW: BSN US: ESL courses; hospital orientation and continu ing education English language F ormal assessment: a dvanced (IELTS 6.5) Oral language : comfortable and confident F ormal assessment: a dvanced (IELTS 6.5) Oral language : un easy and worried F ormal assessment: a dvanced (IELTS 6.5) Oral language : comfortable and uneasy F ormal assessment: a dvanced Oral language : comfortable and confident F ormal a ssessment : intermediate (TOEFL 4 5 0) Oral language : uneasy and worried Nursing experience up to time of study TW: Intern, 1 year US: MICU, 5 years TW: T horacic surgery 9.5 years US: SICU, 4 years TW: Labor and delivery 8 months US: Labor and delivery 1 year TW: Medical / s urgical 4 years; o rthopedic s, 1 year US: Medical / s urgical 6 years; Orthopedic s, 1 yea r TW: ICU, 2 years; anesthesi a 21 years US: SICU, 4 years Primary adjustment to US Stress due to high language demands and cultural conflicts Encountered language difficulties and cultural conflicts Anxious working in the culturally diverse environment Experienced more cultural conflicts than language difficulties Stress due to high language demands and cultural conflicts Note. B H M: Bachelor of Healthcare Management; BSN: Bachelor of Science in Nursing; ASN: Associate of Science in Nursing; IELTS: Inter national English Language Testing System; TOEFL: Test of English as a Foreign Language ; TW: Taiwan; US: the United States; MICU: Medical intensive care unit; SICU: Surgical intensive care unit

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104 Shya s Portrait Shya waited in the arrival lobby and wav ed to me with a big, sincere smile. While I was filled with guilt that the delayed flight had interrupted her schedule and kep t her waiting in the terminal for hours, she took my carry on luggage from me and said Are you hungry and tired? You must be hungry, right? How about I take you to grab some food before we drive home? Shya was a 30 year old female Taiwanese registered nurse (RN) working i n the medical intensive care unit ( M ICU) at a university hospital in southern California. During th is study Shya was also a welcoming host ess She treated me like an inexperienced little sister with the aim of help ing me settle down from Florida to California despite the fact that I had more than five year s of overseas study ing and living experiences and was biologically older than her. Literally, Shya was the nursing practitioner who provided me with the resources necessary for me to work Additionally she provided me with accommodation s emotional support and friendship while I stayed in southern C alifornia during the data collection portion of this work Home Family and Culture nurturing style was the result of her home family in Taiwan, the expectations that her parents had for her, and the care giver responsibilities for her siblings that were required of her from a young age. The absence of her parents was significant in her view. She stated I separated from my parents at a very young age, at seven. We [ sister, brother, and Shya ] lived in Taichung with our grandparents. They [ parents ] stayed in NanTou for their business. We generally saw each other once per week, so there w as nothing specifically for home education. I went to school for primary education. We moved when I was a junior high school student. At that time, they [ parents ] commuted between Puli and Taichung every day, and we met in the evening.

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105 However, I usually p repared food for myself. I also took care of my younger sister and brother, to cook for them. \ Shya was born in a municipality Taichung, located in the center of Taiwan She lived with her grandparents, parents, and one young sister and brother in a s pacious house until college In the community, Taiwanese and Mandarin were the two principal language varieties and Shya naturally became orally fluent in the two languages. In the 1980s, Taiwan s econom y took off and, as a result, Shya s parents took th e opportunity to build their own They [ parents ] did not really educate me. They were so busy in their business. They just paid for my tuition, sent me to the cram schools. Cram schools in Taiwan aim to train students to pass the senior high school and college entrance examinations. During that time wh ile her parents were striving for their livelihood, education and care giving. Sh ya became independent at a young age : I started cooking when I was a high school student She was responsible for food preparation and housework, and she l ooked after her two siblings time, such as my school performance, my conduct. I also needed to share the responsibility from Th ese characteristics and experiences shaped her work as a nurse by taking good care of patients, new friends, and people in need. Although Shya s parents contributed less directly to her schoolwork, they had a deep influence on her communication and social skills : My parents taught me to be sincere and nice to people. When I was young, my parents often took me to others houses. They taught me guest manners. They would say, You can t do this, You can t do that, or

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106 teach me how I should respond when the host invited me for food and drink. When guests came to our house, my parents would ask me to prepare fruit, drink s and snack s They taught me the proper way to provide food. I couldn t say Do you want some tea to guests when offer ing a drink to them. My father would immediately correct me : You please have some tea instead of do you want some tea it is different. [laughs] In reality, he admonished me in front of the guests, not in private. When I said something wrong, he corrected me right away. Shya s stories demonstrated that her parents were active in social events and influenced her concepts of communication They were hospitable people who frequently invited relatives, friends, and clients to their home Shya continued They [ parents ] showed me how to treat relatives, clients, and friends so I am not afraid to get along with people. I behave pretty okay in public. I am sort of confident in getting along with people. I am easygoing I believe that what I do is right. I am comfortable talk ing to strangers. I am not afraid of strangers. D ue to the fact that Shya had been surrounded by guests at home, she developed social manners and communication skills when she was a child and t hese same communication patterns were evident in her interactions in both English and Mandarin. She often gree ted people energetically in both English and Mandarin in her neighborhood, workplac e, and at friends parties. She found it easy to talk to strangers and often initiat ed small talk with customers in a queue or chatted to storeowners at supermarkets, restaurants and car repair shops. Sh ya was eager to make friends, generous to share resources and genuinely car ed for people. Her optimism provided her with many opportunities to embrace U.S. culture. N urse and Language Trainin g in Taiwan and the United States communication ex periences in U.S. healthcare settings were the outcome of both Ta iwan ese and U.S. training programs. T hese included English language learning and nursing education. Shya enrolled in English co nversation and TOEFL ( Test

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107 of English as a Foreign Language ) preparation classes at two private language institutes wh ile she studied at a nursing program at a university in southern Taiwan. Although she attended additional language classes outside of the university, she lacked confidence in English : been bad since I was young After she received a bachelo r s degree in nursing, Shya dedicated herself to excelling in a series of NCLEX RN ( National Council Licensure Examination for Registered Nurses ) and IELTS (International English Language Testing System) preparation courses offered by a RN agency in Taiwan After eight months of studying, the RN agency sent her and other Taiwanese nurses to a partnership U.S. nurse staffing service s company to sit for the NCLEX RN examination in California. The company offered a series of training courses, including I ELTS, clinical communication, nursing practical skills, U.S. medical systems, U.S. insurance policies and U.S. hospital regulations To some extent, Shya believed that the training program offered limited help in terms of her communication skills in U.S. health care settings: For instance, the company provided documentation courses to help us [ international nurses ] fill in medical records and compose nursing notes. However the outcome was not as effective as expected. The course taught overall writing skills in charting. The over generalized skills did not fit my specific needs in the departments where I worked I was even laid off twice because I didn t know how to chart Shya passed the NCLEX RN shortly after she moved to the states, but she continuously failed the IELTS (English language) exam a total of four times. S he noted that NCLEX RN was easier ; it was all about nursing knowledge but IELTS was another story. English language test was so difficult and unpredictable Shya stat ed

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108 that to her, the English language test seemed to have no boundary. She was drowned in academic language tasks, such as questions with respect to anthropology archeology, science, sociology political science, agriculture architecture, and biology ; the se seemed largely irrelevant to the clinical nursing language she felt she needed Shya explained, Studying for IELTS didn t directly prepare me to communicate successfully or confidently in nursing events, such as taking doctors orders, writing nursing c harts, reading laboratory data, or handling complaints from patients and families. Adjustment to the U.S. Healthcare Context experiences in U.S. healthcare settings underscored two main ideas: English language demands in the co ntext of nursing and cultural differences that influenced her professional judgment in nursing. During her first and second job assignments, she was laid off in the initial weeks of the hospital orientation period Shya shar e d a story regarding her first job in the United States: T he preceptor was hosting a meeting, and then she asked everyone to leave the room except for me. She said I could ha ve helped you become a better nurse, but I th ink keeping you longer in the unit was meaningless for both of us. She stressed that I had poor communication skills and was also lacking nursing skills United States were miserable and terrified her principally a result of her English language ability. Her frustration in cluded misunderstanding medica l terminology reading medical documents, giving (oral) shift reports, and engaging in telephone conversations with doctors and hospital personne l. These, she felt, impeded her from effectively implementing nursi ng work. Shya declared Take the basic duty, giving shift reports for example. I remember I couldn t understand my colleagues at all, which was a very serious

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109 problem. If I didn t know the condition of my patients, how could I take care of them? I was unable to call pharmacists. When they [nurses] asked me to make a phone call for patients medication, I didn t know how to make that call. Also, I was unable to communicat e with doctors. I didn t know how to take orders. I even didn t dare to talk to them I was afraid of taking what they prescribed, what they ordered. Shya continued know how to explain it to my patients. For that reason, my patients would easily tell I was a novi ce in the unit [laughs], an inexperienced nurse. Finally, the use of U.S. medical terminology differed greatly from that she learned in Taiwan. This caused her consternation: Sometimes the medical terms we use in Taiwan are different from what Americans pronounce and use here. For example, in Taiwan we say on endo, but U.S. nurses call it endotracheal tube U.S. nurses pronounced it ( insulin ) [ ns l n] while Taiwanese medical teams pronounced it as t he terms Although spelling was not a big deal, I still needed to carry a mini dictionary with me. I looked up words from time to time in order to know unless I looked up their definition s. Shya concluded, I had difficulties in all four skills of reading, listening, speaking, and writing. It was terrible! Although she was laid off from her first two jobs, Shya wa s not discouraged. On the contrary, her optimi stic attitude made her strive to improve her English communication skills She noted I watched CNN ( Cable News Network) and ER (Emergency Room series), studied for the IELTS exam watched movies, and repeatedly took RN preparation courses. She also continued to work as a par t time certified nursing assistant ( C NA) to improve her clinical conversation skills and become more intimate with U.S hospital culture

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110 Eventually after approximately one year of continuous study, in June of 2006 Shya achieved an overall average IELTS s core of 6.5 and a speaking score of 7.0 (i.e., advanced level) which were required by the U.S. VisaScreen program. Soon thereafter Shya accepted an offer as a charge nurse in a skilled nursing facility. A s killed nursing facility was a medical center where patients in noncritical condition were cared for until end of life She described the role of the nursing staff as, We were skilled nurses, which meant our patients were not critical. They came here to wait for death. As a charge nurse, Shya was m ore responsible for human resource management than having direct involvement with patient care and nurse doctor communication S he felt that this meant there was less risky communication, as compared to her prior two jobs : I believe the reason I stayed in the third job, the skilled nursing, was because the job was slow. I was not responsible for taking care of patients personally. I was the one dealing with LVNs ( Licensed Vocational Nurse s) and CN As (C ertified N ursing A ssistant s). Shya perceived the job slow because the demands of language and standard of nursing skills were not high and urgent. In contrast to her feeling unworthy of the job due to communication in English, in her third job Shya felt successful when allowed to take time to prepare for communication She explained, When I needed to communicate or consult with doctors, I would have time to prepare what to say. It was not like acute care. There was no heart attack or other severe symptoms that required us to contact doctors immediately fo r urgent treatments. Context U p to S tudy P eriod Up until the time that this study took place Shya ha d been work ing as a MICU registered nurse in a university hospital in southern California for the prior three years, which was considered as her fourth job in the United States. In the workplace, in

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111 addition to American nurses, many healthcare workers were from Korea, the Philippines Taiwan, China, Vietnam and Mexi co. The inpatient (patients admitted overn ight to the hospital) structure was also composed of diverse ethnici ties including Mexican, Anglo American, African American, Korean, and Chinese patients. The multi lingu al and multicultural working environment in spired Shya to share numerous cross cultur al communication stories during the research period. Shya lived with her Taiwanese American fianc Taylor ( pseudonym ) who was bilingual in English and Mandarin. Taylor effortlessly switched between English and Mandarin when he talked. Shya adopted Mandari n as the primary language she used to communicate with him. E ven so it was common to see Shya incorporate English terms, phrases, and sentences in to conversation s with him, such as Weird! or Why the actor killed the actress? Shya determined her language choices depending on the language that Taylor select ed for communication Taylor had a group of friends who were also Taiwanese American. Some of them spoke both Mandarin and English well, whereas others spoke English as their fir st language. Generally, Shya interacted naturally with them. On Shya s 30 th birthday, I was asked to help in the planning of the surpris e party. When she came home from wor k she was shock ed to find the unexpected guests, candles, and cakes greeting her N onetheless Shya gracefully re sponded to the unexpected situation and spoke fluent English to show her appreciation to her friends. During the study, Shya claimed that she had no recent serious complaints about her communicati on experiences : I am pretty c onfident in my current speaking and listening level As for reading, I have become better at reading medicine relevant reports. Yet,

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112 in regards to writing, it is my weakest skill up to now. Shya planned to pursue a master s degree in the n urse a nesthesia p rogram within two years. The year before she received a rejection letter from a nursing graduate school. The refusal was determined on the basis of Shya s statement of purpose. The graduate school committee commented that Shya s writing skill s w ere not satisfactory to accomplish the coursework and studies at the graduate level. They requested her to take college writing courses to improve her writing skills before submit t ing her next application. N onetheless Shya was faced with a dilemma when talking to patients famil ies Shya usually revealed no serious problems in terms of language use and cultural adaption. She was good at initiating social topics and chatting with familiar people and strangers. Thus, when she first stated that she was afra families, I was perplexed. Shya said, It s always an obstacle for me to talk to famil ies I am pretty okay to talk to patients here are you from ? H ow many sisters and brothers do you have and things like that However, if I need to talk to the patients family, I just cannot do it. I don t know what to say in front of them. I either simply explain the patients health conditions or quietly accomplish my nursing task s. S he did not c larify the reason she felt uneas y with famil ies at that time. We both wondered why she was uncomfortable specifically when talking to families. After several formal and informal interviews over the period of a few weeks, we returned to the issue again. Bec ause her patients were a disadvantaged minority, it was natural for Shya to care of them; she was able to freely pose questions and exchange information with them in order to improve their health Families and visitors, nevertheless sometimes acted like t ed Shya s nursing

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113 tasks. They demand ed that she offer ed additional nursing services Occasionally they criticize d the quality of her nursing care Shya also felt bothered by the frequent medical law suits which she heard about from her colleagues Shya explained mean. Bu s Portrait Bu followed a s imilar path as Shya in terms of her journey to the U nited States as a registered nurse. Both Bu and Shya struggled to pass the IELTS exam, learn clinical communication for nursing purposes and adjust to the cultural differences between Taiwanese and U.S. healthcare settings. However, Bu was highly concerned about her English language performance and communication skills in the workplace. At m y first meeting with Bu, she revealed a strong interest in my research topic. She also worried over her English ability at work: My English is poor. What do you suggest I can do to improve it ? I m very frustrated when speaking English. Can you recommend some books so I can study in my leisure time? Bu was a 35 year old female Taiwanese nurse who worked in a surgical intensive care unit (SICU) as a registered nurse in a university hospital in southern California. She was highly dedicated to performing well, both in terms of her clinical nursing skills and communication in English. She had a n intellectual hun ger and was eager to discover the most up to date knowledge, trends, and innovative treatments in the nursing field and daily life context. This diligence was also discerned from Bu s constant efforts to improve her English accent, pronunciation grammar, and vocabulary during the data collection period; she asked questions with respect to how to advance her

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114 communication skills in English She made the following comments during our interviews: Do you know of any English courses that will help me reduce my accent? Are there any book s introducing the concept of phonics you know that can help me to pronounce words right after I see them? I am looking for a book of slang to teach me how to talk humorously with patients and families; otherwise I just laugh abashedly out of not knowing how to respond whenever they sa y something amusing The doctors can t understand me sometimes because I misuse grammar in my utterances. Can you suggest any eas y to follow grammar books suitable for my English lev el? Home Family and Culture Bu dedication to learning was the outcome of her home family and cultural influences in Taiwan, the educational expectations from her parents, and the characteristics that she inherited from her mother Bu was from a suburban city in northern Taiwan. She wa s orally fluent in both Taiwanese and Mandarin. Un like Shy s wealthy family with a business background, Bu grew up under more strained economical condition s With limited education, Bu s father worked as a bus drive r while her mother was a full time housewife taking care of three children and doing housework at home. D espite the fact that they were on a tight budget, Bu felt that her parents tried hard to support their children by advocating that they obtain a good education. Bu claimed, We weren t rich, but my parents always said You don t need to worry about money; you don t need to find a part time job; just concentrate on your stud ies They always encouraged us to study more. They even managed to hire math and English tutors for me when my test scores were awful in high school. In Bu s opinion, her father was and One of his few hobbies was to me et old friends and drink occasionally Her mother was more socially

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115 active Bu described, My mom enjoyed learning, such as attending community classes to learn sewing, cooking and singing. She also volunteered in hospitals and temples offering assistance to patients and visitors Bu s parents did not intentionally coach child ren for manners, principles ethics, and knowledge : They didn t really teach us. They were too busy earning a living. She doubted whether her parents shaped her communication patterns and social skills. Bu recalled I had probably acquired most social r ules and knowledge from school, peers such as table Nonetheless Bu seemed to have inherited some of Bu wa s a warmhearted person who was enthusiastic in purs u ing update d knowledge and making friends She was conversational and easy going. I initially contacted her for research purposes, but she spontaneously took the initiative in befriending me including shar ing stories about her life, romance, friendships and work. In addition to show ing me around the university hospital where she work ed, s he voluntarily introduced me to her nursing friends in order to help me recruit research participants. N urse and Language Trainin g in Taiwan and the United States Bu communication ex periences in U.S. hospitals were the consequence of both Ta iwan ese and U.S. training programs, including English and nursing education. During her schooling in Taiwan, Bu was frustrated about her English. She noted, My English sucked! I only got 10 out of 100 on my college entrance exam scores. To me, English was a nightmare! Moreover, my reading, writing, and grammar were not very good when I was a nursing student, not to mention my speaking. After Bu graduated from nursing college, she worked as a re gistered nurse in the t horacic s urgery department in Taipei. She frequently met foreign patients at work. In

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116 order to advance her English abilities to communicate successfully with foreign patients, she attended a medical English conversation course provided by the same RN agency in Taiwan where Shya enrolled. Afterwards, the course provider convinced Bu to transfer from the medical conversation class to the U.S. RN preparation program. Bu continued Later on, t hey [RN agents] sent me to California to take the test. I was lucky enough to pass the NCLEX RN. After Bu moved to the United States in 2006, s he enrolled in a series of IELTS preparation and RN training program s offered by the same nursing staffing servi ce company where Shya registered in California. Bu s first attempt at the IELTS test in Taiwan resulted in an overall average score of 4.5 (i.e., intermediate level). After that, she took intensive IELTS preparation classes in California The IELTS course was five hours per day and three days per week Bu stated, Can you believe? I took the IELTS exam once every month for 11 months! beyond craziness! Bu declared that she had no idea how she passed the NCLEX RN and IELTS examination because at that time, she felt that she still lacked basic skills and adequate proficiency in English. She commented, The IELTS courses were not really helpful. The techniq ues that my roommate Cathy [ a Taiwanese nurse] taught me were more useful. Passing IELTS was mostly related to test techniques, not my English level. Al though my speaking score had reached 7.0 (i.e. advanced level) ultimately, I was like a mute during the first year when I worked in the community hospital Adjustment to the U.S. Healthcare Context After Bu passed the VisaScreen, she then worked as a SICU ( surgical intensive care unit) nurse in a U.S. community hospital for three years. Ten months prior to the

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117 research period she transferred to the university hospital where she continu ed to work as a SICU nurse. In the primary stage of Bu s immigrant experiences she encountered language and cultural experiences in terms of cross cultura l, clinical communication The f irst issue was about language. Bu told a story of how miscommunication caused by language per se seriously damaged her patient s safety : One evening, I was working with a Chinese nurse Fen ( pseudonym ) to insert a Foley cath eter in a male American patient to drain his urine I was responsible for inserting the catheter and Fen was responsible for inflating the balloon Then Fen asked me D o you pass the resistance ? I misheard the pass as feel. I assumed she asked me whether I felt the resistance rather than passed the resistanc so I answered her es. This communication mistake caused Fen to inflate the balloon too early. The swollen object pierced through and caused the patient signific ant Fen is not a native English speaker; I am not, either, but we are both requested to speak English only at work. The night was a mes s We spent the rest of the night attempting to stop the bleeding. I felt so guilty to make such a mistake. Th e s econd issue was related to culture. Bu declared that h umbleness was not taken as a virtue in the practical U.S. medi cine In a five participant focus group interview, Bu shared her prior experiences of working with her American colleagues : Bu: It does not work if you are modest here, no way! Let me tell you, one time, when I took over Jinny s [ pseudonym ] shift, I met the first neuro patient of my career. I had no relevant history of dealing with neuro cases. My coworkers had experience in this fiel d. Hence, I observed their communication, and acquired knowledge and skills about how to take care of neuro patients. I told Jinny that I stayed in SICU for many years but I was not familiar with neuro care. I said I would love to learn more if she was wil ling to teach I told her I would learn harder, but her version of t he conversation turned out to be a totally different story. She reported me to the PCC ( p sychiatric c are c onsultant ) and asked her to watch me closely. That shift was dreadful Wei: Wow, su ch big cultural gap between them and us. We are used to be ing humble. Seems that we can t be docile and yielding anymore. They just don t appreciate our communication styles. Shya: That s right. You should have pretended you knew everything. Or

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118 you ought t o say in it C an you tell me more about it ? Bu unassumingly told her American colleague that she was not an expert in neuro care, but she was keen to learn. Bu explained that t h is wa s a typical Chines e based expression. When the Taiwanese c o me upon a n unknown situation, many people habitually underestimate their abilities as an expression of humility, while also demonstrating their dedication to learning. From this story, Bu s American nurs ing colleague Jinny was not pleased by Bu s modesty Jinny reported Bu to the PCC saying Bu was not qualified to deal with the neuro patient It put Bu under constant surveillanc e during that shift. Bu agreed with Shya s statement and made a comment: That s right! Since that incident, I have had a different way to respond to my coworkers : if there is something I don t know I won t reveal my weaknesses in front of Americans anymore. Context U p to S tudy P eriod U p until the time that this study took place Bu had been wor king as a SICU nurse in southern California for four years. Bu lived with her boyfriend, a Leban ese American doctor. Due to the different linguistic background s between Bu and her boyfriend, English was the dominant language they used for communication In addition to limited to few Taiwanese nurses in California including Shya, Wei, and Co. Bu was an energetic person who liked challenge s and excitement including caring for surgical patients who were in critical condition. Bu even naughtily told Shya: MICU [Shya s unit] is a boring unit. SICU is more challenging, has more fun! Bu was diligent and keen to acquire the latest nursing and English knowledg e. W hen she interacted with Mandarin and English speakers in social events, she demonstrated competent

