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Language is considered to be a system of communicating with other people using sounds, symbols and words in expressing meaning, idea or thought. One can communicate primarily through oral and written communications as well as using expression through body language (UniXL). The distinction between one language and another usually arises through country boundaries, population culture, demographics and history (UniXL).
When discussing quality in an international context, Brush, Sochalski, & Berger (2004) claimed that "Rosemary Stevens has argued that one must distinguish between a person's ability to perform specific tasks and their ability to communicate effectively with patients and other professionals to provide culturally appropriate care" (p.82). Language fluency is a critical factor in regards to the issue of patient safety. According to Baumann, et al (2006), communication in the workplace may be considered the greatest barrier during integration:
"Confidence in speaking and clear documentation is essential for patient well-being. However, linguistic competence also includes the social and cultural dimensions of communication. Some individuals find these difficult to acquire. Their facial expression, their view on life, they look like they speak English, but they don't understand English...so they don't get jokes, they don't get sarcasm, they don't get anger . . . so that's the group that has the most trouble integrating and probably the group that does least well here (p.24)."
Foreign educated nurses also tend to speak with heavily accented English, which may contribute to miscommunication with other colleagues and patients (Baumann, Blythe, Rheame & Mckintosh, 2006, p. 25). The foreign educated nurse informants, according to Baumann et al (2006), "were aware of the technical problems of communicating in English and some described telephone communication as particularly challenging" (p. 24). "Fellow workers are not always sympathetic stating that it was not their "problem to fix their language ability" (Baumann et al, 2006, p. 24).
The English language proficiency examination is a requirement prior to foreign nurses' licensure approval. The most commonly used exam is the Test of English as a Foreign Language (TOEFL). It is expected that all foreign educated nurse-candidates meet or exceed the standard before a license is issued to them (O'Neill, Tannenbaum, & Tiffen, 2005). On the other hand, a study has identified a linguistic/structural bias in Multiple-Choice Nursing Exams (Bosher, 2003). Linguistic bias refers to overly complex items that are not easily understood
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