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119 communication skills, such as maintaining fluent and coherent conversations, making jokes, and providing backchannels (i.e. um and well ) and appropr iate nonverbal cues. N onetheless in the cross cultural healthcare communication, Bu experienced more frustration when using English to implement nursing tasks. Bu s English proficiency exam results o n the IELTS defined her as an advanced English user thre e years prior H owever Bu s self evaluat ion of her English level was that she felt insufficient while communicating with the hospital personnel patients, and visitors in the workplace. Bu habitually worried about her communication performance and felt is olated while working in U.S. hospitals. Bu recounted, Because of English chat with my coworkers. I just smile at them. I feel especially uncomfortable talking to white nurses and second generation immi grant worried that they w on t understand me It really makes me feel a shame d Furthermore, Bu declared that in Mandarin, she was accustomed to talking in a circumlocutory style She liked to use refined expressions implying main points during conversations. W hen Bu sp oke English she adopted these rhetorical, speaking feature s but realized that they were not always appropriate in English conversation She noted, I think my speaking is too ind irect. It has happened many times. When I ask questions or request medical orders from doctors, they usually d o not catch my meaning at first. I ha ve to repeat several times or use another way to express myself, and then they may eventually guess what I am sayin g. Bu then gave a specific example : I asked a doctor Do you want to have a sample draw after whi ch doses? He didn t understand the sentence I paused a second and rearranged the sentence by putting keywords of which dose at the start of my speech, After which dose should I have a sample draw? This time he finally got it and prescribed an order. These communication failures become more apparent whenever I talk to doctors or pharmacists over the phone [than

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120 face to face c onversation]. In addition to language barriers, Bu encountered unpleasant communication experiences caused by different cultural perceptions. One day when Co, Bu, Wei, other Taiwanese, and I gathered together to celebrate New Year, Bu shared a story She said that there was an elderly male patient who refus ed to be bathed the night before but she completed the bathing despite his reluctance. In a focus group interview with other nursing participants, Bu explained: Bu: I don t understand why he was s o angry w ith me. Co: He probably didn t want to be aw akened in the mid dle of the night right? Wei: Or maybe he was uncomfortable being naked and served by a young female nurse. Bu: I had to bath e him. It was a requisite nursing procedure to keep him clean to prevent infection. But the nex t morning, the guy s daughter came to me and interrogate d me, Didn t you understand what my father meant? He said he didn t want to be bathed. If you touch him again without respecting his wi shes I will definitely sue y ou for sexual harassment Wei: You should protect yourself. Don t be too responsible [for finishing all nursing procedures]. If your patient has a strong opinion, just leave it to the morning shift nurse or your charge nurse. They ll know how to deal with the case. Bu: I still think I was right. I was doing my job to maintain his hygiene you know, to keep him from infection. Bu recognized her challenges. She stated that Working in Taiwan I fe lt just like a fish in water However, when she worked in U.S. hospitals, she discerned that her nursing abilities were obstructed by language and cultural barriers. Moreover, s he worried about how her hospital colleagues viewed her : Sometimes they [ d octors and n urses] are so impatient when they don t understand my English; I can tell from their faces. She also avoid ed talking to patients and families and confessed : I am so afraid

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121 they [patients and families] do not understand me well. I become nervous when they discuss social or cultural topics and use slang expressions beyond my knowledge. Bu concluded I wish I could be as happy as before. Working in the U.S. is tense. I have become anxious, quiet, and stupid. It is not me. I ought to be composed, talkative, and skillful like I was in Taiwan. C hen s Portrait Chen gained help from the same RN agency in Taiwan where Shya and Bu enrolled for the NCLEX RN and IELTS preparation Owing to budget concern after Chen moved to California, she chose to discontinue the contract with the U.S. nurse staffing services company and walked through her U.S. immigration journey independently. Like Bu and Shya, C hen had difficulty passing the IELTS exam to obtain a U.S. working visa and she also experienced obstacles when adjusting to U .S. clinical communication I met Chen through Shya when Shya invited Chen to her house. We spent an entire afternoon having lunch and chatting together. Chen was kind, polite, and a little quiet. As a guest, she made no requests and accepted all offers from a host. When ever I asked her an opinion about an event or activity coming up, Chen would reply : It s fine. Do whatever you want. You decide. During conversations, she preferred listening to speaking. Despite appearin g withdrawn, Chen did build relationships with others, and was helpful and easygoing. She often need ed time to become familiar with new pe ople During this study after she came to kn o w me better, Chen became more talkative and secure when we met privately at dinner while shopping, and during interviews.

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122 Home Family and Culture Chen s aptitude was led by her father and the anticipation s that her parents had on her Chen grew up in Kaohsiung the largest city in southern Taiwan. Her parents both had master s degree s They were college lecturers teaching accounting and electronic engineering at a university in Kaohsiung. Chen declared My father is a refined and courteous man. He is polite, gentle, and modest. He rarely squabble s with people. When people fee l resentful about him, my father apologizes. If someone is rude to him, he would smile back. Chen s communication style w as influenced by her father. Chen was gracious and unpretentious She was calm and scarcely irritated by people. Whenever she had bad luck, she held her negative emotions in as not to disturb anyone : It s not their [patients ] faults ; I understand F urthermore she was too kind to turn people down when they asked a favor of her Chen said, My charge nurse just called me. I guess she wants to ask me to take on an additional shift I purposely missed the se calls because I am so afraid to say no to her. Once, when Chen was in my car, her cell phone continue d ringing but she avoided pick ing it up. I reminded her of the incessant ringing and she replied to me, It s a friend we met in church. He loves to talk about the bible and Jesus for a long time I don t know how to interrupt him. So, it s better not to answer I ll return his call after we finish our dinner. Chen took words as gold. In public, she spoke sparingly This attitude toward communication was notable during research meetings and at private events that we attended together. Chen usually took the position of a listener rather than eagerly sharing her own stories. She strictly followed the rules of conversation, including patiently waiting for her turn to speak and making an effort not to interrupt the speaker.

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123 H o wever, she was generous with shar ing her feelings and thoughts provided that she was invited to talk, such as being asked do you think, Chen? N urse and Language Trainin g in Taiwan and the United States For much of the time, Chen s parents played an important role of assisting her decision making about school education and nursing career. Chen s communication ex periences in U.S. clinical settings were the result of both Ta iwan ese and U.S. training in terms of English learning and nursing education. Chen avowed, I had no specific preference to study nursing My parents c a me to the decision about my major based on my college entrance exam results. They felt that nursing was a stable job for women compared with other professions in Taiwan. When Chen was a nursing student, her father persuaded her to hasten her overseas prepar ation, such as encouraging Chen to take TOEFL and English conversation classes in foreign language institut ions in Taiwan Chen claimed, S omehow, I just obeyed my father s demands to take the English courses, yet I had only a little interest in English. I seldom reviewed the content. I just put away the books whenever I got home. It s common sense -people never realize how important something is until they definitely need it [to work and live in an English speaking country]. Chen evaluated her college English level as poor She was not motivated to acquire English because she felt no urgent need to use English in Taiwan. After graduation Chen submi tted to her parents advice and chose to specialize in labor and delivery: M y parent s felt that delivering babies was the cleanest job in nursing In 2006, she followed the Taiwanese RN agency s arrangement and traveled to California to sit for the NCLEX RN exam. In her initial experiences as an immigrant in California Chen had a difficult time maintaining her residential status legally in the United States. She entered the United

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124 States on a tourist visa which allowed her to officially stay in the country for a maximum of six months. She d id well o n the nursing license examination (NCLEX RN) but constantly achieved inadequate scores (i.e., 7 0) o n the speaking section of the IELTS exam. Chen became discouraged I felt like I was a deflated balloon The enormous cost of living in California, including food, rent, transpo rtation, course fee s and exam fees almost drowned me. By the end of 2006, with disappointment and regret, she left the U nited States feeling her year effort was in vain Chen went back to Taiwan and pondered her future. Chen said, There w ould be no way for me to improve my English conversation if I remained in Taiwan One year later, with her parents encouragement and fin an c i al support, Chen decided to re enter the United States for another six months. During th is period, she attended English cl asses provided by nonprofit organizations. She self studied for the IELTS and re took the exam. She visited Chinese churches in order to make connections with people and sought emotional and social support It was during this period that she first met her Cantonese American husband Kevin. She achieved an overall score of 7.0 in IELTS but o nce again received a less than acceptable score on the speaking section O nce more she was trapped in the six month time counting game. Chen declared, I was terrified. I didn t want my visa to be revoked. But I was running out of time [to be deported by the United States]. I regrettably felt couldn t make it. I had no ideas how to get a score of 7 on the speaking section A few weeks before she left, she fell in love w ith Kevin. In early 2009, after four year s of going back and forth, Chen eventually achieved her goal Although she didn t

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125 achieve the IELTS required score of the speaking section (i.e., 7.0) she was finally able to stay and work in the United States lega lly under Adjustment to the U.S. Healthcare Context Chen primary communication experiences at work highlighted the ethnic and linguistic diversity in terms of hospital personnel and patient structure in the U.S. healthcare context Chen began working in September of 2009 and was recruited as a night shift labor and delivery nurse in a multi ethnic community hospital. H er 18 month work history in the United States was shorte r than the other four participant s Chen described that the majority of the nursing staff w as Filipino. They occupied 80 90% of the unit. The second large st population w as nurses from China and Hong Kong. They sp oke Mandarin, English, Cantonese and other Chinese dialects Chen continued : We have few White [Anglo American] nurses and Black [African American] nurses, but I rarely work with them during my shift. On one hand, Chen was the only Taiwanese nurse o n the night shift. To some extent, she felt disconnected from her Filipino and Chin ese nursing colleagues. H er communication experiences with them left her feeling socially and emotionally isolated from them. Chen commented: They [ Filipino and Chinese nursing colleagues] form a circle. Except for their own people no other ethnicity is invited in to the conversation. They seem self centered and exclusive. They share medical resources, assist each other s cases, help clean up at work, and discuss one another s family and life. However, when I and other ethnic minority nurses show our enthu siasm to join in the dialogue or make a connection with them they involuntarily act over polite or treat us indifferent ly On the other hand, Chen s patients were mainly Mexican expectant mothers. The second and third large population of patients in the department consisted of Chinese and Vietnamese women, respectively O ccasionally Chen was responsible for the

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126 Korean and Chinese patients. It was understandable how strained Chen was when using a nonnative language to communicate in such a culturally and linguistically diverse environment. One time, she felt hurt by an American doctor who criticized her communication ability : He blamed me for my speech. He doubted how I could deal with a medical emergency by speaking in such a slow pace. In addition, C hen recount ed that one night early in her employment a Hispanic father to be welcomed too many visitors to the labor room. Chen explained, I understand it s their [Mexican] culture to celebrate the important moment [ delivering a baby] with their family, relatives, friends and even coworkers, but we have a strict two visitor only policy. After Chen advised the visitors to leave, the father to be initiated a sever e quarrel with Chen. He yelled at her and asked her out of the room. He reproached her as a n unprofessional alien nurse and requested to change for another primary nurse. He also wrote her up to her supervisor. Chen said she felt extremely wronged and could not stop crying in front of her colleagues. Chen commented, No one would help me except for myself. If I didn t learn to be strong enough for what I said, no one would listen. After that incident, I began modifying my speaking style to be firm and definite, particularly for the purposes of I need to change. I can t always be like my father. We are too polite. Here [in the United States], if you are too polite, people assume you are too soft. Although Chen received an overall score of 7.0 on the IELTS exam, which placed a dvanced English l she no ted, It took me more than one year to be come accustomed to using English to communicate [in the cross cultural healthcare setting]. To some extent, Chen attributed her preliminary uncomfortable communication experiences to inadequate hospital training. S he declared,

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127 T he orientation classes had limited help about our [international nurses ] adaptation to communicating in a multi cultural hospital No class aimed to improve our English communication skills. A lthough there was one lesson focusing on cultural diversity for nursing care, the content was boring and over generalized. [Chen pointed at the orientation booklet.] You can see I took no notes. I have no idea what it was about for cultural diversity. I m ight have fallen asleep during this cla ss. Although her hospital employers did not hing to provide sufficient assistance in Chen s communication in a culturally diverse work environment Chen found a way to overcome these communication difficulties Chen expounded, I continued watching Americ an soap operas, such as Dr. House Everybody loves Raymond Friends Desperate Housewives and Sex in the City I believe watching these TV programs can help me acquire English knowledge, popular expressions, slang, medical culture, and to begin to understand American humor. Context U p to S tudy P eriod At the time of the study, C hen was 27 years old and had worked as a labor and delivery nurse in the U.S. community hospital for one year. Chen settled down in the United States two years before this study and s he lived with her Cantonese American husband Kevin in a mix ed ethnic community. It was a city with a large Asian population in California, including Taiwanese, Chinese, Korean, Vietnamese, and Thai residents. Chen s social networ k consisted mostly of Asian and Mandarin speaking friends. During her leisure time, she met Kevin s family and members of the church who spoke Cantonese and Mandarin. She barely used English when she was off work unless i t was at a particular event that wo uld require the use of English : There is no particular need for me to speak English off work. I spend most time with my husband and his family and friends. I may need to use English with nieces and nephews because they don t speak Mandarin I someti mes wake up in the morning and wonder whether I am in Taiwan or in California [laughs].

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128 I n most situations, Chen s Mandarin and English speech was elegant and unhurried. She acknowledged that she needed additional time to organize her thoughts before speaking While speaking in English took a good deal of effort writing was easier for her: It is because writing offer s the luxury of extra time to arrange my idea s. Up to the time of this study, Chen generally fe lt comfortable with cross cultural clini cal communication She was confident in handl ing common nurse patient and nurse nurse conversations. N onetheless s he envie d her Filipino colleagues (in the Philippines English is one of the official languages) and second generation immigrant colleagues w ho were able to freely express their ideas in English. Chen sighed: E very so often I stammer and hesitate to talk when I lack sleep or when I am under pressure. My brain turn s blank, especially during urgent situations. It s so bad. Due to her immersion in the multicultural work environment, Chen had developed insightful cultural awareness of nursing care. For instance, she came to the realization that American mothers and Mexican mothers were more independent and self assured regarding their beliefs on child care. Chen found it interesting to see that Mexican mothers could not wait to cuddle with their newborn infants. They struggled to put their babies down for even a minute Such mothers also tended to ask numerous questions about how to feed and raise the infants on their own. They were more willing to take care of their babies by themselves rather than being assisted by nurses or allowing them to watch over the ir newborns. On the contrary, Asian mothers such as Chinese and Vietnamese seemed relatively more passive about baby care. They even asked Chen to take the infant away from the labor room in order to let them get some rest. Chen explained that Asian

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129 mothers and their husbands would tell that mothers were exhausted after delivery, so they deserved a few quiet moment s to regain their energy. They believed newborns were under better care in the nursery room than in their hands because parents were not medically trained but nurses were. Through Chen s observation of mothers various attitudes toward newborns, she modified her speaking strategies when serving patients from different cultural backgrounds. To be specific, Chen encouraged Asian mothers to have intensive interaction with their babies: I advocate the bright sides of breast feeding for Asi an mothers. I also strive to increase mothers confidence to look after their infants without our [nurses and doctors ] intervention. On the other hand, Chen tried to tame Mexican mothers enthusiasm about newborns: I keep an eye on preventing them from unintentionally suffocating the baby. I also promote the necessity of formula milk for Mexican parents in those case s where babies are not satisfied with breast Furthermore, like the prevalence of patient care plan s in SICU and MICU, Ch en noticed that the culture of making a birth plan was widespread among expectant mothers in U.S. hospitals Birth plans w ere composed by the patient of the procedures, methods, and care that the mother to be preferred during the delivery process. Chen had opinions about birth plan s : Mothers who have birth plans are usually troublesome to communicate with. They seem opinionated and bossy. Sometimes their plan violates medical procedures. It create s problems for nurses and doctors. In Taiwan, usually doctors dominate the procedures, not the mothers. Wei s Portrait Compar ed with Shya, Bu, and Chen, Wei had less concerns about these communication issues in clinical settings Wei s continuous contact with English via

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130 songs in the school, her excellence at academic achievement in Taiwan, and her 10 years long term immersion in U.S. society before she worked, diminished her struggles with language barriers and cultural conflicts when working in U.S. hospitals. On the fir st day when I visited Bu, she convinced me to drop by Wei s house. Bu kept persuading me: You don t want to miss her. Wei is such a nice, generous big sister Let s go and I m pretty sure you re going to enjoy the time spent with her. We then drove to W house. Wei was a confident mother and a loving person Like what Bu described, Wei was warmhearted and content. She earnestly invited us: Please stay with us for dinner. You guys must be hungry after the interview. Wei had been a registered nurse i n U.S. hospitals for about seven years. She lived with her two sons in an upper class W hite dominant community in southern California. She had been living in the United States for 17 years. Wei was a previous charge nurse in the community hospital where Bu used to work Due to their parallel linguistic and cultural background s they quickly overcame the supervisor subordinate relationship They became close friends who shared happiness, worries, burdens, sorrows, stresses, and support regarding ea ch other s work and life. Home Family and Culture Wei was born in Taipei, the capital of Taiwan in the 1960 s. Her father was a director in an elementary school. From Wei s perspective her parents were her model and backup. Wei claimed, My dad is a welcoming loving man who enjoys inviting friends, coworkers, relatives, and students over to the house My mom is not as socially active as my dad. She is more like a traditional Taiwanese housewife who cares for children and husband and won t ask for cre dit. They always offer support and love to us [Wei and her siblings].

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131 Wei commented that her father was passionate about singing. When Wei was a child, h er father purchased a karaoke machine at home to sing Mandarin and Taiwanese pop songs with guests. Broadly speaking, Wei had her father s talents, singing and generosity First, being immersed in a melody rich environment, Wei had developed a strong interes t in singing. She also built up her foreign language ability through singing songs: I am talented at both classic al and pop music, including many English songs. I was selected to participate in school choir s and won many singing competitions in college an d at hospitals. Second, based on interviews and observations Wei was a generous hostess who held a variety of BBQ parties, feasts, and holiday events for people whom she cherishe d. In addition, Wei s father strictly stood to a Chinese maxim. Wei elucida te d, When I was a child, my father taught us (wu yu ze gang), n o wants, no compromise He is a traditional Chinese man who emigrated from China. He always told us n o wants no compromise If you have no desires from others, you ll have a firm will. The maxim is close to the English proverb C ease to hope, and you will cease to which means i f people do not have expectations they won t be afraid of losing something Wei kept in mind her father s doctrine. She was satisfied and responsible: The last thing for me to do is to expect peers, siblings, friends, or colleagues to favor me. However, after Wei moved to the United States, she realized that the principle of n gradually led her to a detrimental situation at work. Wei noted, In American culture, people go after what they want. It is seen as thoughts. When people are in an unfavorable position they are supposed to fight for their rights.

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132 The conflict of no desire versus pursuit continued to impact Wei s work and life communication experiences as demonstrated below. N urse and Language Trainin g in Taiwan and the United States Wei s communication ex periences in U.S. medical settings were formed by her English and nursing training in Ta iwan, the NCLEX RN preparation in California and her immigrant experiences in the United States. In the 1980s, the university admissions rate in Taiwan was below 30% ( while in 2010, the university admission rate jumped to virtual ly 90% ) Under such competitive condition s Wei gained excellent scores and was able to enter one of the top ranking medical universities in southern Taiwan where she enrolled in the nursing program. Wei recalled, My parents valued a lot on my school learning I did well at many subjects At college, my performance was outstanding and I graduate d with honor s As an inexperienced nursing novice however, my high GPA (G rade P oint A verage ) helped me to get hired by the best hospital in Taipei. Wei worked in the orthopedics and mix ed surgical unit in Taipei for five years. In the middle of the 1990s, Wei and her ex husband moved to the United States. During the first ten years of her immigration, Wei played a role as a full time housewife caring for their two sons, James and Jack. After James was mature enough to take care of himself approximately seven years before the study period, Wei hired a private NCLEX RN tutor to help her review nursing knowledge and gain an understanding of U.S. nursing culture. Afterwards she self studied for the examination for one year pa ssed it, and obtained a California RN license in 2004. This success led her to be recruited as a regular surgical medical nurse in a multi ethnic community hospital. Wei declared, There were no big challenges when preparing for the NCLEX RN exam.

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133 The exam helped me review the nursing knowledge and medical terms that I require to work in the United States. Adjustment to the U.S. Healthcare Context Due to the 10 years long immigration history before she began to work, Wei s early communication experiences in U.S. healthcare settings underlined more cultural conflicts than language issues. During her first employ ment in the surgical medical department in the United States, af ter a nine month training period Wei was promoted to the charge nurse position to lead the nursing team for five to six years. The community hospital was surrounded by the Korean town, the Vietnamese town, the predominately Mexican area th e Chinese commu nity, and the U.S. mainstream residents. The hospital workforce was composed of Korean, Mexican, Filipinos Chinese, Taiwanese, and American. Wei stated, Mostly, you saw lots of Asians in that hospital, such as Korean and Vietnamese. To us [Taiwanese nurs es], it was a good thing. We didn t have much pressure to speak perfect or standard English because there were many second language speakers in the hospital. N evertheless at the beginning of her charge nurse job, Wei found it demanding to be in charge o f the nursing team. One U.S. and one Hispanic subordinate nurse frequently challenged her authority by rebelling against her assignments over and over again Wei mimicked their tones, I don t want to do it. It s unfair. Are you blind? I m busy. Wei recite d, Whenever arguments erupted everyone in the unit waited to see how I would deal with the dispute I was not only disheartened by the two nurses aggressive talk, but also anxious about losing my leadership image in front of others. I innocently he ld hope that my teams would ultimately accept me as long as I kept a low profile, work ed harder, and kept the principle of (wu yu ze gang), n o wants no compromise U nfortunately I was reported to the nursing manager as being an incompetent leader by the two nurses.

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134 In order to keep her position, Wei decided to alter the way of communication which her father taught her. Wei continued, Then, I realized I couldn t be easy going anymore. I should have told the truth. I bravely spoke up to my manager how the two nurses uncooperative and arrogant attitudes compromised their nursing care. This blunt way of speaking led me to a long overdue victory At last I comprehended n or silence is golden are not applicable in the United States Context U p to S tudy P eriod Eight months before the study period, Wei transferred to an orthopedic r ehabilitation unit at a non profit regional healthcare delivery network Th is regional hospital provided more in novat ive facilities, higher standards of operation, and better welfare than her former employer. She was satisfied with resigning from the position of a charge nurse in the community hospital to be come a regular nurse in the current healthcare center. Rece ntly, she had been weigh ing the benefits of decreasing her work time: I am thinking to reduce my working hours so that I can spend more time with my sons and Donny [ pseudonym her Taiwanese American boyfriend ]. As a Taiwanese immigrant Wei was enthusias tic in promoting the Mandarin language and Taiwanese culture. For example, she was devoted to her sons Chinese school affairs such as holding activities for P arent T eacher A ssociation (PTA). She closely monitored Advanced Placement (AP) Chinese classes and tutored him when necessary. She cultivated Jack s interest in learning kung fu. She also decorated the house with lunar calendars and s pring f estival couplets Values, language, and culture derived from Taiwan c ould be seen everywhere in her home. Wei claimed, is such a beautiful language. They [James and Jack] should be able to use the language.

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135 Wei usually spent time with people from Taiwanese population. She had no thoughts to expand her social cont act from Taiwanese immigrants to American mainstream society. Wei declared, We hardly hang out with Americans. It s natural for people to get together with someone from the same ethnic and language background. Americans are with Americans. Koreans spend t ime with Korean s Chinese form a group full of Chinese. We feel comfortable to do that. That s all. O n the whole Wei felt at ease about her communication experiences in the United States: I don t have problems in English conversations. Maybe during the first three to six months [in her first employment ], I was anxious about my job. I tried to pick up everything within a half year. But I was pretty okay after the first six months Wei demonstrate d her sense of humor and wit in communication by making people laugh regardless if she was speaking in Mandarin or English. She was fluent in English communication For instance, she was capable of explaining complicated mahjong rules (a Chinese gambling game) to Bu s Leban ese American boyfriend in English, which might be viewed as a challenging communication task to other nonnative English speakers. In Wei s opinion, it was satisfactory for her to speak English with a Taiwanese accent, with flaws, as long as her English was comprehensible to others. She realized her advantages at work: They [ hospital employers] hire me not because of my good English. They want me because I have the professional skills they are look ing for. We i was confident of her English ability, immigrant life, and nursing job in the United States She was viewed as a warmhearted and thoughtful big sister by people

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136 around her. She revealed few difficulties in language and cultural adjustment except for the c ontradiction that her father taught her. Wei reasserted We, Asian s don t call a spade a spade but since I work here, in the United States, I ha ve had to come up with a way to prove myself I should become determined to be tougher Co s Portrait I n contrast to Shya, Bu, and Chen seeking for help from a RN agency, Co prepared NCLEX RN exam and English proficiency test on her own in Taiwan. She believed that w ithout having received assistance and training from the nurse staffing services company, she obstacles in cross cultural clinical communication. Co claimed Sometimes I envy Bu and Shya. They have a training background from e before they jumped into the U.S. nursing industry. I had experienced a hard time since I started to work here L anguage, culture, even basic nursing skills all left me exhausted. I met Co at a New Year celebration party held by Wei. Co was a 47 year old female Taiwanese nurse who had immigrated to the United States in 2004. Co s life experiences had turned her into a witty woman. She was loquacious frank, and outgoing. She was the spotlight among many people. E veryone seemed to be att racted to her la ugh ter and eloquent speech at the dining table As soon as Wei introduced me to Co, Co grabbed my arm and teased me, causing everyone to double over with sidesplitting laughter: Are you Cloudia? The doctoral student Cloudia ? Come on, you must be joking, right? I assumed the doctoral student interested in nursing English was a lady in her mid 40 was disappointed in romance, life, and everything else You look young and healthy, wh at made you entwined with the PhD mess? [laughs]

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137 Home Family and Culture were almost a reproduction from her parents and home culture in Taiwan. Co grew up in Taipe i the capital city of Taiwan. She had one sister and one brother. She was the oldest child in the family. Co noted, My father is a solemn man, like other fathers in a traditional family. My parents believed that honesty was the best policy. They taught me to be blunt and resp onsible. When she got in to trouble her parents always encouraged her to take responsibility for her actions Moreover, they e xpected Co to take challenges and face difficulties They advised Co to be cooperative in order to get along with siblings, friends, and colleagues. Co indicated, I think m y parents had a huge impact on me I m very grateful for their doctrines. I am humble about what I have and never exaggerate my abilit ies I never claim I can do something which I don t know how to which is quite different from ( some ) Americans. I am supportive of my coworkers, by doing additional work for them. Although ( some ) Americans may not appreciate our culture, I still keep these values. N urse and Language Trainin g in Ta iwan and the United States Co U.S. healthcare communication ex periences can be traced back to her education history of English and nursing in Ta iwan and language learning in the United States. W hen she was 15 years old Co enrolled in a 3 year nursing program in an occupation al focused senior high school in Taiwan Co felt that the school paid little English ability development in the context of nursing : teachers taught us to sing many English pop songs but not really covered the content of y English improve d much during the three years. After receiving her nursing diploma Co enrolled in a nursing college

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138 program. In the nursing college, it was her primary experience to be engaged with medi c al material s written in English. Co recalled In high school, our medical and nursing textbooks were all written in Mandarin. However, everything had changed in college. We were required to read loads of English medicine textbooks. It wa s extremely exhausting especially for me such a vocational school nursing graduate with poor English Co s work history in Taiwan involved 2 year s of intensive care and 15 year s of anesthetic care including working in a n ursing m anagement position in the anesthesiology department at a reputable hospital in Taipei In the era of 1990s, the U.S. RN agencies in Taiwan were not as popular as at the present. Co self studied and passed the NCLEX RN examination in 1997. She also took a TOEFL ( Test of Engli sh as a Foreign Language ) paper based exam and scored 450/677, which classif ied her at a n intermediate level. In 2004, although her TOEFL exam result s did not match the U.S. VisaScreen regulations for international nurses (i.e., advanced level) Co was all owed to work in the United States without the English test proof under her Taiwanese American husband s spouse visa. In spite of the fact that Co had nearly two decade s of clinical experiences in Taiwan, her management background and outstanding qualifica tion s in nursing did not contribute to her initial communication experiences in the U.S. medical setting. Co declared In Taiwan, I worked in the intensive unit and anesthetic department over 20 years. I was promoted to a nursing manager to handle the whole floor. I even participated in the unprecedented c ardiac and multiple organs transplantation However, after I moved to the United States, I had to revert my empirical skills to zero. Everything started from the beginning. I pic ked up nursing skills, hospital polices, medical systems, language, and culture day by day. I was as new as a novice. Even now, I am still learning new words, new phrases, new culture and new nursing skills and

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139 knowledge during my shift every day. Adjus tment to the U.S. Healthcare Context Co experiences in U.S. hospitals accentuate d two main issues : English language demands in clinical interaction and cultural differences in the context of nursing Co s first job in southern California was as a recovery registered nurse in the post anesthesia care unit for half a year. The unfamiliarity with English language, U.S. medical systems, and hospital subcultures le d to frequent confusion and misunderstanding s for her. Co felt uneasy at work. Even worse, she suffered from mental and physical syndrome s of strain : I had sleep disorders menstrual disorders depression, and anxiety. Co continued I was tremendously discouraged I had no choice except to t ell my manager I wanted to quit. I felt overwhelmed The pressure caused me hormonal disorders ; what s worse, it caused my immune system to deteriorate mak ing me chronically ill! After a six month trial, she discontinued her job and took a 2 year leave to regain her health and confidence. Between the two year interval of her first and second job, Co watched CNN news, read local newspapers, socialized with her husband English speaking friends, and practiced English conversations in daily life. She assumed If I immersed my self in U.S. culture and an English speaking environment, I might be able to adjust to working in the United States. F urthermore Co registered in a six month ESL program at a community college in order to enhance her communication skills in clinical settings. Nonetheless, the ESL courses focused on academic English as well as general English, but not cross cultural healthcare communication. Co commented, The ESL courses improved my reading and writing skills but not my conversatio nal ability. The courses didn t help me much. I picked up more

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140 and more conversation skills during my second job. Co noted that registered nurses usually preferred to work the day shift and rested at night in order to maintain a normal life style. Q uite the opposite she voluntarily work ed the night shift for the first three and half years. Co explained, In contrast to the day shift, working at night creates fewer opportunities to communicate with people in the hospital In the day shift, I need to talk t o patients famil ies Famil ies always have so many inquiries for me as a primary nurse because someone they care for is in an urgent trauma condition. Then the chief resident, attending doctor, neurologist and cardiac surgeon all come to me to get patient s detailed lab reports, CT scan ( X ray computed tomography ) and MRI ( Magnetic Resonance Imaging ) resource s I just can t stop talking, which is very demanding! Moreover, Co declared that some American colleague s had prejudices against her, especially since Co was the first Mandarin speaking nurse recruited by the SICU: Actually, I cried in the car after work everyday for almost six months. Every day every night, every shift, as long as I met new coworkers, as long as they didn t see my work but c a me across my speaking first, they always jumped to conclusions based on my po or English ability Co then shared a more specific story about the communication conflict with her American colleague in her early work experiences: During my first day on duty, I was giving a shift report to Mary ( pseudonym ). Mary prompted a number of questions about the patient s conditions, but she gave little time for me to respond. I stuttered and paused for a while. I was processing English words and sentences in my head. A l l of a sudden Mary became angry. She raised her voice and relentlessly condemn ed me, Where did you get your nursing degree? Do you even speak English? It t fun ny at all. If you don t do this right, you will kill people, you re aware that? I don t think you deserve th is job! Co continued I bit my tongue, worked harder, and spent additional hours in the SICU to acquire nursing knowledge and improve my Englis h It was a struggle for Co to gain the approv al of her nursing coworkers. As time went by, fortunately, her family

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141 traditions and cultural values in terms of facing challenges and being helpful, strengthened her and dr o ve her to overcome these communication difficulties at work. Besides language barriers, Co perceived that the differences in nursing concepts and medical culture between Taiwan and the United States hamper ed her adjustment in the U.S healthcare context. She spent time developing critical thinking skills required by the U.S. nursing profession but not by Taiwanese nursing industry, such as nursing assessment and temperature measurement In the primary immigrant stage, she often quarreled with her American colleagues about the way to measure patients body temperature. Co described, Do you remember that I have 20 years working experience in Taiwan? Taking body temperature should have not been a big deal to me at all. Whenever I was corrected by my supervisors and colleagues I fe l t insulted. But after I observed my coworke rs temperature measurement techniques for a couple of weeks, I finally realized they had profound knowledge about th is basic skill. In Taiwan, Co used whichever tools were available for her to measure patients temperature. She had never considered tha t different methods of measurement could a ffect the patients health. On the other hand, in the United States, nurses critically considered the advantages and disadvantages of taking r ectal, ear, oral, and axillary temperature of their patients. Co clarif ied that as to patients with facial fractures it was inappropriate to take the temperature oral ly Regarding ENT ( ears, nose, and throat ) patients, it was unwise to measure the temperature from their mouths and ears. As for young children checking their r ectal temperature could generally result in the most accurate reading She expounded A basic nursing skill actually requires our critical thinking ability to accomplish it; nevertheless we (Taiwanese nurses) are not trained to think critically in Taiwan Every nurse is used to following doctors orders,

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142 being their assistants. No wonder the ICU nurses here are only assigned one to two patients every shift. Since we are doing nursing in such detailed manner in the United States. Context U p to S tudy P eriod Up to the study period, Co had been married to a Taiwanese American husband for six years. They adopted Co s 14 year old niece Anna from Taipei. Co and her husband, niece and parents in law lived together in an urban city in southern California. In the community, Anna was the only Mandarin speaking teenager at school. The neighborhood they lived in was predominately filled with white American s Their social network was made up of a mixture of Asian and mainstream American friends. Co had been work i ng as a SICU registered nurse in California for four years. The nursing staff in the hospital included domestic and international nurses, who were American s Filipino s, Africans, Vietnamese Mexican s Korean s Chinese, and Taiwanese. The p atients were main ly Americans. S ince the university hospital was near the V ietnamese community there was also a large population of Vietnamese patients A small proportion of Korean, Chinese, and Hispanic trauma patients were admitted to the hospital. Even though Co had d eveloped better communication skills comparing with her first job experiences in the United States, in the current position, she was apprehensive about the communication challenges that she encountered in the linguistically and culturally diverse workplace For example, Co worried about her Taiwanese accent in English. She also felt confused by patients unfamiliar accent in English. Co narrated: The Hindu patient had a strong accent. I also ha ve a noticeable accent. What he said was really incomprehensible I had to ask him three times what he was saying and he still couldn t understand my English. It was extremely frustrating

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143 Co appreciated the American culture of individualism and self reliance : I am adjusting myself to speak out my t houghts more day by day. Meanwhile, she insisted on her famil y s values of being humble and honest. Even if she had over 20 years working experiences in nursing Co was fonder of keeping modest than showing off what she was capable of Co stated, Though I am good at nursing, in front of my coworkers, I still behave like I would like to try, like to learn, instead of being pretentious about my abilit ies and experience. Chapter Summary The pre and post immigration stories of Shya Bu, Chen, Wei, and Co helped to paint a picture of their first language, home culture, prior training, feelings the challenges they faced and the changes they implemented into their lives in order to adjust to the U.S. culture, especially medical cultu stories were unique yet there were overlapping similarities. This chapter offer ed an exploration of h ow language, culture, and education al experiences of the participants impact ed and influenced their cross cultural communication in the U nited States. Recognition of their past and present experiences helped to construct a frame work from which their communication experiences in the cross cultural environment c ould be interpreted. In the following chapter, I present fin dings from the cross case analysis. The four main themes include: (a) the use of complex and s pecialized language in c linical settings; (b) cross c ultural d ifferences in c linical s ettings ; (c) identity negotiation in a ne w U.S. e nvironment ; and (d) gaps i n l anguage and c ulture in U.S. nurse training

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144 CHAPTER 5 FINDING S : MAIN THEMES Overview T his chapter present s the findings and main themes which emerged from the cross case analysis aim ed at answering the three research sub questions of this study The three sub questions included: (a) how nursing participants described language needs for communication in clinical settings; (b) how they perceived cultural factors as influencing communication events; and (c) how they believe d that their education and training prepared them for U.S. healthcare communication. The results of the analysis showed four main themes regarding how the participants perceived the roles of language, culture, and education that affect ed their clinical communication experiences in t he U.S. healthcare context These included: (a) the use of complex and s pecialized language in c linical settings; (b) cross c ultural d ifferences in c linical s ettings ; (c) identity negotiation in a ne w U.S. e nvironment ; and (d) gaps in l anguage and c ulture in U.S. nurse training Shya, Bu, Chen, Wei, and Co all experienced clinical communication events not only with mainstream Americans but they also interacted with people from various linguistic, racial, and ethnic backgrounds. The diversity of language uses, cultural differences, and hospital customs increased the complexity of their cross cultural communication experiences. Using a nonnative language (English) in the context of life and death situations in a multicultural clinical environment m eant that the participants encounter ed communication difficulties in the workplace. A summary of the main themes is provided in Table 5 1. The data in this chapter are presented in the order of frequency in the coded data.

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145 Table 5 1 Summary of main the mes Themes Sub themes Sub sub theme T he use of complex and s pecialized language in c linical settings Oral c ommunication Discriminating non Mandarin s ounds Jokes, s lang, and multiple d ialects Occupation s pecific v ocabulary and hospital register Written c ommunication Open e nded w riting in medical c harting Reading genre specific, medical documents C ross c ultural d ifferences in c linical s ettings Linguistic and c ultural divers ity of hospital personnel and patients Independent role of nurses in U S healthcare Patient c entered care Identity negotiation in a ne w U.S. e nvironment Accent: Retaining or r educing the Taiwanese accent in English Choices of s peech r egisters t versus p rofessional tone (with patients) Assertiveness versus compromise (with patients and hospital personnel) Pretentiousness versus humility (with hospital personnel) U.S. n urse trainin g g aps : Language and c ulture Lecture o riented classes: Hospital orientation Lack of essential l anguage n eeds Lack of cultural k nowledge: Patient b ackgrounds, h ospital s ubcultures, h ospital p olicies, and n ursing r outines Learn by d oing: Clinical s hadowing Limitations in addressing nurses second language needs and building cultural knowledge

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146 Complex and Specialized Language in Clinical Settings isn good enough. All five participants identified specific difficulties in their early communication experiences in U.S. clinical settings. Up to the time of the study the c omplex ity of the Englis h language demanded by the U.S. healthcare context continued to interfere in the interactions with patients and hospital personnel. The language was complex difficult, diverse, confused, and to the participants. For example, as Bu declared, My English isn t good enough. I often have miscommunication with doctors, my nursing colleagues, and patients in the hospital The complexity of the English la nguage in U.S. clinical settings appeared in two main categories : oral and written communication In terms of oral communication the participants encountered communication difficulties in three ways: d iscriminating non Mandarin sounds ; comprehending jokes slang and dialects ; and discerning o c c upational specific vocabulary and hospital register. In terms of written communication the participants faced difficult y writing open ended charting and reading genre specific documents in hospitals. These issues a re expanded upon below. Oral Communication The complexity of oral conversation was one of the primary challenges that the five participants encountered in their cross cultural, clinical communication experiences The challenges included (a) sound discrimination; (b) jokes, slang and dialects comprehension ; and (c) o ccupation specific vocabulary and hospital register discernment.

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147 Discriminating non Mandarin sounds The difficulty in distinguishing meaning from non Mandarin sounds, such as English ac cents, English medicine and medic al terminology and English telephone conversation s made all participants experience communication difficulties Shya, Bu, Chen, Wei, and Co all worked in a culturally and linguistic ally diverse healthcare context in south ern California. The multicultural patient and hospital personnel structure introduced a mixture of native and non native American accents and dialects to the five participants The situation became more complex for the participants to interpret meaning whe n trying to navigate through differing American accents such as African American Vernacular English Hind i English Vietnam ese English and Filipino English Bu narrated: The largest proportion of nurses in my unit is Filipino s. Other nurses are Vietnamese Korean, Chinese, Mexican, Romanian African American, and White American. Patients consist of American s Korean s Vietnamese, Mexican s and a few Chinese. I have to deal with a variety of English accents and cultural differences in my work hour s. It is demanding and confusing. Participants provided multiple examples. Chen declared, The accent of Hind i English is very i ncomprehensible to me. Co had similar complain t s about the Hindi English accent Wei claimed, It is difficult to discern mea ning from the Vietnamese doctor s English accent Shya stated, I have difficulties in understanding Arabic and Spanish English accents. At times, native English speakers dialects also hamper ed the participants listening comprehension in clinical settings. Bu added, I was barely able to take a physician s orders due to his typical southern American accent. Many words were obscure

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148 Second, four participants (Shya, Bu, Chen, and Wei) acknowledged that they misinterpreted medicine s and medical terms due to inconsistencies in pronunciation between the Taiwanese nurses and American healthcare professionals; this could often lead to miscommunication and even serious medical errors Shya s different pronunciation of insulin was an exa mple: ( insulin ) [ ns l n] while Taiwanese medical teams pronounced it as Even language pronunciation differences in stress in words created confusion. For example, Bu noted, In Taiwan, we all pronounce respiratory [r spa tor ] we put the stress in the back; but here, Americans call it [r r tor ] They put the stress in the front. Chen provided her explanation of this situation: N urses in Taiwan acquire d inappropriate pronunciation of English medical terms in nursing programs. We continuously use them inaccurately in practice. We feel our pronunciation. I f someone sp eaks accurately using the English pronunciation of medical terms, the Taiwanese medical teams may be un abl e to identify what he/she is referring to. It is our custom to pronounce these terms using a Taiwanese English accent. \ Identifying and managing these inconsistencies in medical pronunciation complicated the five participants communication experiences from their early experiences as nurses in the U nited States up to the study period. Wei claimed, There are a lot of medical terms and medicines which are different from what we pronounce in Taiwan. There is always a new pronunciation, which is different from what we have heard It happens during phone orders, shift reports, and ground meetings. We have to be very sensitive to these differences, to guess, to ask, and to confirm these terms. Shya continued If we don t recognize these terms and we administer wrong orders, the consequence can be very serious.

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149 Third, when face to face communication was largely influenced by speakers American accent s such as pronunciation, intonation, and tones, negotiating meaning bec ame increasingly complex especially during telephone conversation One participant shared a story: One time when I was on the phone, I misunderstood the doctor s oral diagnosis regarding the patient s phlegm throat I took it as a flame throat. The cha rge nurse looked at my chart and yelled loudly : What? Is her throat on fire? I didn t know I made a mistake until the charge nurse noticed it. The word phlegm [fl m] and flame [flem] were analogous sounds to the participant and may be difficult to discriminate for second language learners. Shya, Chen, and Co also experienced difficulties in communicating with doctors on the phone. Chen recounted Without seeing the doctors faces, I feel it is more challeng ing to express my ideas and clarify misunderstanding freely. Jokes slang and multiple dialects The special ized language used in American humor, jokes, slang, dialects, and social cultural topics made all participants experience communication difficulties when having c asual conversation s (or social conversation) with patients and hospital personnel in the clinical settings. Slang, jokes, social topics, and culturally specific language required the knowledge not only of the English language, but also of cultural meanings in the U.S. mainstream community. Shya, Bu, Chen and Co discovered that in addition to professional conversation, there was a need for them to engage in casual conversation with patients and healthcare colleagues in the workplace. Chen declared, Nurses ability to interact socially with patients and nursing colleagues is generally taken for granted by U.S. society. When the five participants paid more attention to their nursing tasks than

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150 causal conversation, their q uiet and introverted behavior was easily interpreted as indifference. Bu elucidate d, I always do too much and speak too l ittle. (Some) Americans don t appreciate that. They may assume I am not easygoing. All participants agreed that the most complicated aspect of casual conversation was responding to American cultural topics, slang, and jokes. Wei indicated, My patients a nd their families like to talk about American sports, beer, potlucks, pop singers, and country music. I have no ideas about such things Chen narrated one experience : When I left the labor room, a visitor grabbed me and asked whether the expectant mother had turned into a happy camper I responded to him by asking W hat Co also shared her story: A senior bragged about his cowboy history. He explained how famous he and his son were in the ir hometown. Although it was a fun communicat ion experience I was unfamiliar with any of the cowboy vocabulary; besides his southern accent was difficult to catch. I hardly understood what he said. All participants felt bad when they misunderstood casual conversation ; it was often attributed to t heir lack of knowledge of American slang or the topic specific vocabulary. Shya had an American colleague Jenny ( pseudonym ) who frequently used slang and local phrases when describing job related scenarios to her. Shya recounted, One time, I was asking Jenny to cover my case. I asked her whether she could help me put i n an IV drip for Mr. Li because I had to take a patient to do the EKG ( electrocardiogram ) straight away Jenny replied Certainly. I will put it i n in a New York second I had no idea what in a New York second st ood for. I did not realize people use New Yorkers time to imply something that happen s quickly. I muddily suppose d that Jenny agreed to help me. In another example, Jenny and I were gossiping about one of our colleagues retirement plan. Jenny said to me, Amanda ( pseudonym ) is out of her mind Although I recognized the phrase out of mind, I felt it was a little strange to hear Jenny using mind to describe the situation.

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151 Wei and Co both experienced embarrassment when hearing sexually charged jokes from their American colleagues. Wei described that one day William ( pseudonym ) and his supervisor Vivien ( pseudonym ) came to Wei to consult about a case: William is my former sub ordinate who transferred to work in the emergency room. After the consultation, I said something casual to Vivien: I heard you are moving to another healthcare center. She responded to me, Yes, I am leaving. I am thinking to take William with me. Then I replied to her, No, you can t take my Willy. William looked up astonished and said to me, What? Did you just say my willy? Oh, no. I didn t mean it. Wei asked me whether I understood the implication behind what she said I told her I did: was an oral expression referring to the male sex organ Wei clarified that she had no intention to sexually harass her male coworker when she used the word illy She mistook illy as a cute nickname for her acquaintance Wei continued I was so emb arrassed. My cheeks flushed right after I uttered the word. Co shared another mis communication story that had sexual implications: On e afternoon, I wa lked in to a conversation that my coworkers having in the lounge They joked around and laugh ed happily with each other. I kind of heard the word bonus within their dialogue S ubsequently I interrupted them and asked, What s so funny for you guys to talk about bonus? Are we going to get an extra bonus this month? They laughed more loudly They taught me that the word boner refer s to the erect state of the male organ rather than a raise or an additional benefit. I was too innocent to continue the conversation at that moment, so I just left the lounge room. Shya, Bu, Chen, Wei, and Co noted th at the ability of engaging in casual conversation could trust in nurses but also smooth the nurse patient i nteractions for the remainder of the shift H o wever, three participants (Bu, Chen, and Co) admitted that they often had delayed reactions to American jokes or misinterpret ed people s statements The incomprehension of American humor and

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152 English implications often resulted in a feeling of disconnect ion and isolation It also led to unsuccessful communication between the par ticipants and patients, families, and hospital personnel in the clinical settings and meant that they had an increasingly difficult time establishing relationships with them. Occupation specific vocabulary and hospital register The c omplexity and specialization of o ccupation specific vocabulary and the linguistic register of hospital talk made Shya, Bu, and Co experience difficult ies when reporting their nursing cases to people from different occupational fields, such as coroner s, social workers, a nd police officers. Co explained: Our Taiwanese culture stress es that human life continue s after death P r eserving the intact corpse is considered important for the afterlife Medical examination s, organ donation and other intrusive actions to ward cadavers are not encouraged in our society In contrast, in the United States, we are legally requested to inform coroner s and OneLegacy (a donate life organization) about our patients death. It is a brand new concept for me, for Bu to call coroner s to in form them of our dying and dead SICU patients. The particular death report phone calls and custody procedures demanded that the three proficiency in linguistic registers and vocabulary fields be broader than those restricted to nursing co ntexts Shya declare d, I sometimes stutter when talking to OneLegacy or the coroner over the phone. I usually don t have trouble in my conversational English, but I am not good at expressing myself when talking about non nursing issues at work such as le gal, administrati ve, or ethic al stuff. Bu said, We have no such training. I lack of knowledge to speak with officers about the law or the social welfare system. Those conversations are trick ier than the common English we use in nursing care. Additionally, all participants depict ed the special ized register of SBAR ( Situation Background Assessment and Recommendation ) technique advocated by the hospitals

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153 where they worked in California. They also discussed how this specialized technique affect ed their communication experiences at work. The SBAR technique aims to ensure healthcare ing brief concise and timely It includes talk of patients health state s ( situations ), reasons for p atients admission (background), evaluation of patient health (assessment), and patient care plans (r ecommendation ). Bu explained, American physicians and nurses prefer the SBAR speech pinpoint ing keywords to an indirect speech hinting at meanings Wei elucidate d more about the background of the SBAR skill: Since in the United States many doctors stay in their own offices outside of the hospital and spen d l imited time with patients it is seen as crucial for primary nurses to give brief and accurate inf ormation when talking to doctors G iven that doctors are frequently out of the hospital, nurses mainly r el y on telephone c onversation to obtain medical orders Therefore the SBAR technique is also used during phone conversation s Hence, the complex spe ech task associated with utilizing SBAR was exacerbated by the difficulty in talking on the telephone, which meant that the nurses could not use face to face communication skills (interpreting body language, gestures, or reading lips). In addition to talking to doctors, all participants were expected to use the SBAR standardized technique to communicate with all other hospital personnel such as nursing colleagues, pharmacists, physical therapists, occupational therapists, and respiratory therapists. Shya, Bu, Chen, and Co confessed that the SBAR technique was totally strange to them in their early U.S. communication experiences Co stated, Based on our previous work experiences in Taiwan, we were under trained for the assessment and recommendation te chnique required by the SBAR skill in the United States. Bu, Chen, and Co felt pressure to adapt to the succinct and instantaneous SBAR linguistic register promote d by the U.S. medical context.

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154 Even up to the time of the study, Bu claimed, I am still not used to this brief report skill. My indirect speech often makes my American colleagues and doctors confused about what I say. Bu s sample draws incident described earlier was taken as a support for her statements: I asked a doctor Do you want to h ave a sample draw after whi ch doses? He didn t understand the After which dose should I have a sample draw? This time he finally got it. In addition, an American doctor blamed Chen for her slow speech because she didn t perform the standardized manner needed using specific SBAR terminology Furthermore, three participants warned that nurses non SBAR, indirect speech had the potential to bring trouble when reporting death cases to coroners. Shya, Bu, and Co noted that MICU and SICU nurses in California were oblig ed to report a patient s death to the coroner over the telephone. Nurses should account for the patient s diseases wounds, symptoms medical procedures, and cause of death in detail The c oroner would then determine the nece ssity of utilizing a postmortem examination on the case depending on the nurse report. T herefore the semantic choices, coherence, tones, and phrases that the participants used during the phone conversation required careful reflection and selection. One participant narrated a story of her Korean coworker: I have a Korean colleague who stuttered in English when she reported a normal dead case to the coroner. Her indirect tone of speaking made the coroner feel suspicio us about the cause of death. Hence, the coroner requested that the Korean nurse transfer the case to a n inquest. This experience made me conscious of how indirect, non SBAR speech could produce medical confusion. We should be more assertive and more skillful in SBAR when we make a report to the coroner.

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155 Written C ommunication The written communication events that the participants experienced in the U.S. healthcare context involved a large degree of reading and writing tasks to comprehend medical documents and record patients health informati on. The lack of language skills in medical reading and nursing charting forced Shya to be laid off and Co to resign from a job in the United States As noted in Chapter 4, the limitations in specialized American English for nursing contexts had a direct, n careers. Open ended writing in charting Shya, Bu, Chen, and Co were concerned about the specialized genre of keeping nursing notes, referred to as charting by the participants. Charting is a nursing skill t o rec and the given treatment, medication, and care provided to the patient s. Nurses and other hospital personnel rely significantly on reading the charts to understand patients latest healthcare status in hospital s. Overall, Shya Bu, Chen, and Co experienced difficulty in learning to accomplish charting at the beginning of their U.S. work experiences The unfamiliarity with American English spelling, American medical terminology medicine used in the United States, and the format of charting increased the complexity for the participants to finish the writing tasks in clinical settings. One day when I was with Bu in her unit lounge, she showed me a pile of printed blank forms and said: Nurses in our hospital rely on computer s to re cord health relevant information, including charting, diagnosis notes, shift forms, and incident reports. You see this? [She flipped through the paper.] I can spend 30 minutes to 1 hour to just fill out all these forms every shift.

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156 Although nurses char ting involve s a great degree of computer literacy, such as clicking on options and filling in medical numbers or laboratory data in columns it requires nurses ability to write accurate open ended descriptions of patient health information. The main diffi culty that all participants experienced in writing nursing notes was the open ended descriptions and writing them with accuracy Shya recalled in her first and second job in the United States, s. I was unskilled in charting Co shared her frustration in her first employment as a recovery nurse in California : I didn t know how to do charting at all. Nobody taught me or showed me. If you don t have a good charting, you won t be able to make (oral) shift reports appro priately ( to nursing colleagues ), which is the basic requirement of nursing care It was an awful experience I felt useless and frustrated so I quit my job. Shya, Chen, and Wei were cautious about grammar and details in charting because they were a fraid of medical disputes or lawsuits caused by their mistaken charting. Chen was told that based on California law, a delivery nurse is held accountable for a child s health from the time he/she wa s born until the child turns 16 years old. Chen supposed F or that reason a comprehensive charting with accurate vocabulary and grammar can be seen as the only evidences to judge my responsibilities as a nurse in medical disputes. Wei remembered she took a charting class offered by her employer. She learned th at careless nursing records could result in complicated lawsuits, particularly for second language writers who misused pronoun s in charting: I don t remember the exact sentence but when the instructor showed us the slides, I was astound ed by the authentic examples from an Asian nurse s charts. It was related to pronoun arrangement in sentences. For instance, in a long sentence and maybe the second part of the sentence used which or what but the which or what didn t match the first sentence s pron oun, and what s worse it led to a total opposite meaning.

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157 That s almost everything I can recall. I was totally shocked that minor grammatical errors in charting can even mess us up with medical disputes Besides English grammar, Bu worried about English spelling and vocabulary when she composed official nursing documents: Some general vocabulary words not medical words applied in charting are not easy for me to spell correctly or I misspel l medical terms especially words constructed with the double L For example, I omit one of the Ls in Moellerella and Molluscum. The English spelling errors appearing on my charts frequently embarrass me in front of my coworkers during the shift reports. I feel uncomfortable for them to notice my English mistakes. It make me look professional at work. Reading medical documents Shya, Bu and Co claimed that reading the genre specific doctors diagnoses laborato ry data, machine monitors, medical documents, and machine manuals were difficult in their U.S. communication experiences They had limited knowledge of the meanings of American vocabulary and abbreviations, the interpretation of medical and laboratory numb ers, and the layout of machine manuals. Shya was remind ed of her first job experience in the United States: unskill ful at everything. The job required me to read telemetry, CT ( computerized tomography ), EKG (electrocardiogram) something like that, but I was incapable of reading the data. Co resigned from her first job in California : I felt extremely discouraged when I nearly became a medical illiterate. I w as unable to read doctors diagnoses and medical notes in English. D uring the study perio d, besides Bu s full time position at the SICU, she worked as a per diem nurse in the dialysis department. As a per diem nurse, Bu was on cal l and

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158 filled in for other nursing members on leave. Bu acknowledge d that it was difficult for her to read the machi ne manuals of the dialysis equipment: The booklets o n the newly arrival dialysis machines are so difficult to me. The manuals contain incomprehensible technological terms and complex sentences in an unusual format. It doesn t look like the medical documents that we read in the hospital. It is not like reading a newspaper or an English subject textbook. It is very hard to read. I am completely lost by the manuals. Those words are neither like medical terms nor daily life vocabulary. I hardly understa nd what it says. Cultural Differences in Clinical Settings about everything. In addition to English language, culture was another main feature shaping the five cross cultural, clinical communication experiences in the Un ited States. This study investigated the role of culture in communication from the perspective s of the five Taiwanese nurses. It identified three sub themes including (a) l inguistic and c ultural divers ity of hospital personnel and patients ; (b) patient ce ntered care; and (c) i ndependent role of nurses in U S healthcare Co declared I was perplexed about everything. I can t transfer my past 20 year work experiences in Taiwan to practice nursing care here. The culture, environment people, and system are very different. Linguistic and Cultural Divers ity of Hospital Personnel and Patients Referring to Co s statement: Cultural differences result in a huge impact on me I ve never experienced such diversity in my work history in Taiwan All participan ts experienced a more complicated work environment than in Taiwan because of the diverse population in California. Shya, Bu, Chen, Wei, and Co encountered speakers from a variety of ethnic and linguistic backgrounds who spoke English with various accents, dialects, and cultural interpretation s This diverse environment complicated the clinical communication in the United States.

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159 There were two groups of people whom the participants frequently interacted with, including (1) patients/families/visitors and (2) hospital personnel. First, t he residential population of p atients at each hospital determined which linguistic and ethnic backgrounds that the participants would face To be specific, the hospital where Chen was employed had a large population of Mexican, Chinese, Vietnam ese, and Cantonese patients. The SICU where Bu and Co worked was occup ied by American, Vietnamese, Chinese, Korean, Mexican and Middle Eastern trauma patients. The healthcare center to which Wei was devo ted was famous for taking care of Korean, Chinese, Vietnamese, Taiwanese, Mexican, and American elderly orthopedic patients. Wei commented, The culturally and linguistically diverse patient structure results in a growing need for us, bilingual nurses to s erve the multi ethnic community here. Second, all participants indicated that their healthcare colleagues were also from diverse cultural and professional backgrounds. The hospital personnel w as composed of Americans, Filipinos, Japanese, Koreans, Chinese Taiwanese, Mexicans, Cambodians, Indians, Lebanese, Arabians, and Turks, among other ethnicities. Besides their varied and diverse linguistic and cultural backgrounds, these people represented and were trained in different occupations and positions in th e hospital such as doctors, pharmacists, dieticians, respiratory therapists, physical therapists, occupational therapists, speech therapists, and nurses The diverse population in the U.S. healthcare context required the participants cultural knowledge not only of Americans but of people from multicultural backgrounds. Refer ring back to data presented in C hapter 4, Chen s observation of expectant mothers reactions to newborns patients cultural specific dietary preference and

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160 people s diverse expectations toward medicine health, illness, life, and death all complicated the communication experiences in U.S. clinical settings. These complex contexts meant tha t the nurses, who lacked training in multiculturalism, were req uired to navigate cultures about which they had limited knowledge. For example, four participants (Shya, Bu, Wei, and Co) had experiences of interacting with patients from different cultural backgrounds who disliked being cared for by the opposite sex (f emales) Wei shared a story about gender issues with one of her American male patient s : When I entered the ward, the elderly male complained to me that he hated old women. He was referring to my col l e ague an experienced American nurse in her 50s. I didn t know whether he discriminated against old women or if he detest ed females of all age s But the next day, he requested a male nurse to replace my American female co worker. Probably in this situation he favored me n Who knows? Co came across a gender i ssue in nursing care with a Hindu male patient: One morning, I was given charge of a 60 year old male Hindu patient. This guy is a n academic with a PhD degree and his son is a physician. Before I met him, I was told by my coworker that this guy was labeled as a difficult patient due to his aggressive behavior and irritat ing attitudes toward our female nurses. Likewise, I found it very challenging to interact with him. He refused t o take pills and barraged me with insult s At the end of the shift, I was info rmed that this patient had requested a male nurse to be in charge of his father s health care. My coworker said, o nce the change was made t his patient s annoying behavior diminished and his complaints disappeared We discussed his transform ation: inferring from his age bracket in Hindu culture that men and women might be segregated based on hierarchical difference s His high academic achievement could have contributed to him being easily offended and upset by women Moreover, he was weak fro m his illness He could be unhappy that we female nurse s were in charge of his care Shya learned to be cautious not to uncover a mid 60s Muslim lady while Shya was bathing her: I have to be very careful when I take care of female M usli m patients. Thei r

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161 bodies can t be exposed to males. I put a do not disturb sign on her bed curtains and started bathing her. I used a towel to cover her body ex c e p t for the area that I was cleaning. I was paying attention to anyone who came close to the bed to avert unexpected exposure while my patient was undressed If I failed to respect the patient s M usli m culture which did no t allow me to expos e the lady s body particularly in front of males, I could imagine that a big communication clash would easily occur Independent R ole of N urses in U S H ealthcare Shya, Bu, Chen, Wei, and Co noted that nurses in the United States were taken as independent professionals rather than doctors assistants. Bu discussed the different nurse s roles in Taiwan and the United St ates: In Taiwan, nurses are viewed as caring machines We are expected to be silent about our opinions of medical care. Once we provide professional opinions, we will be considered arrogant or thought to be challenging decisions In the United States, nurses were req uired to have more independent judgment and c ritical thinking ability to implement nursing care and to determine p atient p riority than in Taiwan. Shya s story below represents an example of how critical thinking played a crucial role in her nursing practices in the United States: I had a code blue patient today We spent the entire afternoon resuscitat ing her. My arms and shoulders are sore now. We took turns do ing CPR ( cardiopulmonary resuscitation ) for nearly two hours. Earlier this morning, I received a doctor s order to send her to do a n EKG ( electrocardiogram ). I noticed this patient s vital signs were unstable. In addition, her r espiratory rate was not good. Then, I evaluated that she was too weak to move. To prevent acute deteri oration, I made a phone call to the doctor and told him my concerns. I also advised the doctor to prescribe injections in the case that a critical condition would emerg e Besides pick ing up the injections, I carried a crash cart (a cart with emergency medi cation and equipment for life support ) with her wh en we were heading to the EKG room. Like what I assessed, her heart was abruptly stopping when we were only half way to the examination room. Due to Shya s critical thinking and advance professional judg ment, s he was fully equipped to save the patient s life. Shya concluded,

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162 It is our job to discover and predict potential problems. Doctors are out of the unit most of the time. It s the primary nurses duty to estimate whether patients are at risk. We are not submissively waiting for medical orders or submis sive toward our jobs. The participants all felt more pressure and required more responsibility when communicating with patients and hospital personnel than when they worked in Taiwan. Wei claimed, In non teaching U. S. hospitals, doctors are not on duty 24 hour s in the department. Attending physician s often ha ve their own personal clinics outside the hospital They may conduct round s twice a day and rely principally on our patient reports. They monitor patients via our phone calls through out the rest of the day. O u r jobs are similar to what interns and resident doctors do in Taiwan. Shya, Bu, Chen, and Co agreed with Wei s perspective that what registered nurses did in U.S. hospital s were more like what resident physicians did in Taiwan. Shya presupposed that due to their assistant roles with doctors in Taiwan nurses were less responsible for medical lawsuit s. P hysicians and surgeons in Taiwan were typically blamed for controversial medic al cases that arose. On the contrary, nurses in the United States require d additional assess ment skills, professional contributions, and intensive interaction with patients. Nurses were sharing the responsibilities for medical care and disputes Co stated, Working in U.S. hospitals require s our critical thinking skills to Therefore, we are held legally responsible for medical disputes Shya also declared, Nurses and doctors cooperate together by consult ing each other about is a question about a medical case, we and doctors are both liable As a result, we have to be very careful about what we say at work. T o effectively communicate with doctors and nursing colleagues, all participants were implored to creat e care plan s and to develop independent judgment. It t ook them

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163 time to transit thinking independently within clinical settings. Co s temperature incident was a support of this statem ent: After I observed my coworkers temperature measurement techniques for a couple of weeks, I finally realized they had profound knowledge about th is basic skill. Co admit ted, I didn t know what critical thinking is until I work ed in the United States My past 20 year work experiences in Taiwan help me develop this ability. Chen acknowledged, It took me several months to get used to thinking and judging independently at work. People rely on me to make decisions, to say something even if I have no idea what to say and what to do. Shya also indicated, When I was in Taiwan, I wasn t trained to think critically and independently to help the patients. I suffered a difficult time in deve loping this thinking ability in my first and second job. However in contrast to nurses passive roles in Taiwan, all participants perceived that nurses were more appreciated in U.S. society. Wei addressed, The public assumes that nursing involves complicated knowledge and professional qualification s which cannot be substituted by others easily. Co stated, Although I feel more pressure, I prefer to work in the United States. It is because I discern people are respecting me as a nurse who is competent to think critically, judge independently in my profession. Patient C entered C are All participants stated that the patient centered care in the United States was different from the doctor center ed environment in Taiwan, including the emphasi s of patient safety, p atient r ight s p atient confidentiality family/v isitor friendly p olicy and intensive communication between nurses and patients. Chen declared, I feel more pressure to work here (to take care of nursing tasks and satisfy patients ne eds). Patients have such big privilege Bu revealed, I feel like we (nurses) are in the service

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164 industry to serve our clients, instead of working in the healthcare industry. Wei also claimed, Patients rights are a priority This country requires us to take more responsibility for being a nurse than in Taiwan. The patient centered care resulted in intensive communication between nurses and patients. Bu declared that i t wa s standard for nurses to introduce themselves to patients and t o explain how th ey could be reached in the hospital department, which was a practice that was not required in the Taiwanese nursing industry. Bu expressed more about the contrast ing doctor centered versus patient centered care between in Taiwan and in the United States : R egistered nurses in Taiwan are viewed as doctors assistants. We are usually not that valued or respected by doctors and patients. We are generally overwhelmed by an excessive workload of eight to 20 beds per shift. We are busy running in and out of ever y ward to change intravenous injection s (IV s ), administer medicine, check vital signs, do assessment s and monitor data from medical equipments. When I was in Taiwan, I was normally occupied in the entire morning just conducting my first round After a short lunch break, I began the second round By the time I finished the second round of patient check s it was often already past working hours. You can see other than informing patients about essential nursing procedures and treatments we rarel y ha ve the need and opportunity to initiate relax ing, social, casual conversation with our patients, their families and visitors On the other hand, to make up f or the lack of time doctors nurses in the United States took charge of only two to six patients depending on the unit types per shift in the hospitals. Bu continued We are expected to have intensive interaction with patients and families in order to build rapport between patients and nurses Due to the patient centered culture, we bump into a lot of communication events whic h we didn t go through when we worked in Taiwan. My awkwardness of these communication events make me look unprofessional and unprepared in front of my coworkers and patients. I feel shameful whenever it happens.

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165 Second, patients were highly aware of their rights and care in the hospital. All participants noted that in contrast to Taiwanese patients patient s in the United States tended to have a greater interest in being informed by the nurses and doctors of their detailed care plan. Wei noted, Patients are eager to understand their health condition and the medicine they are on. Shya claimed, Families ask numerous questions about remed ies and request to be kept regular ly apprised of the patient s condition Bu declared Patients won t let me physically assist them unless I can offer clear explanations to clarify their concerns and questions. Wei added, American patients are aware of their right s which is different from Taiwanese patients I have s everal patients in the U.S. who refused to take the prescription pills or rejected the pre arranged treatments until they received a second medical consultation. Moreover patients are educated enough to give opinion s to doc tors about pills and treatments benefiting their condition, which is not common in Taiwan. Two participants described the different reactions from patients in Taiwan and in the United States. They felt the pressure to explain a lot to patients: Shya: In Taiwan, patients don t express opinions They take medicine acquiescently They don t even need you to explain what pills you are distributing Bu: That s right. Here, you have to explicit ly make clear the effects of drugs while you are giving medication s It s bothersome, especially when you have a patient who keeps asking you questions. In a ddition patients in the United States seemed to be alert to the food they eat in the hospital. U nderstanding the preferred diet s became an important part of the nurses jobs All participants were requested to monitor patients intake in order to maintain their physical condition, such as some patients who were on a cardiac friendly diet s and others were on regular unrestricted diet s Shya compared patients dietary preference s to the issue of patient rights between Taiwan and the United States:

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166 In Taiwan, it is easy to observe patients diet ary control because patients usually follow meal plans which are prescribed by diet icians Taiwanese patients tend to express few opinions about hospital meals. They accept the fa ct that they are ill and weak and the hospital team is provid ing the most professional care for their condition. They listen to our suggestions Some patients even assume that b ad tast ing food can have better curative properties It is rarely seen that nurses and patients discuss diet ary preferences in the hospital. On the contrary, patients in the United States usually desire personalized services. They are not content with hospital meals. They are liable to make many requests about their meal choices. Occasionally, their questions and requests are difficult to answer because I have no such dietary knowledge from their cultures. T o pr event patients from eating inappropriate foods all participants were under stress to be familiar with popular American foods as well as the dietary preference s of multi cultural population s The following dialogue occurred regarding four per ceptions about diverse dietary preferences: Chen: Korean and Chinese moms should be give n warm or hot water after they give birth Yet, if you offer hot water to American and Mexican mothers, they won t be happy. They ask for iced drink s They fe el they sweat a lot while laboring. They desperately want a pitcher of orange juice to c ool them. Shya : The cooler the better. Chen: Yes, the cooler the better. And you don t wait till they ask. You are supposed to prepare the stuff spontaneously Labor is an exhausting process. Mothers usually don t have much patience to wait. Co: Some Hindus and M u sl i ms do not eat pork. They consider it to be common sense and anticipate you should know instinctively You have to check their menu contain ing no pork When a patient orders g orgonzola cheese I have to know whether the ingredients of g orgonzola cheese are suitable for a diabetic diet. How could I know this? I don t know what g orgonzola cheese is, so how could I possibl y know its ingredients? I think one of the biggest challenges for international nurses. We have no idea about food s and diet ary habits ( across cultures ). Bu: Exactly. Like Co, we always carry a mini notebook with us. We write down patients requests for any food or dishes which are unfamilia r to us, and we ask our American coworkers about them or Google them on the internet.

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167 Furthermore, cultural differences about food and drink could cause communication difficulties between the participants and patients. Co confessed, I often need to search for ingredients. This action frequently postpones my reply to the patients inquiries. I am worried that my professional image will be depreciate d if the co nversation between me and the patient is disrupt ed by the need to look up food vocabulary ag ain and again. Third, the protection of patient confidentiality in the United States was different from how the participants were trained in Taiwan. Shya, Bu, Chen, Wei, and Co referred to the HIPAA ( Health Insurance Portability and Accountability Act ), the federal r ule to preserve the privacy of patients personal health information They explained how the HIPAA laws affected their communication experiences Interesting, three participants, Shya, Bu and Co associated the concept of privacy protection w ith patients family structures and relationship sta tus in the United States. Shya described In Taiwan, when patients are hospitalized, their relatives and friends normally show sympathy by visiting them in the hospital. We (nurses) are usually not bothered by who is invited or who is prohibited to see our patients. Visitors are generally appreciated by our patient s and their famil ies Moreover it is taken for granted that when someone allege s he/she is the pat ients family member we will inform him/her about the patients health condition. N evertheless four participants (Shya, Bu, Chen, and Co) were perplexed by patients fastidious concerns about visitors in the United States. They discovered that patient s in the United States tended to be sensitive about their medical privacy. Bu wondered: I don t get it. Even though children may have been ex wife, how can a current wife forb i d ? Shya stated, I cannot let go that my mid 40 year old patient refused to let his b iological mother see him. She s his mother. They have blood connection! Co narrated: I met a man who claimed my patient wa s his wife, so I told him about the

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168 patient s condition. All of a sudden the legal husband showed up to correct me th at this man was my patient s ex husband. I was blamed for violating the HIPAA because I shouldn t have revealed patient health information to the inappropriate person. Wei then made a comment about t hese phenomen a: I think a large proportion of Americans have multiple marriage s and multifaceted family structures Besides the next of kin (i.e., parents, spouses and siblings), we care for patients who have extended families due to marriage such as stepparents, stepchildren ex wi v e s and ex husbands When the family has broken relationship s the next of kin and the power of attorney will protect the sick one from being harmed by anyone whom they don t favor. Maybe that s why Americ an patients become particular about the visitors when they are in the hospital. Because of this, four participants (Shya, Bu, Wei, and Co) declared that besides a there was a need for them to study structures and social relationship at work. Co elucidate d, I remember the first tim e Michelle ( pseudonym ) gave me a shift report S he spent 10 minutes talking about the patient s physical condition, and the other 20 minutes explaining the patient s family relationship s including his first and second marriage s his relatives from other states, his cousins from out of state, his spouses and so on. I was confounded at that time. But now, I realize how important it is to communicate with my patients by unders tanding their family backgrounds. It s a part of nursing communication. Fourth, the patient centered care was also observed from the hospitals establishment of a 24 hour a day visitor period for patients and their families. According to Shya and Bu, in the intensive care unit (ICU), their hospitals offered a 24 hour visiting policy for the ICU ies and visitors. A n additional bed was also found inside the ward allowing caregivers to sleep near the patients. Shya illustrated how this was different from the Taiwanese medical context: In Taiwan, the hospital culture is driven by a doctor centered care. Doctors are thought of as superiors who hold medical knowledge which is difficult for the public to obtain and und erstand. T he ICU is a high alert

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169 unit. In order to precisely monitor patients critical condition, visitors and families are restricted from visiting at certain times of the day They are only permit ted to enter the ICU twice a day, such as for half an hou r in the morning and afternoon. The different cultural emphas i s in hospital s resulted in the participants having stressful communication experiences from time to time. Bu and Shya disclose d their fretfulness about the ICU 24 hour visiting policy: Shya : It is annoying to have the family around you all the time. It is an intensive unit. We deserve a work environment without disturbance s in order to keep a cautious eye on our patients. Bu: You re right. Families like to keep asking you questions and expect you to engage in conversation with them. But as you know, SICU patients are generally serious ly injured Their conditions are supposed to be bad. Some serious treatments and procedures are required. Sometimes it is nothing bi g However, while I am b usy saving patients li ves I should not have to be distracted by answering family s questions and pacifying their anxiety. Shya: True! I usually feel stressed about that kind of conversation. An additional finding related to the patient centered environ ment was the role of pets According to Wei s training in Taiwan, cats and d o g s carried viruses and parasite s which pose d a threat to hospital hygiene Wei asserted, t is well known that pets are prohibited from entering hospitals and clinics in Taiwan. Wei was astounded when she discovered the hospital where she worked in California allowed pets to visit patients. Before she was informed of the pet friendly policy, she was irritated by American visitors who brought pets to the hos pital. O ne time, when she was about to prohibit a visitor who carried a puppy from enter ing the unit, she was stopped by an American coworker. Her coworker clarified that pets wer e viewed as family member s in many America families. The hospital just announ ced a new policy to tolerate bathed pets to accompany the hospital inpatients. Wei concluded, I can say it is a cultur e shock to me (because of the pet friendly policy). I

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170 was close to start ing a quarrel with the visitor and it turned out to be my misconc eption of the hospital policy. N evertheless I learned a lesson about the relationship between pets and my American patients. U.S. hospitals make efforts to accommodate their patients, which is hardly found in Taiwan. I dentity Negotiation in a N ew U.S. E nvironment (being Taiwanese or being American?) From time to time, all participants discerned the need to negotiate who they were and chose how they talked and/or acted depending on whom they were with in the U.S. healthcare context. They e xperienced com plaints and arguments from patients, families, visitors, and the hospital personnel caused by cultural and language misconceptions. They detect ed s distrust and unfriendliness because of their non Americanized looks and ways of speaking. They also b alanced and negotiated notions of assertive ness and compromise However, while all of the participants discussed the need to negotiate their identities and feelings of separation, three of the participants found this uncomfortable and difficult (Bu, Chen, and Co) and two of them ( Shya and Wei) did not. For example, although Shya and Wei were comfortable in being Taiwanese, Bu convey ed that she wanted to be more Americanized in her speech : I wish I can speak like an American nurse, work like an Am erican nurse; then no one will look down on me in hospitals One way that two participants (Bu and Chen) felt culturally isolated was in informal, social settings in the hospital. For instance the participants described t he typical s eat ing arrangement in the nursing lounges at their places of work. They were usually ethnically and socially separated from their coworkers. Bu illustrated, In the lounge room, American nurses are staying with American s Hispanic nurses are talking in Spanis h in one table. Filipino nurses speak Tagalog. Asian nurses, such as Korean, Chinese, Vietnamese Japanese, and I are clustered around one table. N urses from different cultur es greet

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171 each other and occasionally joke around, but generally we only engage i n i nti mate co nversations with the coworkers of the same or similar language background. I am not satisfied with this segregation. I hope I will be co nsidered a member of my nursing peers someday. Chen also revealed her frustration of being lonely in her unit. When Bu and Chen were disappoint ed at the social isolation and emotional remoteness that they felt from their coworkers, Wei and Co held more positive perspectives about the phenomenon Wei declared, I think the interaction boundaries between Taiwanese nurses and other ethnic nurses are acceptable We all like to hang out with people from similar backgrounds. All participants ha d similar experiences of being humiliated by people who worked or stayed in U.S. hospitals. These people verbally insult ed the participants and question ed their nursing qualifications owing to their imperfect English and Asian look s One doctor doubted Chen s emergency competence based on her slow speech. Shya, Wei, and Co had American certified nursing as sistant s (CNAs) and nursing students who rebelled against the tasks for which they assigned Furthermore Co noted, I have had some patients ridicule my Taiwanese accent in English. The se incidents remarkably impacted the cross cultural clinical communication experiences They were forced to not only negotiate meaning s and quell arguments but also to fight for their professional image in front of patients and hospital personnel. Accent : Retaining or Reducing the Taiwanese A ccent in Engl ish As mentioned in the prior section, all participants experienced difficulty in discriminating the diverse English accents in U.S. hospitals, but Shya, Bu, Chen, Wei, and Co held different viewpoints of retaining or reducing their own Taiwanese accent in English.

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172 On one hand, b esides be ing influenced by people s accents in clinical settings, Bu and Co were highly aware of their own Taiwanese accent when speaking English. They had strong concerns about it and considered taking steps to reduce their acce nt They Co said apprehensively My Taiwanese accent cause s a lot of miscommunication for the doctors, pharmacists, and my nursing coworkers. I wish I could speak without the acc ent, but I am too old to get rid of it. Bu asked, Are there accent reduction courses so that I can enroll in ? I feel guilty whenever my accent hinders the smoothness of the conversation with my coworkers and doctors. Moreover, Bu and Co indicated that their obvious Taiwanese English accent reduced their professional image in the eyes of the hospital personnel. It also made people question their nursing competence. Co claimed, Many hospital personnel upon meeting me look down on me. They jump t o conclusions that I am unqualified because of my poor English with a strong accent. Their impatience to wards me is observable On the other hand, Wei and Shya held optimistic perspectives toward s their Taiwanese accent in English. They had no thoughts to r e duce their accent. Wei asserted, I don t discern a need to remove my accent. It is a part of my identity. I am hired not b ecause of my perfect or English; instead it is because I am qualified to work as a registered nurse in the United States Shya stated that her Taiwanese accent didn t obviously impede the flow of the clinical conversation at work: I am fine with my accent. In fact, I am confident in my current speaking ability in clinical communication It s acceptable to speak with an ac cent as long as we can understand each other.

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173 Choices of Sp eech Registers In the focus group interviews individual interviews, and casual conversation s several q uestions arose related to the differences in speech registers between Taiwanese nurses and A merican nurses These questions inspired enthusiastic discussions from the participants along three main subthemes: sweet talk versus professional tone; assertiveness versus compromise ; and pretentiousness versus humility Shya Bu, Chen, Wei, and Co all experienced the conflict between altering and maintain ing their native, natural ways of speakin g, in order to deal with the specialized speech registers in U.S. clinical settings. These are described below. S weet t alk versus p r ofessional t one (with patients) While in Taiwan, Shya, Bu, Chen, Wei, and Co were co mfortable with working hard and talking l ittle in front of patient s They were used to engaging in brief conversation s in a professional tone when talking to patients and f amilies. As a result of those communication patterns, w hen they work ed in the U.S. context, the participants suffer ed from feeling awkward when attempting to be friendly or mak ing casual conversation with patients and families The following conversation i s extracted from one of the interviews: Bu: My colleagues, American nurses, Filipino nurses, and other second generation immigrant nurses, are good at family communication Patients share stories of their family and relationship s to the nurses. They always have pleasant co nversation. My colleagues also like to use honey to address patients of all ages They use sweet talk similar to talking to babies which sounds a bit ridiculous to me. We are SICU nurses, not kindergarten t eachers or babysitters. Co: They also use Oh, dear, darling [She raised her tone to imitate the sound] to address adult patients. They have very good language skills when communicat ing with patients and families. We need to improve this weak ness. Chen: Yes. They use such as I am so sorry, sweetie [She raised her

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174 tone to imitate the sound] Patients favor this, you know, but somehow I feel it s too much. Although four participants (Shya, Bu, Chen, and Co) expressed that they were not totally accustomed to using sweet talk with patients, they gradually adapted to it in order to act like American nurses, in order to fit into the U.S. hospital culture Bu declared, Although it is uncomfortable, I persuaded my self to use y dear, sweetie such sweet talk when addressing patients in order to fit into the hospital culture I c annot understand why my colleagues always apologize to patients when the patients feel hurt owing to their wounds or diseases When we assist patients by bathing them or moving them during which patients may experience pain. P atient s discomfort is caused by their own physical condition not by my fault I don t agree we are responsible for the patients suffering I also believe it is unnecessary to make apologies in this kind of cases. N onetheless i n order to act like American nurses, I am forced to adjust my speech. I am an Asian. I am already different from my colleagues If I want to play a part in the U.S. medical settings, I need to adapt to t his kind of sweet talk in the workplace Furthermore, all participants viewed American nurses had more apparent language advantages to communicate with patients than the y did Shya addressed, When speaking English, American nurses are linguistically elo quent and socially skillful. They are good at handling demanding patients and visitors. They know how to diminish medical disputes. They are expert s at persuading patients and families to accept accessible medical resources which are limited to their needs They also excel at pacifying patients and families anxi ety by offering sweet talk, such as Honey, I ll hold your hand. Four participants (Shya, Bu, Chen, and Co) avow ed that when they practic ed English in clinical settings, they became clumsy at th e se negotiation skills. Particularly Co and Bu worked in the SICU. T rauma patients, such as gunshot and wound patients result ing from fights, occupied a large proportion of the patient population. It was tense fo r them to solve disagreements between patients and visitors who were gang members

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175 or had criminal backgrounds. Co stated, I usually call for help from my American coworkers to ease squabble s. I envy their cleverness in talking to patients and families. B u said I have to admit that I envy their positive relationship s with patients and families I u ch talent for getting along with patients. I have no clue to how to become as good as they are in the workplace English is an unending problem for me. A ssertiveness versus compromise (with patients and hospital personnel) First, all ( meaning too nice or too concess ionary ) In order to survive in the U.S. work environment and to contend with American nurses, t hey modified their speech to demonstrate that they were determined and assertive in their words in front of patients and hospital personnel. T hey also learned to fight for their rights when injustice occurred Wei s cultu ral conflict regarding (wu yu ze gang) (n o wants no compromise ) provided an example of how this contradicted her identity in the United States: American nurses are more confident and definite in their words. I told you my father s (wu yu ze gan g), (n o wants no compromise ) is not practicable in the United States, but I didn t notice it in the early stage of my work. That s why I suffered in my first six month employment But now, I realize if I concede people will think I am weak, and then they can take advantage of me. I don t like to be mean, but if I want to get along with my colleagues, I should learn to be more assertive in my words, to be more determined in my attitude. S imilarly Chen s two visitor policy story with a Mexican father described in C hapter 4 also changed her communication habits from being delicate and modest to taking a strong er approach : I learned to be more assertive when I talk to my colleagues, patients, and their families. If I keep being nice, p eople will infer I am too soft.

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176 Second, all participants found that the U.S. hospital culture highlighted individualism. Nurses tended not to have misgiv ings about challenging their superiors Co recounted, In Taiwan I was a charge nurse. A hierarchy in the Taiwanese workplace is easily perceived One of the prevailing occupational ethics for us is to be submissive to reasonable supervision and tolerant of irrational management. N onetheless since I have work ed here, I have been challenged by my subor dinate s many times, including certified nursing assistants (CNAs), licensed vocational nurse s (LVNs), new graduate nurses, and student nurses. They refuse d to do what was asked of them Interestingly, all participants assumed that their American nursing coworkers would not likely encounter similar on bullying as they had faced. They concur red that American nurses were tough enough to handle the situations. The following dialogue took place in one of the interviews: Bu: Sometimes you just don t know how to get along with CNAs. Co: They (verbally) bully you. Shya: Because you don t know them well. Cloudia: Is it due to language barriers? Bu: ot only related to language. Co: They bully you because you are new (in the U.S. medical envir onmemt) and they have been there Wei: They think they are better and more knowledgeable than you, so they bully you. Cloudia: Do they only target the international nurses like you guys, or do they also bully American new grads? Chen: No way! American s ca nnot be taken advantage of by others! Bu: They (CNAs) don t bully people who speak out. Shya: I presume every ethnicity has its own culture. Basically, it s impossible for American s to be stepped on by others, but Asian nurses are another story.

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177 P retenti ousness versus h umility (with hospital personnel) Shya, Bu, Chen, Wei, and Co reached a consensus that in the same way as it is in U S than humility. This caused cultural conflict at work. All participants revealed that they some of their American ( ) at work especially showing off or their job ability. All participants were trying to find a way to balance between hum ility and confidence. In order to work alongside their American colleagues, they le arned to present themselves in a confident manner without being arrogant First, all participants noted that Taiwanese nurses had a tendency to bear hardships and hard work silently, whereas American nurses might like to highlight their work to others ver bally. Co claimed, Many American nurses report a good shift while we (Taiwanese nurses) practice a good shift. Competing with American nurses, the efforts often went undisclosed out of their quietness and humility in the U.S. clinical s ettings. Bu s unpleasant communication experience regarding neuro patient care introduced in C hapter 4 was attribut ed to her humility: I told her I would learn harder She reported me to the PCC ( p sychiatric c are c onsultant ) and asked her to watch me closely. Chen also addressed, They (American nurses) are all good at making you notice their contributions to the hospital. Nevertheless, when I work so hard and feel so exhausted, there is usually few people would be aware of what I have done. Second, to certain extent, all participants appreciated the American culture of individualism and self reliance Shya, Bu, Chen, Wei, and Co were all adjusting to

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178 speak ing their thoughts more day by day. Nonetheless, all participants still insisted on their family and cultural values of being humble and honest. For instance, although Co had nearly two decade s of work experiences in nursing she was fonder of keeping humble than of showing off what she was capable of Co claimed, M any of my American colleagues and subordinates are inclined to highlight their excellence at nursing. Even the nursing students whom I supervise ha ve a propensity to exaggerate their competence during the internship It can lead to my unrealistic anticipat ions of those students performances. I learned to underestimate those students credibility when I assign them tasks; otherwise I may put my patients in danger, such as being fed or injected improper ly. U.S. N urse Trainin g G aps : Language and Culture ( well prepared Generally, t he hospital training for new nurses was composed of two portions: lectured oriented classes and clinical shadowing The two portion training period lasted from three weeks to three months depending on the hospital s All participants declared that hospital training in the United States overlooked their specific language needs and cultural adjustment for clinical communication Communicating in a multicultural context required the sensitivity to differen t language uses and their understanding of patient backgrounds and hospital subcultures, policies, and routines. However, there was little education focusing on developing the cultural awareness and communication ability to deal with the cros s cultural, clinical communication events. Shya recalled her first and second job experiences in California: In the hospital training programs, except introducing medic al concepts, the application of the English language, culture, and law that we require to communicate at work were usually neglected and over generalized Although I have completed the whole hospital orientation requirements, I wasn t well prepared to work here. My conversation skill s were poor. My reading comprehension was bad. My charting was a mess. I keep up with other nurses.

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179 Lecture Oriented Classes: Hospital Orientation All participants agreed that the mandatory lecture oriented classes which they attended in their first three weeks to three months of employment were limited in two ways: (1) help ing them to adapt to the US healthcare context and (2) providing support for cross cultural communication. Getting a superficial understanding through quick and casual observation of hospital rules and policies did not su ffice for their clinical communication needs Surpris ingly, all participants noted that American nurses and international nurses received the same training in the hospitals where they worked. In the orientation classes, American nurses, the participants a nd nurses from other ethnic backgrounds who were newly recruited by the hospital s were clustered together in a meeting room to listen to lectures. Co claimed, T he orientation classes were designed based on the assumption that American nurses and internati onal nurses h ave the same English level, work experience cultural background and nursing knowledge Bu commented Our employers m ay communication ability during our job interview s, but the interview languag e is very different from the language we use in clinics. Wei affirmed, Our employers depend a lot on the NCLEX RN results to determine if international nurses are capable of cross cultural nursing care. However, a test cannot cover everything. Passing the exam doesn t mean we have all knowledge in hand. In other words, a s long as the participants were hired, it was suppose d that they were both competent in nursing and in communication skills to w ork in the multicultural medical environment. Furthermore, all participants inferred that their hospital employers

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180 were reluctant to waste resources in accommodating international nurses cultural and language adjustment : Bi: Come on silly. They won t provide such courses (developing language and cultural skills) helping international nurses. Wei: They assume you are ready to work and you are as capable as an American nurse. Lack of e ssential l anguage n eeds All participants perceived that the lecture oriented classes didn t fit their essential language needs in terms of oral and written comm unication in clinical settings. The classes had no emphasis on developing the participants and other international nurses English language skills in clinical communication settings Wei expounded, The classes were instructed by the nursing managers and s upervisors from each department They introduce d the hospital history, medical equipments environment and facilities, department regulations, and the latest knowledge with regard to diseases, illnesses, and nursing skills. Nonetheless, I recall cont ent targeting language development for international nurses. The difficulties t hat subsequently arose in all five clinical communication settings were not prevented (or even predicted, as would be indicated in the orientation training curriculum) by the hospital orientation classes There was a great need for training in oral language development ( discriminating accents, pronunciation and phone conversation s ), socia l conversation s (comprehending jokes, slang, and dialects), o ccu pation specific vocabulary and hospital register (talking in specialized occupational fields), open ended writing in charting (keeping nursing notes), and genre specific reading (reading labor atory data and medical documents). T he only

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181 (S ituation, B ackground, A ssessment, and R ecommendation ) Unfortunately, nurse patient communication was not included in the curriculum, which was one of t he major communication difficulties that the participants encountered in the workplace. Shya, Chen, and Co particularly addressed the lack of training in charting made it difficult in their early work experience. These classes missed the mark in showing t hem how to compose medical documents. Shya said, I did n t know how to chart medical notes I didn t understand what these numbers, abbreviations meant on the document No one ever taught me. Co even worse suffered from emotional and physical illnesses due to the anxiety of her medical illiterate in English. Co indicated The way which American nurses chart looks very different from what I did in Taiwan. The hospitals provided no support to develop our document skills. They just assumed you are able to chart because you have the nursing license. Usually, I imitate d my American and Filipino coworkers charts. I observed their writing and learned from their sentences. That s how I overcame my writing shortcomings. Even now, I still rely on my coworkers a lot. They also help me chart whenever I have difficulties in English. They can chart more quickly than I do. Lack of cultural knowledge: Patient backgrounds, hospital subcultures, hospi tal policies, and nursing routines All participants indicated that the lecture oriented classes didn t satisfy their particular needs of cultural adjustment when cultural differences caused them to experience communication difficulties in the workplace. First, patients diverse cultural and ethnic backgrounds were only s uperficial ly introduced in the classes. This meant that there was an acknowledgement of cultural differences but there was no training on what to do as a result of those differences. Bu c laimed, I don t have much impression on whether we had this course, cultural diversity. Wei recalled, The hospital didn t go through the cultural issues seriously

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182 because they thought we have learned them in the NCLEX RN exam already. Chen expounded that although there was one course focusing on cultural diversity for nursing care in her orientation classes the content was unattractive and over generalized She continued After the class, I remembered I ha d no ideas what was about for cultural dive rsity. I actually pick up most cultural knowledge when I really practice in U.S. nursing. I observe my patients. Whenever arguments and conflicts occur, I learn from these lessons. Second, all participants declared that the classes didn t explicitly exp lain the medical systems, hospital subcultures, hospital policies, and nursing routines. They felt confused and concerned whenever they broke the hospital rules that resulted in communication conflicts, including the hospital specialized medical terms, pat ient confidentiality ( e.g., next of kin and power of attorney), dying and death care ( e.g., advanced directives, DNR, organ donation, and coroners), dosage amount, and visitor policy. Co narrat ed, P atient confidentiality and the California law were not inc lude d in the c ourse content I ha ve been uninformed about the concept of power of attorney and who can make decisions for my patients if they are in coma I was also confused who m I should reveal information about my condition to Therefore, I mistakenly kept all family members informed at the beginning of my work. Based on medication, but this aspect was not emphasized in the classes : I was un aware the maximum dose o f morphine for my patient is t wo milligrams until I was corrected by my preceptor. The dosage is less than what I could give in my prior hospital. Moreover, Shya, Bu, Co, and Chen were apprehensive about medical disputes and lawsuits that resulted from vi olating these uninformed hospital regulations Chen stated I am very

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1 83 uncomfortable about the frequent lawsuits that my coworkers have discussed. I am anxious whether I will be sued someday if I innocently breach the rules that I don t mean to. Shya, Bu, and Wei pointed out that the hospital orientation classes lacked training to help them decipher medical acronyms and abbreviations Bu indicated that her American laceration, which perplexed her Nevertheless, the orientation classes did not mention such issues. B elow is a dialogue between Wei and Bu from one interview: Wei: Are you sure ve never heard it. We don t use this abbreviation in our hospital laceration Wei: They should have told you first; otherwise how can you understand it? In addition, Shya noted that he r unfamiliarity with subcultures and policies in the U.S. healthcare context negatively affected her in her primary work experience : I was so frightened in the first three months because everything was new and unknown Shya described an incident when she had worked in the skilled nursing facility: I remember the first time when I called a doctor I was newly arrived in the center for just about two weeks. I didn t know the system of our facility. The LVN was new, too. She told me Call the doctor right away! The patient is crashing! Then, I made a phone call. However, the doctor couldn t understand what I said. I couldn t understand him, either. Shya tried hard to overcome these communication challenge s with limited supports from the doctor and her subordinate, but she remained dedicated to the care of her patients : We decided to call 911 to transfer the crashing patient to the hospital ER (emergency room). Shya continued While the ER team was resuscitat ing the patient, they found that it was unnecessary for us to transfer him. Thus, they sent the patient back to our

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184 facility. He died in the middle of the way, in the parking lot He had signed the DNR (Do Not Resuscitate) form, but I wasn t aware and informed. We were not supposed to be busy r ushing in and out throughout the night. S arcastically we should have done nothing but just watched him die peacefully Despite the medical mistake made due to inadequate orientation and lack of training regarding facility policies Shya did not blame anyone for this incident. Instead, she reminded herself of becoming more cautious about patients documents a nd learning specific terminology that would affect their care. Learning by Doing : Clinical Shadowing In contrast to the lecture oriented classes, all five of the participants appeared to benefit more from clinical shadowing, that is, learning by doing. C linical shadowing is a system of assigning each new ly recruited nurse a preceptor (a senior nurse ) to follow when the new nurse work s The clinical shadowing period is typically arranged for from six weeks to three months in the hospitals Shya, Bu, Chen, Wei, and Co consented that shadowing under a preceptor wa s the most practical and efficient way to improve their communication and work skills in th e cross cultural clinical settings: Co: Doing is better than simply listening to lectures. Bu: Following a preceptor was really helpful. You know the proverb, Shya Bu: I acquired more communication and nursing skills interacting with patients by shadowing a preceptor than attending the classes Chen: I agree. I forgot many things which I was taught merely sitting in t he classes. I was even dozing off during the lectures. There were too many slides to study. Wei: When you personally come across a case, the impression will naturally imprint itself on your mind.

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185 During clinical shadowing, preceptors explained and show ed the participants work routines, nursing skills, department specific regulations work environment s, and medical equipment. All participants claimed that they were able to build their knowledge of the particular hospital subcultures at that time. Shya sa id excitedly, My manager even matched the s characters and personal ity with me when she assigned clinical shadowing. I love to talk and I am eager to ask questions Thus, I was matched with a tolerant preceptor who ha s powerful theoretical background in nursing in order to satisfy my curiosity about work. Co was supervised by an elderly female nurse known for her even temper and attentiveness : My preceptor helped me establish my confidence in work She show ed me nur sing skills and hospital care step by step. She modeled the way to negotiate with patients and families if they have irrational requests. Bu stated, O bserv ing the preceptor and being supported by an experienced nurse has helped me a lot It made me feel secure when I was a novice in a completely strange work environment. Nonetheless all participants perceived that clinical shadowing didn t comprehensively develop their second language ability namely specific English medical terminology and pronunciati on, or cultural knowledge which they needed in cross cultural, clinical settings. Wei declared Nurses can t just rely on their preceptors. It is impossible to teach you everything within a couple of weeks. Bu also claimed, Nursing jobs are complicated and unpredictable Shadowing could only give me general ideas of how to practice here, but I often feel anxious and stressful whenever new things come up. It is not enough for our (international nurses) preparation to work here I actually keep picking up new vocabulary and new skills during my shifts. Chapter Summary In this chapter the four main themes (a) the use of complex and s pecialized language in c linical settings; (b) cross c ultural d ifferences in c linical s ettings ; (c) identity

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186 negotiation in a ne w U.S. e nvironment ; and (d) gaps in l anguage and c ulture in U.S. nurse training that emerged from the cross case analysis were presented. These included how the participants perceived that l anguage, culture, and education influenced their clinical communication experiences in U.S. healthcare settings Results from analysis of the data indicated that the complex and specialized language complicated nurses oral and written communication in cl inical settings. T he diversity of the patient and staff population s and cultural differences in hospitals meant complicated the participants communication experiences The parti cipants also discerned a need to negotiate the ir Taiwanese identity in the U.S. hospitals. However, their hospital training programs overlooked the multi cultural and multilingual diversity of the U.S. healthcare context. These courses put more emphas is on equality, or providing the same training to nurses from the U nited States as for international nurses. Th erefore the participants experiences to understand language and cultural differences in cross cultural clinical settings w ere left unaddressed. Fi nally, the preceptor model of shadowing in clinical settings was a welcomed relief to the nurses but it did not comprehensively include the specific language and cultural knowledge that the participants needed in cross cultural, clinical settings In the following chapter, I discuss these findings as they relate to the literature on second language teaching and learning contexts and second language acquisition training

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187 CHAPTER 6 DISCUSSION AND CONCLUSION O verview This qualitative study was designed to understand the perceptions of five internationally educated Taiwanese nurses about their cross cultural communication experiences in the U.S. healthcare context. The findings revealed that the communication experiences of Sh ya, Bu, Chen, Wei, and Co were complicated due to (a) the complexity (specialized vocabulary and linguistic registers) of English language use in c linical settings; (b) cross c ultural d ifferences in the healthcare context; (c) personal ide ntity negotiation in a ne w U.S. e nvironment ; and (d) gaps in l anguage and c ultur al training of international nurses in U.S. hosp itals. The five participants were required to communicate in high pressure, multicultural clinical environment s in hospital set tings; all were located in southern California Despite the fact that four of the participants (Shya, Bu, Chen, and Wei) were categorized as having an advanced English level based on the U.S. VisaScreen regulations, this study suggested that language demands and cultural differences played a crucial part in the five international nurses cross cultural, clinical communication experiences This chapter c onnect s findings with the theories empirical studies, and the theoretical framework s of second langu age development and communicative competence presented in Chapter 2 According to the definition of terms in Chapter 1, this chapter use s internationally educated nurses, international nurses, and ESL nurses alternatively to refer to the study participants. This chapter is presented in two sections. First, the five cross cultural communication experiences are discussed according to (a) language needs; (b) cross cultural differences; (c) the role of

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188 education; and (d) communicative competence model. A summary of the following discussion is illustrated in Table 6 1. Second, this chapter provides implications of the study for international nurse training programs and for researchers Table 6 1 S ummary of discussion Main findings C onnection to theory Language needs in hospital settings Oral language use Specialized language and hospital register : Verbal orders: nurse vs. hospital personnel ( Bola et al., 2003 ) Speech register: nurse vs. patients and nurse vs. hospital personnel ( Bo sher & Smalkoski 2002 ; Halliday, 1978; Sherman 2007 ; Simon Vandenbergen, 1983 ) Taiwanese American pronunciation : Sound (Bosher & Smalkoski, 2002; Bola et al., 2003 ; Xu et al., 2008) D econtextualized language : telephone consultation: Phone conversation (Hearnden, 2007; Xu et al. 2008 ) Quadrant theory (Cummins 1981) Written English : G enre specific medical reading and writing C harting and medical documents ( Adeniran et al. 2008 ; Bola et al., 2003) Culture in hospital settings Role of nurses: Patient centered care and independent professional P atient centered care (Galanti, 2008; Munoz & Luckmann, 2005) A ssistance role vs. independent professional (Sherman, 2007; Xu et al., 2008) Discourse style s Direct vs. indirect discourse ( Escamilla & Coady, 2001; Kaplan, 1996) Education and training: The need for specialized, ongoing training Pre U.S. training: Language and culture assessment (Bola et al., 2003)

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189 Table 6 1. Continued Main findings C onnection to theory Early U S training : Hospital orientation and mentorships (Abriam Yago et al., 1999; Adeniran et al., 2008; Bola et al., 2003; Hancock; 2008; Sherman, 2007) Application to the c ommunicati ve c ompetence model More relevant aspects of the model Grammatical competence S ociolinguistic competence Cultural competence ( Bachman 1990 ; Campinha Bacote 2002 ; Canale 1983; Canale & Swain 1980 ; Grice 1975 ; Hymes 1971, 1972 ) Less relevant aspects of the model Discourse competence S trategic competence ( Bachma n 1990 ; Canale 1983; Canale & Swain 1980 ;; Hymes 1971, 1972 ) Discussion on Nurses Cross Cultural Communication Experiences In many ( medical ) interactions, communication is cloudy to how individuals perceive and construct reality, and reality is based on cultural experiences, beliefs, values, and practice s. (Munoz & Luckmann, 2005, p p .1 2 15 ) C ross cultural clinical communication is a critical issue in the current U.S. healthcare context ( Galanti, 2008 ; Giger & Davidhizar, 2008; Munoz & Luckmann, 2005). T he nature of clinical communication in a multi cultural context is intricate and complex. While Abriam Yago et al. ( 1999 ) declared that language ability, cultur al knowledge, and nursing education are influential factors in prepar ing ESL nurses to participate in U.S. medical settings this study revealed that the five international nurses communication experiences were influenced by how they acquired and used the L1 (first language) and

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190 L2 (second language) how they perceived and interpret ed the home and host culture s and how the y were trained in both Taiwan and the United States The communicative competence model provides insight into the experiences of international nurses in the context of oral and written clinical communication events in U.S. hospitals. Language Needs in Hospital Settings This section discusses the main findings related to research sub question 1: How do internationa l nurses describe language needs for communication in cross cultural medical settings ? Lack of communication skills hinders foreign nurses from assuming lead to frustration for the nurse, other staff m embers, and patients (Bola et al 2003 p. 40 ) The findings of this study verif ied that language barriers are one of the main forces obstructing the five communication in the U.S. healthcare context Xu et al. ( 2008 ) also pointed out that a lthough internationally educated nurses varied professional training diverse cultur al backgrounds and unfamiliar ity with the U.S. medical system can hinder the smoothness and precision of clinical communication international nurses English language barriers are a leading cont ribution to healthcare miscommunication between the nurses and patients/hospital personnel in the United States. Oral langu ag e use Specialized language and hospital register. The five nursing participants described the ir English language use in clinical settings difficult, diverse, confused, and This study found that c omplex language use in the context of healthcare included (a) a specific hospital register (e.g., context

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191 specific terminology with patients / families and medical personnel) ; (b) multiple meaning in semantics (e.g., o ccupation s pecific v ocabulary ; dialect) ; (c) culturally relevant pragmatics (e.g., j okes and s lang ) ; and (d) genre specific reading and writing (e .g. r eading medical documents and writing o pen e nded nursing notes) Bola et al. ( 2003 ) had similar findings and noted that internationa l nurses face particular language difficulties in understanding verbal orders from doctors. W hen international nurses fail to understand their nursing coworkers and doctors verbal instructions mis communication arise s. The se communication difficulties between international nurses and hospital personnel can result in risks to patient care or even worse, cause serious or fatal damage to patient s. T his finding was similar to those in the current s tudy. For example, t he DNR ( do not resuscitate ) patient and Foley catheter incident demonstrated how language barriers between international nurses and hospital personnel severely compromised patient safety. In addition, t h is study found that there is a specific linguistic register related to hospitals, and lack of knowledge of that register is one of the main issues that c omplicated the five international communication in the work place A ll five participants discerned a need to adjust their spe ech in particular situations and to use the speech registers valued by the U.S. hospital culture. For example, the participants adopted American nurs es swee t talk when caring for adult patients. When talking to hospital personnel to discuss patient cases, the participants were requ ired to apply the SBAR (s ituation b ackground a ssessment and r ecommendation ) skill, a brief and concise technique to make an or al report.

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192 Adopting a s peech register is a strategy of c hang ing speaking styles when talking to different interlocutors in different situations (Halliday, 1978; Simon Vandenbergen, 1983) It is a skill that requires one to discern the social and cultural rules of language use with in conversations Register plays an important role in international nurses clinical communication For example, b esides medical conversations, t he specialized hospital register also included social conversations in clinical setti ngs The discomfort and lack of confidence in talking socially with patients, families, and hospital personnel made them feel social ly and emotional ly isolat ed in the workplace Bosher and Smalkoski ( 2002 ) and Sherman ( 2007 ) found that in ad dition to engaging in communication events relevant to medical issues, there is a need for international nurses to be engag ed in social conversations with interlocutors from a variety of cultural, linguistic and occupational backgrounds. International nurses unfamiliarity with American jokes, slang, and socially culturally specific topics frequently hinder their communication and social interaction with patients, families, and hospital personnel. It is stressful for international nurses to converse wit h the patient s of diverse backgrounds, especially when patients and families talk about cultural relevant matters beyond healthcare topics. Taiwanese American pronunciation In this study, unfamiliarity with English phonolog y further complicated the five nursing clinical communication including phonemes, accents, intonation, and stress. Shya, Bu, Chen, Wei, and Co struggled with difficulties either discriminating English sounds or pronouncing English words, such as the examples of the different stresses on insulin [ ns l n] versus and the phonemic distinction of phlegm versus flame. These English

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193 phonological confusions between Taiwanese and American pronunciation resulted in frequent miscommunication between the pa rticipants and hospital personnel. The participants also encountered embarrassment by not comprehending patients speaking due to their diverse accents. Several researchers suggested that the ethnically and linguistically diverse population of U.S. patient s and hospital personnel can provid e a range of phonological input for international nurses to negotiate. Bosher and Smalkoski (2002), Bola et al. ( 2003 ), and Xu et al. (2008) noted the difficulty for international nurses to master enunciation pronunciati on, stress, intonation, and accent in cross cultural, clinical conversations. Although international nurses we re overall assessed as advanced English speakers, they require more phonological assistances to help them overcome difficulties in discriminating sound s and pronouncing words in English. De contextualized language: Telephone consultation. The nursing participants revealed their worries regarding consulting with doctors, pharmacists or coroners over the phone. Likewise, studies emphas ized that it is more challenging for international nurses to comprehend phone conversations rather than face to face dialogue. Hearnden (2007) found that call ing doctors to request medical orders is a challenge for international nurses. Xu et al. ( 2008 ) cl aimed that communication is specifically demanding over the phone for Mandarin speaking nurses in the United States. that the level of cognitive challenge and contextual support in a given context affects communication performance. Cummins argues that academic language skills [also known as CALP, C ognitive Academic L anguage Proficiency ( Cummins, 1979

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194 1980)] reflects cognitively demanding and context reduced situation s. Specific medical language used on the phone is one example of this type of language. These skills typically involve using abstract concepts and complicated speech tasks, such as medical relevant terminology On the other hand, social language [also known as BICS, Basic Interpersonal Communication Skills ( Cummins, 1979 1980 ) ] occur s in everyday communication These contexts are less cognitively challenging because they provide more contextual clues within conv ersations such as interpreting the speaker s utterances and observing his/her nonverbal cues in daily life face to face interactions (e.g., checking out items with a supermarket cashier). Again, using q uadrant theory international nurses phone consultation with doctors and pharmacists is a typical contextually reduced and cognitively demanding speech event. Phone conversations require a combination skill of two areas including mastery of medical English (i.e., CALP) as well as social English (i.e., BICS) all delivered without the use of nonverbal cues Talking on the phone about medical issues without seeing doctors and pharmacists facial expressions gesture s and body language can be extremely difficult for international nurses. Nurses l ack nonverbal cues to know that they should repair conversations. If technological devices are used in these cases such as teleconference and online meeting assistance it is possible to help international nurses decrease miscommunication in phone convers ations International nurses are able to observe doctors and pharmacists facial expressions and read their lips via computers, laptops, tablets, and smart phones. Written English: Genre specific medical reading and writing Reading and writing in clinical settings were integral aspects of international nurses communication experiences. The nursing participants ha d a difficult time

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195 reading genre specific laboratory data/medical documents and chart ing nursing notes especially using open ended w riting Furthermore, varying English acronyms or abbreviations of medical terminology and medication used by U.S. hospitals led to communication difficulties for the five participants such as the usage of LAT for laceration in one hospital but not found in others. Generally the various uses and understanding of medical term inology and genre specific reading/writing between international nurses and U.S. hospital personnel is a potential risk to cause miscommunication Bola et al. (2003) noted, T he differences in medical terminology, abbreviations, jargon, medication names, suffixes, and prefixes even the names of common items can pose a significant limitation for these (international) nurses ( p. 40 ) Adeniran et al. ( 2008 ) highlighted unfamiliarity with the use of medical idio ms, acronyms, and abbreviations in U.S. hospitals a s being a common challenge for internationally educated nurses to overcome Bola et al. (2003) discovered that although international nurses may make documentation errors unintentionally their less developed writing skills in nurs e charting are a possible t hreat to patient care and may even have legal repercussions In order to shorten the gap between academic re ading/writing in school settings and genre specific medical reading/writing in clinical settings, it is important to provide international nurses specific training about reading comprehension of medical documents/ laboratory data and charting skills of nurs ing notes.

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196 Culture in Hospital Settings This section discusses the main findings of cultural differences that relate to the research sub question 2: How do international nurses perceive cultural factors as influencing communication events? Culture is the sum of mutual attitudes, values, customs and behaviors. It includes thoughts, communication patterns ethnic traditions, family structures, social hierarchy, religion, and beliefs o n health among people from different communities (Brown, 200 0; Nieto & Bode, 2007; Peregoy & Boyle, 2008 ). C ulture also influences people s interpretations of clinical conversations Speakers from diverse communities interpret and value health relevant conversations in different ways. Everyone possesses his/her own framewor k s and perception s toward healthcare. Therefore, c ross cultural clinical miscommunication result s not only from language barrier s, but also from cultural difference s. Role of nurses: Patient centered care and independent professional A variety of medical systems, health beliefs and traditions, and hospital staff patterns between the English speaking healthcare context and the Mandarin speaking healthcare context give patients and nurses different expectations of what a n urs job entails First, t his study revealed that U.S. medical culture is patient centered and privacy oriented L acking knowledge of patient confidentiality in the U.S. medic al system for example, made all participants encounter communication difficulties in clinical settings They also felt bothered by intensive interaction with patients and families due to the U.S. hospital patient centered care S everal researchers, such as Galanti (2008) and Munoz and Luckmann (2005) have documented patient centered care in the United Sta tes. T he U.S. healthcare

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197 context assumes a specific standard of nursing care with particular expectations of a role, which is different from that of international nurses in the home country When international nurses are perceived to be by patients or hospital personnel in the United States, this is frequently a result of cultural differences regarding nurses role s and expectations between the two communities rather than t hese nurses inability to provide adequate care. For instance, the patient centered care in the U.S. healthcare context requires nurses to provid e patients with low skilled tasks such as Activities of Daily Lives (ADLs ), and some Asian nurses find this to be an inappropriate task ( Xu et al. 2008 ). S imilarl y i n Taiwan, due to the heavy workload that nurses manage registered nurses are not in charge of patients ADLs. P atients usually request family members or hire caregivers to help them arrange their meals and with bathing. It is not difficult to imagine that a Taiwanese international nurse is perplexed and irritated when family members request him/her to take care of patients ADLs in U.S. hospitals In the study, the contradictory expectations of the medical system s and staff duties between the U .S. and Taiwan also cause d frequent communication difficulties for the participants. In addition, the five international nurses were used to a task oriented, doctor centered medical environment in Taiwan On the contrary, n urses in the United States are tr eated as professional practitioners who can think critical ly and independently to manag e patient cases The participants perceived it stressful to adapt their working styles from following to assessing patients providing professional advice to doctors, and taking legal responsibility for medical disputes

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198 Wang et al. (2008) claimed that Taiwanese nursing students who studied overseas ha d difficulty transitioning from task oriented classes to seminar and tutorial based classes. Abriam Y ago et al ( 1999 ), Sherman ( 2007) and Xu et al. ( 2008 ) stated that it is important to help ESL nurses transition from task oriented nursing traditions to a U.S. work environment where critical thinking and individual judgment are valued. Using n eeds analysis ( Dudley Evans & St John, 2002; Hutchinson & Waters 2006 ) to i nvestigate international nurses cultural traditions of nursing care can help discover their learning needs in terms of cultural transition in U.S. hospital settings. Discourse sty le s The five international nurses experienced cultural shock with respect to the different discourse styles between them selves and Americans They perceived that humility and compromise were not as valued as pretentiousness and assertiveness in American so ciety. They claimed th ey were perceived to be weak due to their soft discourse style, as compared with hospital personnel and patients in the United States. According to Sherman ( 2007) many Asian nurses com e from settings that emphasiz e harmony and collectivism where a greement and obedience are appreciated within communication Relatively speaking American culture emphasizes individualism being unique and expressing personal and professional opinions. Therefore, different concepts between the two context s can result in confrontations for international nurses. Additionally, i mmigrant Mandarin speaking nurses in Xu et al. research (2 008) demonstrated t hat hierarchy and hard work are important work pr inciples in their home country T hey fe lt discouraged when American subordinates blatantly refused to follow their orders Shya, Bu, Chen Wei, and Co also viewed their nursing (CNAs, LVNs and nursing students) refusal and noncooperation as rebellious behavior s

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199 Consequently, Yoder ( 2001) suggested improving ESL nurses negotiation skills in terms of speaking in an assertive manner in order t o convince nursing subordinates, nursing colleagues, nursing supervisors, doctors, patients, and families in clinical settings of their professi onal views and to build trust. Moreover the five participants discourse styles transferred from the first language, Mandarin, clearly distinguished them from native English speaking American nurses. For example, Bu and Chen were accustomed to speak ing in an indirect manner which made them encounter communication difficulties at work. Escamilla and Coady (2001) and Kaplan ( 1996 ) have indicated that many American speakers are used to adopting a linear and direct logic to express their thoughts Wh en spe akers are from two different discourse traditions, it is easy to imagine that in addition to language barriers, t he different cultural emphases on discourse strategies can result in communication obstacles in cross cultural, clinical settings. At times it was easier for American nursing supervisors to attribute international nurses communication difficulties to their limited English language proficiency, while ignoring the role of cultur e However, knowledge of the international nurses culturally specif ic discourse tradition s in which listening is stressed and indirect speech is advocated may have alleviated many of these miscommunications. A background survey can contribute to U.S. employers understanding of international nurses first language and cultural traditions regarding discourse styles. I t is also beneficial to listen to international nurses voices, provid e counseling services to these nurses, and invite experienced nurses from the same first language and cultural background to share perceptions of their struggle with English discourse. It may be

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200 impractical to expect every mainstream American to appreciate or embrace discourse diversity. Nonetheless it is p racticab le that the hospital provides courses to teach international nurses to switch between first language discourse and second language discourse when talking to different speech communities By means of switching between two discourse styles, international nur ses can both maintain their identit ies in the United States and communicate more successfully in U.S. clinical settings. Education and Training: The Need for Specialized Ongoing Training This section discusses the main findings of the role of education to relate to the research sub question 3 : How do international nurses believe their education and training prepared them for U.S. healthcare communication ? Foreign educated nurses leave familiar settings and move into a system with From the employee perspective, differences in nursing practice and training between the two countries contributed to the confusion ( Bola et al., 2003, p .41 ) The above quotation suggest s that international nurses prior education influence s their communication experiences in education such as schooling and nursing training in Taiwan, RN exam an d English test preparation, and hospital training in the United States Education reinf orces cultural values for students from a particular community ( Bruner, 1996 ; Heath, 1983 ) T he different educational training programs prepared nurses in different ways in terms of communication and nursing care N onetheless it appears from this study that i nternational nurses require special ized ongoing training both before and after they work in the U.S. healthcare context. In English for Specific P u rposes (ESP) courses, t he main purpose is to satisfy both students and employers specific needs whil e taking time limitations and resource constraints into consideration ( Dudley Evans & St John, 2002; Hutchinson & Waters

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201 2006 ) D ue to the diverse linguistic, cultural, clinical and educational backgrounds of individual international nurse s needs analysis is essential Needs analysis is not only the preparation of an ESP Dudley Evans & St John, 2002 p. 121 ) L istening to international own voices regarding education and training, language difficulties, work concerns, curiosities and worries is as important as identifying target needs and prerequisite knowledge for U S nursing care (Abriam Yago et al., 1999; Bola et al., 2003; Choi, 2005) In addition, c ol lecting background research on internationally educated nurses can help prevent redundant instructions of medical knowledge or nursing skills which the international nurses have already learned in their home countries Pre U.S. training: Language and culture assessment O n the whole i nternational nurses are requested by the U.S. Immigration Bureau to meet the English language proficiency criterion. Even though Shya, Bu, Chen, and Wei were categorized as advanced English users based on their academic En glish language test results (i.e., IELTS or TOEFL), their initial communication experiences in the workplace were overwhelmingly frustrating. This study suggested that English language tests (e.g., TOEFL and IELTS) and nursing examinations (e.g., NCLEX RN) c an on ly attend to basic competencies, instead of assessing the five participants comprehensive communication abilities in transcultural nursing care In short, the language and nursing examinations did not reflect the language and cultural needs of the international nurses. S everal empirical studies have indicate d that language and cultural issues hamper the smooth execution of ESL nurses and international nurses clinical communication

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202 despite the fact that the nurses have passed a rigorous English language and nursing license assessment (Bosher & Smalkoski, 2002; Sherman, 2007; Xu et al., 2008) Bola et al. (2003) for instance, found that the VisaScreen process in the United States which includ ed language and nursing test s fail ed t o address issue s regarding (a) differences in translation ( i.e., documentation, medication titles, medical terminology, and abbreviations) ; (b) cultural conflicts ( i.e., hospital subculture, nonverbal cues, concepts of medicine, and nursing ethics ) ; and (c) transitional confusions ( i.e., immigration experiences) for international preparation to work in the United States. Although international nurses are qualified as nursing professionals to work in the United States based on their nursing license examination (i.e., CGFNS and NCLEX) and English language test results (i.e., IELTS or TOEFL), the reliability validity, and feasibility of relying on non medical relevant academic English tests to evaluate international nurses clinical communicat ion ability is ques tionable The study signified a need for specialized kinds of assessment. Through preparing for the assessment, international nurses can develop and be evaluate d for their English proficiency and cultural knowledge in cross cultural, oral and written clini cal communication Early U.S. training: Hospital orientation and mentorships In th is study, U.S. hospital employers assumed that the five participants are competent enough to provide transcultural nursing care and to attend to cross cultural communication based on the results of their nursing license exams and English language test scores They d id not acknowledge that context specific language needs and nursing skills play a crucial role in international nurses English communication particularly in term s of vocabulary ( semantic choices and spelling), grammar ( syntactic

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203 structures), pronunciation (phonemes, accents, intonation, and stress), and slang and dialect (pragmatics). Unfortunately, t he employers neglect ed the five international nurses need for s econd language development and cultural adjustment in the new U.S. environment. Shya, Bu, Chen, Wei, and Co received limite d assistances from hospitals to help them transfer from the L1 to L2 medical context. Nursing remains a vocationally based activity, and therefore curricula have to be based both on education and practice settings if the goal of realized Hancock, 2008, p .260 ) The data from this study revealed that lecture oriented classes during the early U.S. training and hospital orientation placed little and surface attention on enhanc ing the cross cultural, clinical communicat ion abilit y Although clinical s hadowing (following an assigned preceptor) did not provide comprehensive training t o facilitate these nurses language and cultural transition Shya, Bu, Chen, Wei, and Co developed more communication skills and cultural knowledge through learning by doing than by sitting and listening to oversimplified class content. When Abriam Yago et al (1999), Adeniran et al. (2008) Bola et al. (2003), and Hancock (2008) discuss training programs for international nurses and ESL nurses, all highlighted the importance of clinical practice in these nurses early transition in the U.S. healthcare c ontext Sherman (2007) promoted the mentor mentee system as a valid method to help international nurses communication ability development and cultural adjustment Every hospital has its regulations and cultures that U S supervisors and nurses may take f or granted. Nevertheless, international nurses are truly concepts and without precise training may not learn those rules. Research has shown

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204 that international word choice may be interpreted as a professional error, such as mistak enly refer (Bola et al., 2003) or using ( a pain medication in Taiwan) ( the same pain medication in the United States) for acetaminophen between patient nurse conversations In order to bridge th e gap for international nurses in the U S medical culture, Sherman (2007) emphasized the necessity of providing a comprehensive orientation program to internationally educated nurses by address ing the details of medical literacy and nursing care in the hospital, including physical assessment and systems review, I.V. (intravenous) placement nasogastric placement and ECGs (electrocardiogram), scope of practice and professional expectations, supervision and delegation, critical thinking in patient care si tuations, pain management, instruction on unit technology and equipment, medication review, planning the workday U.S. healthcare delivery system and health beliefs, physician/nurse communication, documentation, and cultural competency with diverse populati ons (p.16) Application to the C ommunicative C ompetence Model Andrews and Boyle ( 2003 ) estimated that 90% of cross cultural nurse patient interacti on failures are caused by miscommunication. I t is important to help international nurses be linguistically and culturally competent when taking care of patients from diverse backgrounds Andrews and Boyle ( 2003 ) described nurses communicative competence from a medical perspective: C ultural and linguistic competence refers to an ability by health care providers and health care organizations to understand and effectively respond to the cultural and linguistic needs brought by clients to the health care encounter. (p. 16) A c ommunicative competence model emphasizes both the form and function of la nguage. Form refers to structures of language, while function refers to cultural norms in language uses ( Hymes 1971, 1972, 1974) There are two aspects of the

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205 communicative competence model, including linguistic and cultural competence. Linguistic competence consists of grammatical, sociolinguistic, discourse, and strategic competence s N onetheless not all components of the communicative competence model that researchers ( Bachman 1990; Canale 1983 ; Canale & Sw ain 1980 ; Hymes 1971, 1972, 1974 ) proposed appeared to carry the same emphasis among the international nurses in this study. This study showed that grammatical competence, sociolinguistic competence, and cultural competence played a larger role in the fiv e participants cross cultural, clinical communication experiences than did discourse and strategic competences (discussed below) Figure 6 1 illustrates the component s involved in communicative competence for international nurses Figure 6 1 Components of c ommunicative c ompetence for international nurses

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206 More relevant aspects of the model : Grammatical, sociolinguistic, and cultural competence among international nurses Grammatical competence Bachman (1990), Canale ( 1983 ), and Canale and Swain ( 1980) defined g rammatical competence as the knowledge of language rules at the sentence level, including vocabulary (i.e., semantics and morphology) grammar (i.e., syntax) and pronunciatio n (i.e., phonology). It assumes speakers ability to master lexicon, spelling, syntactic rules, morphemes, and phonemes This study revealed an urgent need for the five participants to develop grammatical competence in sound discrimination, occupation specific voc abulary social topic semantics and medical terminology/abbreviations/acronyms. For instance, in their communication stories, t he words and willy boner a happy camper and in a New York second which the participants misunderstoo d at work suggested how the knowledge of semantics in the category of grammatical competence influence d the flow of their social co nversations with patients and hospital personnel Moreover the study showed that phonology, including differences in English pronunciation and the diversity of English accents in U.S. hospitals, further complicated the five communication experiences The participants were concerned that they w ould easily misunderstand their coworkers reports and doctors o rders because some medical terms and medication were pronounced in a way different from what they ha d heard and used in Taiwan. If they had developed the grammatical competence in terms of sound discrimination they could have avoided miscommunication in n urse patient and nurse hospital staff conversations. Sociolinguistic competence. S ociolinguistic competence refers to the socio cultural sensitivity of language use It emphasize s functional and c ultural aspects

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207 of language use ( Bachman 1990; Canale 1983 ; Canale & Swain 1980 ; Grice, 1975; Halliday, 1973, 1978 ) The components include pragmatics speech register, topic relevance language functions and speaker listener relationship The study indicated that lack ing s ociolinguistic competence was one of the main factors to obstruct the five communication in U.S. clinical settings The finding suggested that the participants limited knowledge of oc cupation specific vocabulary and less developed linguistic register impeded them from competently s witch ing between speech registers with different interlocutors such as switching from talking to patients/ hospital personnel about social topics in an informal manner to discussing /reporting patient condition with doctor s/nurses/coroners in a professional tone. In addition, this study found that the participants need ed to develop sociolinguistic competence in medical writing Four of them had passed the IELTS academic writing exam but they all stated difficulty composing open ended writing in nursing charting. Additionally interpreting multicultural patients and hospital personnel s meanings from their slang and various dialect s was difficult for the participants. A s part of building sociocultural competence in communication, there is a need to develop the international nurses pragmatic skills in clinical settings. Pragmatics ( Grice 1975) is a study of meaning and context of communication. It examines how speakers use language within a particular context and why they use it in a specific way Boxer ( 2002 ) claimed that an awareness of cross cultural pragmatics in face to face interaction can facilitate ESL speakers in the workplace When international nurses have the ability to interpret culturally specific meanings beyond utterances, they are able

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208 to interact more socially with patients, families, and hospital personnel in the U.S. healthcare context. Cultural competence. In addition to linguistic competence which was addressed in the above section knowledge of cultur e can considerably affect the smoothness of cross cultural communication. Munoz and Luckmann (2005) claimed that cultural competence has become a necessity for nurses as documented both in U.S. nursing academic and pr ofessional associations. L ike all other international nurses, the five participants were striving to develop culturally relevant communication skills to accommodate the ethnically diverse patient structure in the United States. Campinha l known for its application to healthcare delivery. Based on this model, cultural competence is a cultural knowledge, cultural skill, and cultural encounter ; this occurred spontaneously based on immediate need rather than as a planned learning task. C ultural awareness requires deliberate reflection own cultural belief system. It is considered the first step and basis for healthcare professionals to develop cultural competence. Once nurses are aware of their own cultural perceptions of ethnic belonging, heritage, socioeconomic status, communication patterns and behavior styles, education history, language, and professional background, they are able to discern their prejudices abo ut people who are different from them. In this study, Shya, Bu, Chen, Wei, and Co were aware of their own identity, culture and advantages and disadvantages of nursing care in the United States. Shya and Wei believed that their bilingual

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209 competence and nu rsing qualification s made their employers hire them, rather than whether they could speak standard or perfect English or not. C ultural knowledge requires knowledge of s. C ultural knowledge for nurses includes patients health values, common diseases, and treatment toward life, death, health, and illness is i mportant for cross cultural medical care. patients own utterances and behaviors to facilitate communication In this study, the five perceptions of Mexican Asian and American patients often determined the success of cross cultural communication. T reatment efficacy refers to the study of cultural medications and medication effects and side effects on a particular ethnic population. E very cultural group has its own life styles, dietary preferences and daily routines If the five participants had access to knowledge of these treatments, such as food therapy, alternative herbal remedies or religious remedies, they might have been able to assuage their apprehension dietary preferences. I n addition c ultural competence can be viewed as a skill intertwined with sociolinguistic competence. It considers international nurses knowledge of the sociocultural conventions required to communicate with people from diverse backgrounds. During the process of cultivating nurses cultural competence, international nurses can gain knowledge of interlocutors word choice, discourse patterns, nonverbal communication and cultural vi ews of health care and medicine.

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210 Less relevant aspects of the model : Discourse and strategic competence among international nurses Discourse competence D iscourse competence is advocated by Bachman (1990) and Canale and Swain (1980) I t is the knowledge of rhetorical organization in inter sentential relationships, a skill to make discourse logically sequential, coherent, and cohesive. This study did not reveal major findings from the five reflection s regarding the need to make clinical discourse coherent or cohesive; hence, this competence may be considered less important overall for nurses cross cultural communication N onetheless, this study found that the five and modest rhetorical organization b orrowed from L1 speaking was contradictory to English speakers direct and assertive discourse strategies in the United States. Bosher and Smalkoski (2002), Gardner (2005), Sherman (2007), and Yoder (2001) claimed that many ESL nurses and international nur ses were not accustomed to Americans directness and assertive ness in speaking International nurses are advised to develop discourse competence in order to r espond to these particular rhetorical strate gies. Strategic c ompetence S trategic competence is a skill decisions and ability to compensate for errors and miscommunication in face to face communication (Bachman, 1990; Canale,1983; Canale & Swain ,1980). Chinen (2001) highlighted the importance of the compensati on skills for EFL Jap anese nurses, includ ing conf irming information asking for repetition / clarification, and raising cross cultural awareness. These skills can give EFL nurses the ability to understand foreign to avoid any serious problems or medical mistakes caused by miscommunication.

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211 Although this study showed that the five participants experienced communication difficulties at work, they revealed no major problems in discern ing misunderstanding and repair ing miscommunication with the interlocutors at work. Their overall advanced English proficiency e ndorsed by the English language tests appeared to correspond to their performance of this competence. For that reason, the development of strategic competence for nurses to (a) c onfirm treatment procedures with nursing colleagues; (b) double check doctors verbal orders; and (c) verify patient complaint and background is more urgent for nurses who are beginning English speakers, such as Mandarin speaking nurses working in Taiwan, in the EFL medical context. Implications of the Study I nternational Nurses Training in the United States There are several implications for developing international nurses communicative competence and cultural knowledge for clinical communication These implications derive from my interpretation of the findings from this study. T he objective s of international nurses training are to increase these abilities both in cross cultural communication and nursing practice s in multicultural, U.S. cl inical settings According to Nieto and Bode ( 2007 ) and Peregoy and Boyle ( 2008 ) m ulticulturalism addresses both mainstream and other cultures. R esearchers including Coady, Hamann, Harrington, Pacheco, Pho, and Yedlin (2007), de Jong and Harper (2007), a nd Knight and Wiseman (2006) have noted that c ulturally responsive pedagogy is a learner social development in a culturally and linguistically responsive way. Likewise, i nternational nurses have t heir existing knowledge of language use communication patterns, nursing skills, job experiences, and worldviews. It is important for hospital

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212 employers to remain open to the culture that international nurses bring to the United States A training program embracing international nurses first language, identity, cultural traditions and work values can help enhance international nurses confidence in their cross cultural communication experiences T he main learning goals of international nurses training are to (a) relate class content to and to build on new knowledge based on what they have been already capable of ; (b) develop nurses ability to transfer language and communication skills (linguistic competence) ; (c) facilitate nurses understanding of cultur al knowledge and nurses role in U.S. clinical settings (cultural competence); and (d) learn by doing ( clinical practice). Communication and cultural mediation Samway and Mckeon ( 1999) claimed that s econd language acquisiti on depends largely on the development of conceptual and linguistic knowledge and it can be added successfully at any age International nurses are efficient adult ESL learners because the y are able to transfer their first language concepts and structures to second language Therefore it is important to facilitate international nurses language transfer of l inguistic competence such as grammatical competence (e.g., sound discrimination and recognition of medical terminology/ abbreviation /acronym), socioli nguistic competence (e.g., hospital register and pragmatics ) and discourse competence (e.g., rhetorical organization for SBAR skills). Furthermore, n ursing care is a vocationally based activity (Hancock, 2008) Every hospital has its special framework of r outines and emphases It is important for international nurses to be familiar with U.S. hospital routines and traditions. According to the study doctor centered care is valued in Taiwan while patient centered care is more

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213 stressed in the United States. The d ifferent perspectives on nursing care can lead to d iverse expectations of clinical communication between international nurses and interlocutors in U.S. hospitals In order to familiariz e international nurses with U.S. hospital culture Adeniran et al. (2008) recommended introduc ing the following concepts during the hospital orientation training program for ESL nurses : (a) the U.S. healthcare delivery system ; (b) skills that are necessary to practice communication successfully in U.S. hospitals ; (c) leg al and ethical matters relevant to U.S. nursing practice ; and (d) the roles of multidisciplinary members of the healthcare team in the United States N ursing is an occupation based profession that relies on hands on practice. Class es which rely 100% on lectures do not result in significant outcomes of international improve international nurses communication skills by provid ing contextual background of nursing care, explain ing nursing procedures through authentic cases, and practic ing nursing tasks via hands on activities. Abriam Yago et al. (1999) and Choi (2005) suggested adopting model of second language acquisition (1983 & 1984) to increase contextual support and reduce cognitive dem ands of course content for ESL nurses. During the training period instructing with c ontext embedded and contextualized language can help develop international ideas to understand English language and U S medical culture. Course instruc tors or nursing supervisors are suggested to model the steps of accomplish ing nursing tasks, writing nursing notes and manipulating medical equipment It is also advantageous for international nurses to observe and practice each aspect of nursing care ra ther than receiving overview introduction to these

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214 procedures Finally encouraging international nurses to formulate ideas and give feedback can help them reflect upon what they have learned in a more concrete way In addition, c ultural competence is a awareness, cultural knowledge, cultural skills, cultural encounters and cultural desire (Campinha Bacote, 2002) International nurses bilingual backgrounds may make them become sensitive t o multicultural pati ent groups but l ike all U S medical professionals, international nurses should receive sound ongoing cultural educ ation of diverse patient groups They need to regularly examine personal biases and assum ptions of certain ethnic groups It is also import ant to continuingly illness es in order to bridge the cultural gap s between themselves and the served community. On the whole, a community based nursing care project creates practice opportunities for international nurses to develop their cross cultural communicative competence. Abriam Yago et al. ( 1999) claimed that a home care practicum extends the interaction and communication between international nurses and their ethnic diverse patients in a context embedded situation Critical thinking in nursing care T he U S hospital culture p laces emphasis on nurses critical thinking, autonomy, and independent role at work Neither speaking fluent English nor passing language /nursing exam s can significantly help international nurses develop their critical thinking skills in nursing care. A collaborative classroom culture encouraging inquiry and personal v iews can l thinking skills (Bruner 1996; Townsend & Pace, 2005) T o transit ion international nurses who are from p revious task oriented / instruction guided nursing traditions to independent judgment, explicit

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215 demonstration of how critical thinking functions in the U S healthcare context is advocated One way to do this is to ask international nurses to compare nursing procedures between their home country and in the United States Additionally r ole play ing is a practical tool for international nurses to simulate and apply critical thinking. B y means of group discussion of scenarios international nurses can learn to be critical about nursing care via seek ing modeling from other nurses. More important ly allowing international nurses to brainsto rm ideas rather than just recalling nursing steps contributes to the ir development of critical thinking (Abriam Yago et al 1999) C linical practice It is important to physically prepare international nurses for the U S hospital environment and increase their social interaction with American society. Abriam Yago et al. ( 1999 ) and Yoder ( 2001 ) suggested valuing international bicultural background as a resource for medical services in ESL nurses trai ning programs, especially in ethnically and linguistically diverse communit ies C onstruct ing a supportive environment for internationally educated nurses in clinical practice is primary It is beneficial to incorporat e international backg round s and help preserv e these nurses ethnic identity. American nurses may be advised to show positive attitudes toward international colleagues. They may also be open minded toward the differences that international nurses bring into the United States. Once American nurses gain insight into how international nurses perceive the medical world they are able to accommodate the ( dis ) similarities between the two groups of nurses Furthermore, international nurses can be more co mfortable in maintain ing their identity in the new U.S. culture. B uilding a supportive environment can

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216 not only promote work efficiency among medical teams but may also enable them to retain their employment. Moroever r esearch shows that the mentor ment ee relationships can improve immigrants in the new environment (Jeffries & Singer, 2002) In this study, all five participants described the positive effects that their preceptors brought to their cross cultural cli nical communication experiences I f the reality allows, it is helpful for the new coming international nurses to follow the preceptor s who have similar ethnic / linguistic backgrounds and immigrant experiences Sherman (2007) recommended that assigning international nurses who have similar transitional experiences as mentors can help the nurses overcome their unease in the primary immigration stage L inking international nurses with successful and experienced ethnic role models in U S clinical settings will increase t he se nurses confidence in cross cultural communication Yoder ( 2001) suggested that joining associations or ethnic nursing clubs is helpful for international nurses social integration in the United S tates It also sets up a tangible goal for international nurses to achieve because they see someone like them as successful in the new U.S. environment By means of access to the same ethnic community, international nurses receive social and emotional support f rom people who understand them and who act /speak/think like them They can also build on their understanding of U.S. medicine in a professionally culturally supportive way from the ir ethnic role models Implications for Researchers: Further Investigation s This study can inform both TESO L (Teaching English for Speakers of Other Language) educators and nursing trainers about the way s in which the Taiwanese

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217 subgroup internationally educated nurses perceived communication in cross cultural clinical settings From a theoretical perspective, the study provided examples for TESOL and nursing researchers to discern the relationship between language, culture, education, and communication. In practical terms, the study explored the components that international nu rses lacked or required for cross cultural clinical communication by looking at the insights gained from the five nursing experiences The first implication is to gather authentic data from cross cultural clinical settings In many qualita tive empirical studies investigating real discourse is the primary method used, especially when studying ESL speakers communication experiences ( Boxer, 2002 ; Burns, Joyce, & Gollin, 1996) This study was conducted by a TESOL graduate student w ithout acce ss to the U.S. healthcare context to examine international nurses authentic communication In addition the non nursing background with subjective understanding of the data may have led to a biased discussion. F or that reason future studies can be conducted in cooperation with the nursing field and the TESOL field English for Nursing Purposes (ENP) and communicative competence for international nurses count as cross field research that requir e acknowledgement of both second language acquisition and transcultural nursing knowledge. The collaboration between the two fields can facilitate the data collection procedure, such as the IRB approval process for clinical observation as well as data analysis, finding s and discussion This w ou ld allow for a more comprehensive interpret ation of international nurses perceptions of cross cultural communication The second potential research area is an extension of this study to invite more culturally, ethnically, linguistically diverse internationally educated nurses to participate

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218 in the research I used my first language and cultur al background as an advantage to focus on the exploration of Taiwanese nurses communication experiences H o wever, it is noted that the U.S. nursing market is replete with multi ethnic and multilingual nursing professionals (Abriam Yago et al 1999; Adeniran et al 2008; Bola et al., 2003; Brown, 2008; Gardner, 2005; Hancock, 2008; Ross et al., 2005; Sherman, 2007; Xu et al. 2008; Yoder, 2001). Altho ugh this study provided perceptions of the five Taiwanese nurses communication experiences international nurses from other cultural communities may have divergent perspectives of clinical communication It w ould be beneficial if the voices of internation al nurses from different subgroups can all be heard. Third in addition to studying international nurses experiences it would be helpful to investigate the p erceptions of communication experiences from the perspectives of nursing supervisors, hospital personnel and patients/families/visitors in the United States Their reflection s can help researchers examine multi faceted aspects of cross cultural communication rather than plainly fixing on international nurs e s s ubjectivity. This section introduced three areas of prospective investigation that emerged from the study including (1) gathering authentic data from cross cultural, clinical settings ; (2) inviting more culturally, ethnically, linguistically diverse internationally educated nurses to participate in the study ; and (3) i nvestigat ing the p erceptions of communication experiences from the perspectives of nursing supervisors, hospital personnel, and patients/families/visitors in the United States. T here are possibly other aspects of the research that are worthy to be explored in the future Any empirical study intend ing to increase the understanding of international nurses cross cultural clinical communication experiences is encouraged.

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219 Conclusio n Transcultural nursing has became an important issue in the U.S. healthcare context since the mid 1960s (Giger & Davidhiz ar, 2008) However, little research has been conducted in the field on the communication experiences and perspectives of internationally educated nurses The study was based on the theoretical perspective of constructivism embedded in the epistemology of constructionism. The r esearch question was, internationally educated nurses perceive their cross cultural clinical communication The three sub questions of this study were : (a) how do part icipants describe language needs for communication in those settings ? ; (b) how do they perceive cultural factors as influencing communication events ? ; and (c) how do they believe that their education and training prepared them for U.S. healthcare communica tion ? Qualitative methods were employed in this study in order to gain a better understanding of internationally educated nurse s perspectives and experiences of cross cultural, clinical communicati on Purposeful sampling was used to recruit five internationally educated Taiwanese nurses Shya, Bu, Wei, Chen, and Co to participate during the four month research period Data collection methods included (a) primary data: focus group interviews and in depth individual interviews ; and (b) supplementar y data: background information derived from surveys, i ntensive participant observations and post interview reflection journals. Data analysis method s included both narrativ e and thematic analys e s. This study provide d a description and background for each of the five nursing participants The stories illustrate d the participant s home family and culture with respect

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220 to language use; their nursing and language training programs in Taiwan and the United States ; and their immigration experiences and adjustment to the U.S. healthcare context. By investigating the participants communication stories, t his qualitative study described the ways in which the five international nurses perceived how language needs cultural differ ences and educational training influenced their communication in U S clinical settings Shya, Bu, Wei, Chen, and Co came to the United States with knowledge of their home culture first language English proficiency nursing skills, and world views. Altho ugh the five participants were from the same ethnic group, findings indicated that their different famil y backgrounds, social surroundings immigra tion experiences and preparation methods resulted in each having a unique perception of themselves in cross cultural clinical communication. In addition, t his study present ed the findings which emerged from a cross case analysis. The results showed four main themes: (a) the use of complex and s pecialized language in c linical settings; (b) cross c ultural d ifferences in c linical s ettings ; (c) identity negotiation in a ne w U.S. e nvironment ; and (d) gaps in l anguage and c ulture in U.S. nurse training The four main themes indicated how Shya, Bu, Chen, Wei, and Co perceived the roles of language, culture, and e ducation affecting their U.S. clinical communication experiences This study also use d findings from the five participants communication experiences to draw discussion and i mplications for developing international nurses communication ability and cultural skills in clinical settings Shya, Bu, Chen, Wei, Co were much like professionally trained American registered nurse, but their

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221 communicat ion in the workplace was often impeded by the fact that they faced unfamiliar language and cultural environme nt s It is important for U S supervisors and American nurs es to remain open to th e cultur al resources that internationally educated nurses bring to the United States. A comprehensive training program pay ing close attention to international nurses background knowledge and the development of communication ability, cultural competence and critical thinking skills is suggested Generally, t he improvement of international nurses communicative competence and critical thinking ability require sufficient language input and output A dynamic dialogic class giv ing ample opportunities for international nurses to ponder, to question, to practice, and to present their communication skills is advocated The training program aims to help international nurses dim inish language barriers and contribute to their second language development and cultural adjustment in the United States. The r ecommendations included (1) f acilitating international nurses language transfer of l inguistic competence ; (2) familiarizing international nurses with U.S. hospital routines and traditions;(3) provid ing contextual background of nursing care, explain ing nursing procedures through authentic cases, and practic ing nursin g tasks via hands on activities ; (4) providing international n urses sound ongoing cultural education of diverse patient groups ; (5) explicit ly demons trati ng how critical thinking functions in the U S healthcare context ; and (6) establishing a supportive work environment including the mentor mentee system. Finally, t here are two major contribut ions of this study to the field of TESOL and nursing. First, it outline d how language factors cultur al differences and educational training influenced the five U.S. clinical communication experiences

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222 through deep, detailed, qualitative case study descriptions. By living with the participants, listening to their storie s, and sharing their joys and burdens, this study disclose d individuality and commonality in the cross cultural communication via the par Second, this study discussed the linguistic theory of communicati ve competence and communication from a transcultural nursing care perspective Second, this study discussed linguistic theory of communicati ve competence and communication from a transcultural nursing care perspective The connection established by th is study between second language acquisition and trans cultural nursing can help both TESOL educators and nursing researchers to have insight into the what, where, why, who, and how of affecting

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224 APPENDIX B RECRUITMENT FLIER I am looking for 5 Mandarin speaking nurses to participate in a cross cultural communication study. If you are an internationally educated nurses who o speak s Mandarin as a first language o possesses intermediate or higher level of English proficienc y o has receive d nursing education and professional training in your home countr y o currently work in a clinical setting in the U S healthcare context You may be eligible to participate in my study. What you will be asked to do is to o participate in focus group interviews and individual interviews to talk about your experiences of commu nication in U.S. medical healthcare settings. o P articipate in observations regarding social non medical talk. For more information, please contact: Ya Yu Cloudia Ho Doctoral student in ESOL/Bilingual Education School of Teaching & Learning, College of Education University of Florida. Phone: (352) 870 8143 E mail:

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225 APPENDIX C EMAIL SCRIPT OF RECR UITMENT Dear Sir/Madam, I am a PhD candidate in the College of Education at the University of Florida, conducting dissertation research on international ly educated Mandarin speaking cross cultural clinical communication under the supervision of Dr. Maria Coady. The purpose of my study is to investigate how international ly educated nurses perceive their experiences of cross cultural clinical discourses and explore how language, culture, and education influence cultural communication experiences in U.S. he althcare setting s The results of the study can help to understand the nature of cross cultural communication and benefit future curriculum and material development of English for Nursing Purposes. The study includes focus group interviews individual inter views and nonmedical observations of social events The compensation is $100 gift card. If you are interested in my study or have any questions about this research, please contact me at 352 870 87143 or my committee chair Dr. Coady (, 352 273 4228 ). Questions or concerns about international participants may be directed to the IRB0 1 office, University of Florida, Gainesville, FL 32611, (352) 846 1494 Best Regards, Cloudia Ya Yu Cloudia Ho PhD Candidate ESOL/Bilingual Education, School of Teaching and Learning College of Education, University of Florida. Tel: 1 352 870 8143 E mail: Address: 2901 SW 13 th Street, Apt 226, Gainesville, FL32608, USA

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226 APPENDIX D INFORMED CONSENT FOR M Purpose of the research study: The purpose of my study is to investigate how you perceive yourself as an internationally educated nurse experiencing cross cultural clinical communication in U.S. healthcare settings. What you will be asked to do in the study: You will be asked to participate in focus group interviews and individual interviews regarding you cross cultural communication experiences. You will be also asked to participate in nonmedical observations of social events. You will be asked to voluntarily attend three focus group interviews and three individual interviews to talk about your experiences of healthcare communication, language, culture, and education in cross cultural communication while you are workin g in the United States. You will be asked to exclude any identifiable information, personal health, and employability information in the interviews. The focus group interviews will be held for about 90 minutes and individual interviews will be held for 60 90 minutes. Interviews will be held in a place where you feel comfortable except in your workplace. Conversations will be audio taped and transcribed. Risks and Benefits: There are no anticipated risks to you as a participant in interviews. You are free to withdraw your consent to participate and may discontinue your participation in the interviews at any time without consequence. The benefit of my study is to develop a more insightful exploration of language use, cross cultural awareness, education al effects, and communicative competence for international registered nurses working in the United States. Compensation: $100 gift card Confidentiality: Information that you provide will be completely confidential. Your name, identity, except the study investigator. Study will include discussion of general phenomenon in the United States rather than any regional issues, which risks identifying you and your employability. No personal medical history will be revealed, discussed or included in my study. I will transcribe the interview tapes in a private room and ensure t hat nobody will be present when I am transcribe them. These audiotapes will be never played under

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227 any circumstances except when I am making transcriptions and analyzing the data. The audiotapes will be destroyed when the study is completed. The interview n otes, transcripts, and observation field notes will be stored in a locked cabinet where only the principal investigator will be able to access to them after the study is completed. Voluntary participation: Your participation in my study is complete ly voluntary. There is no penalty for not participating. Right to withdraw from the study: You have the right to withdraw from the study at anytime without consequence. Whom to contact if you have questions about the study: Ya Yu Cloudia Ho PhD candidate in ESOL/Bilingual Education, School of Teaching & Learning, College of Education, University of Florida. Tel: 352 870 8143, E mail: Dr. Maria Coady, Ph.D. Associate Professo r in ESOL/Bilingual Education, School of Teaching & Learning, College of Education, University of Florida. Tel: 352 273 4228 E mail: Whom to contact about your rights as a research participant i n the study: IRB01 Office, University of Florida, Gainesville, FL 32610 0173; phone 352 846 1494. Agreement: I have read the procedure described above. I voluntarily agree to participate in the procedure and I have received a copy of this description. Participant: ____________________________________ Date: _________________ Principal Investigator: _____________ _______________ Date: _________________

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228 APPENDIX E BACKGROUND INFORMATI ON SHEET NAME ______________________________ GENDER Male Female AGE _____________________________________ NATIONALITY RELIGION _____________________________________ _____________________________________ YEARS IN U.S. _____________________________________ U.S. VISA STATUS Foreigner working visa Citizenship Permanent resident with Green Card Other________ PHONE NUMBER ________________________________________ EMAIL ________________________________________ ADDRESS ________________________________________ Sampling Criteria Is Mandarin your first language? Yes No Is your English level intermediate or higher? Yes No Did you receive nursing education/training in your home country before you enter the United States? Yes No Are you currently working in the U.S. healthcare settings as a registered nurse? Yes No Home Country Professional Information Place of Employment _________________________________________________ Position of Employment Department _________________________________________________ _________________________________________________ Years of Working _________________________________________________ U.S. Professional Information Place of Employment _________________________________________________ ______ Position of Employment _________________________________________________ ______ Department _________________________________________________ ______ Years of Working _________________________________________________ ______ Education Information Language Information Highest Education in Home Country __ _____________ English Level Exam results if applicable. e.g., IELTS 6.5 ___ __ ______ like ______ Highest Education in U.S. _______________ Years of Learning English _____________________ Other Languages _____________________ __

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229 APPENDIX F INTERVIEW PROTOCOL The following q uestions are examples of the questions which were asked during the interviews. Daily Work and Communication Events 1. D escribe a typical work day. What kinds of nursing job are you involved with? What kinds of communication are involved? [prompts: listening, speaking, reading, writing, nonverbal] 2. Please s hare any specific experiences / stories of cross cultural communication you encounter duri ng your working hours place between you and a non native Taiwanese and non native Mandarin speaker in which you experienced (enough to recall) surprise, discomfort, misunderstanding or the opposite typical, comfortab le, understanding. Personal Background H istory and Communication Events Data collected from the previous interviews will inform questions, such as the following: 1. Please share your stories of moving to the United States (How did you prepare to work as a U.S. register nurse here? Why? What made you come to the US ?) 2. Whom do you commonly talk to or write to during your working hours? (Why do you frequently communicate with them? What do you talk or write to them about ?) 3. Can you share any special stories of communication during your working hours (such as talking to colleagues or patients, cultural adjustment, relationship with supervisors, salary and job promotion, immigration and visa application)? 4. Probe individual themes t hat appear from the 1 st focus group interview Nursing Education and Communication Events Data collected from the previous interviews will inform questions, such as the following: 1. Please share your stories regarding your nursing education in your home coun try and in the United States. 2. Can you compare the two country s nursing education and nursing environment ? 3. Can you share any special stories of cross cultural clinical communication events you encounter ? Language, Education and Communication Events

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230 Data collected from the previous interviews will inform questions, such as the following: 1. Can you describe your own English ability? To what extent do you feel confident in or used to using English to talk to or write to patients, families, caregivers, or medi cal colleagues during your working hours? 2. What kinds of nursing education have you had? 3. Can you share any special stories of communication during your working hours ? 4. Probe issues of 2 nd focus group interview Working in Home Country vs. U.S. and Communica tion Events Data collected from the previous interviews will inform questions, such as the following: 1. Please share your stories about working in your home country. What kinds of nursing job are you involved with? 2. Can you compare working in your home countr y versus working in the United States (e.g., medical terms, routines, medication, hospital culture, nursing concepts, patient nurse doctor relationships medical systems)? 3. Can you share any special stories of cross cultural clinical communication events y ou encounter ? E nglish program s Hospital Orientation and Communication Events Data collected from the previous interviews will inform questions, such as the following: 1. H ave you attended any English programs for nursing purposes in your home country or in the United States? Can you describe these English programs? To what extent did they contribute to your clinical communication abilities in the U.S.? 2. Please share your hos pital orientation stories. (What was it like? How long did it take? A ny specific experiences regarding cultural and communication events?) 3. Can you share any special stories of cross cultural clinical communication events you encounter ?

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231 APPENDI X G CONSENT TO BE AUDIO TAPED Consent to be Audio taped and to Different Uses of the Audio tape(s) With your permission, you will be audio taped during this research. Your name or personal information will not be recorded on the tape, and confidentiality will be strictly maintained. When these audio tapes are played however, others may be able to recognize you. To prevent this, the Principa l Investigator will transcribe the tapes in a private room and ensure nobody will be around when he/she is making the transcriptions. The Principal Investigator of my study, __ Ya Yu Cloudia Ho ____ will keep the audio tapes in a locked cabinet. These audio tapes will be never played under any circumstances except when the Principal Investigator is making transcriptions. Please sign one of the following statements that indicates under what conditions ________________ has your permission to use the audio tapes I give my permission to be audio tape d solely for this research project under the conditions described. ______________________________Signature ____________________________Date I give my permission to be audio tape d for this research project, as descr ibed in the Informed memo and for the purposes of education at the University of Florida ______________________________Signature ____________________________Date I give my permission to be audio tape d for this research project, as described in the Informed memo ; for the purposes of education at the University of Florida; and for presentations at ESOL, language teaching, and science meetings outside the University. ______________________________Signature ____________________________Date Ya Yu Clou dia Ho Doctoral student in ESOL/Bilingual Education School of Teaching & Learning College of Education University of Florida. Phone: (352) 870 8143 E mail:

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232 APPENDIX H EXAMPLE OF NARRATIVE ANALYSIS Data are extracted from 12.29.2010 Shya and Bu Focus Group Interview

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233 APPENDIX I EXAMPLE OF THEMATIC ANALYSIS Codes are extracted from Co s data.

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234 LIST OF REFERENCES Abriam Yago K., Yoder, M., & Kataoka Yahiro, M. (1999). The Cummins model: A framework for teaching nursing students for whom English is a second language. Journal of Transcultural Nursing, 10 (2), 143 149. Adeniran, R. K., Rich, V. L., Gonzalez, E., Peterson, C., Jost, S., & Gabriel, M. (2008). Transitioning internationally educated nurses for success: A model program. Online Journal of Issues in Nursing, 13 (2), 12 12. Agresti, A., & Finlay, B. (2008). Statistical methods for the social sciences N ew Y ork, NY: Pre ntice Hall. Andrews, M. M. (2003). Theoretical foundations of transcultural nursing. In M. M. Andrews & J. S. Boyle (Eds.), Transcultural concepts in nursing care (pp. 3 14). New York NY : Lippincott. Andrews, M. M., & Boyle, J. S. (2003). Transcultural concepts in nursing care Philadelphia PA : Lippincott Williams & Wilkins. Ariza, E. N. W., Morales Jones, C. A., Yahya, N., & Zainuddin, H. (2007). Why TESOL? Theories and issues in teaching English to speakers of other languages in K 12 classrooms. Dubu que, Dubuque, IA: Kendall/Hunt. Austin, J. L. (2001). How to do things with words. In A. Jaworski & N. Coupland (Eds.), The Discourse Reader (pp.63 75) New York NY : Routledge. Bachman, L. F. (1990). Fundamental considerations in language testing New Y ork NY : Oxford University Press. Bakhtin, M. M. (1986). Speech genres and other late essays. Austin, TX : University of Texas Press. Baleghizadeh, S. (2007). Speech acts in English language teaching. Iranian Journal of Language Studies, 1 (2 ), 143 154. Baxter, P., & Jack, S. (2008). Qualitative c ase s tudy m ethodology: Study design and implementation for novice researchers. The Qualitative Report, 13 (4 ), 544 559. Berger, P., L. & Luckmann T. (1967). The social construction of reality: A treatise in the sociology of knowledge. New York : Anchor Books. Bernard, H. R., & Ryan, G. W. (2010) Analyzing qualitative data: Systematic approaches. CA : Thousand Oaks Bola, T. V., Driggers, K., Dunlap, C., & Ebersole, M. (2003). Foreign educated nurses: Strangers in a strange land? Nursing Management, 34 (7) 39 42.

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235 Bosher, S., & Smalkoski, K. (2002). From needs analy sis to curriculum development: D esigning a course in health care communication for immigrant students in the USA. E nglish for Specific Purposes, 21 (1), 59 79. Boxer, D. (2002). Applying sociolinguistics: Domains and face to face interaction Philadelphia, PA: John Benjamins. Brown, H. D. (2000). Principles of language learning and teaching White Plains, NY : Pearson ESL. Brown, J. F. (2008). Developing an English as a Second Language program for foreign born nursing students at an historically black university in the United States. Journal of Transcultural Nursing, 19 (2), 184 191. Bruner, J. S. (1990). Acts of meani ng Cambridge, MA: Harvard University Press. Bruner, J. S. (1996). The culture of education Cambrid ge, MA : Harvard Univ ersity Press. Burns, A., Joyce, H., & Gollin, S. (1996). I see what you mean: Using spoken discourse in the classroom Sydney, Australia: Macquarie University. California Board of Registered Nursing (20 11 ). Practice Information Retrieved from Campinha Bacote, J. (2002). The process of cultural competence in the delivery of healthcare services: A model of care. Journal of Tran scultural Nursing 13 181 184. Canale, M. (1983). From communicative competence to communicative language pedagogy. In J. C. Richards & R. W. Schm idt (Eds.), Language and communication (pp. 2 27). New York NY : Longman Group Limited. Canale, M., & Swain, M. (1980). Theoretical bases of communicative approaches to second language teaching and testing. Applied Linguistics 1 1 47. CGFNS (2008). CGFNS/ICHP Visascreen: Visa Credentials Assessment Program Applicant Handbook. Commission on Graduates of Foreign Nursing Schools Chen, W. W. (2006). The study of oral English testing in some large scale EFL/ESL tests from a communicative perspective. Wu han, China : Wuhan Univ ersity of Technology Chien, C. C. Y., & Tsao, C. C. H. (2009). Communicative course design for ENP Proceedings of International Symposium on ESP & Its Application in Nursing & Medical English Education pp. 77 107.

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236 Chinen, C. L. ( 2001). Christine's easy English conversation for nurses Tokyo, Japan: Igaku Shoin. Chinen, C. L. (2001). Christine's "level up" English conversation for nurses Tokyo, Japan: Igaku Shoin. Choi L. L. S. (2005). Literature review: Issues surrounding Education of English as a Second Language (ESL) nursing students. Journal of Transcultural Nursing, 16 (3), 263 268. Chomsky, N. (1965). Aspects of the theory of syntax Cambridge MA : M IT Press. Co ady, M. Hamann, E. T. Harrington, M. Pacheco, M. Pho, S. & Yedlin, J (2007). Successful schooling for ELLs: Principles for building responsive learning environments Inclusive pedagogy for English language learners: A handbook of research informed practices New York : Lawrence Erlbaum Associates Coelho, E. (1994). Social integration of immigrant and refugee children. In F. Genesee (Ed.), Educating second language children: The whole child, the whole curriculum, the whole community (pp. 301 327). N ew York NY : Cambridge University Press. Commission on Graduates of Foreign Nursing Schools, CGFNS (2008). CGFNS/ICHP Visascreen: Visa Credentials Assessment Program Applicant Handbook Retrieved from Crotty, M. (2003). The foundations of social research: Meaning and perspective in the research process. London United Kingdom : SAGE Cummins, J. (1979). Language functions and cognitive processing. In J. P. Das, J. Kirby & R. F. Jarman (Eds.), Simultaneous and successive processing (pp. 175 185). New York NY : Academic Press. Cummins, J. (1980). The cross lingual dimensions of language proficiency, linguistic inte rdependence, the optimal age question and some other matters. Working Papers on Bilingualism, 19 197 205. Cummins, J. (1981). The role of primary language development in promoting educational success for language minority students. Sacramento CA : Califo rnia State Department of Education, Office of Bilingual Bicultural Education. Cummins, J. (1983). Academic achievement and language proficiency. In J. Oler (Ed.), Issues in language and testing and research (pp. 11 129). Rowley, MA: Newberry House.

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243 BIOGRAPHICAL SKETCH Ya Yu Cloudia Ho is a Taiwanese doctoral c andidate in ESOL/Bilingual Education, Curriculum and Instruction, School of Teaching and Learning College of Education, University of Florida in Gainesville, Florida, USA She received her Master of Education degree in TESOL from University of Sydney in Sydney, Australia in 2002. She taught English as a foreign language for vocational high school students in Tai pei in 2003 and taught college level English courses at University of Technology as a lecturer in Taipei Taiwan from 2003 to 2006. She also taught the undergraduate course: ESOL Foundations of Language and Culture in the Elementary Classroom in School of Teaching and Learning College of Education, University of Florida for five semesters between 2007 and 2010. She is currently teaching English as a Foreign Language (EFL) at universities in Taiwan. Her research and teaching interests focus on curriculum and instruction in English for Specific Purposes (ESP) and English for Occupational P u rposes (EOP) for adult EFL learners.