Developing and using good communication skills is a challenge for all nurses — but especially for those working with patients in a hospital setting. Nurses who speak English as a second language face additional challenges, particularly when they are required to take full, comprehensive assessments of patients presenting with mental health crises in a fast-paced, high-pressure emergency department.
To perform a thorough assessment, nurses on the emergency psychiatric consultation team at North York General Hospital in Toronto must build rapport with patients from diverse cultural backgrounds who have a range of psychiatric illnesses.
They have to observe and understand non-verbal cues and body language, evaluate patient insights and perceptions and recognize cultural issues and values that may affect behaviour and thought.
The manager of the emergency psychiatric consultation team recognized that newly hired nurses with English as a second language (ESL) had problems writing their assessments. These assessments, which take at least one hour to write, were often sparse or incomplete.
They missed key points, lacked attention to significant details, reflected difficulty using and understanding common vernacular or idioms, and showed limited awareness of behavioural norms common in diverse cultures.
Overall, the assessments lacked sufficient depth for the emergency department’s on-call psychiatrist, who relies on the assessments to determine a patient’s followup treatment.
To address this problem, a specialized, innovative orientation component for nurses with ESL was added to the requisite one-month orientation for all new nurses hired by the psychiatric unit.
During this orientation, the nurses work directly with an experienced mental health nurse at the hospital who specializes in crisis assessment. Using a variety of teaching techniques, the nurse identifies and addresses gaps in the new nurses’ communication skills, and provides one-on-one role modelling and mentorship.
This role-modelling and mentorship is essential because mental health nurses in the emergency department work autonomously, requiring them to make on-the-spot recommendations, referrals and decisions in collaboration with the on-call psychiatrist.
They work under extreme pressure and require strong crisis resolution skills. Therefore, in addition to improving communication skills, the training with the crisis nurse was designed to help the new nurses become more comfortable working independently.
Because some come from cultures where all decision-making is left up to the doctor, this training is essential to develop the nurses’ ability to make rapid, well-founded and confident decisions independently.
The nurses with ESL were receptive to enhancing their skills with additional training. One communication exercise they found particularly useful involved role play, where the experienced nurse demonstrated how to gently probe patients to elicit detailed responses.
For instance, rather than asking a question by rote, such as: “Tell me about your employment history,” the nurses were encouraged to create their own “cheat sheets” to elicit comprehensive information about the patient’s type of work, length of employment at various jobs, work stresses, absenteeism, ability to perform job functions, work absences or work injuries or disabilities.
Nurse develops her own script
One nurse who received this orientation training came from Russia but graduated from a nursing program at a Canadian university. Though she understood English, she referred to it as “textbook English.”
She felt challenged by writing information in a particular format, providing accurate information relayed by the patient and writing her assessment “in a non-judgmental manner.” She says she now uses her cheat sheets to remind her how “to describe my observations using professional language.”
On one of her cheat sheets, she has examples of possible language to use in an assessment question about a patient’s “appearance.”
Her cheat sheet sample says: “P is a 45 year-old Caucasian/Latin/Indian/Chinese female who appears her/his stated age. He/she was of a medium/large/tall/short height and a slim/robust/muscular/thick/slight/build. S/he was casually dressed in a lilac summer dress/grey suit, and has a large snake tattoo around her/his left forearm.”
This nurse also required help “to ask patients questions on delicate topics in a non-offensive manner using professional language.” During her additional training, she learned how to ask personal questions and developed her own script to use during assessments.
One example of a sensitive question was regarding self-harm: “Have you ever thought of hurting yourself? What kind of thoughts did you have? Did you act upon them? Is there anything that would stop you?”
During their orientation, new hires with ESL also shadow other staff in related mental health programs at the hospital, enabling them to make better recommendations for followup treatments.
Upon completion of their enhanced orientation, the nurses have reported increased confidence in their ability to prepare comprehensive assessments.
“Thank you so much for identifying and understanding my problems, then helping me to remove the obstacles I faced,” wrote one crisis nurse in a letter of gratitude.
The nurses who received this training have transitioned well into their new roles. Colleagues have reported increased satisfaction with the new nurses’ assessments as well as improved confidence — resulting in a more cohesive working team and optimal patient care.
Mary Ann O’Hearne is a registered nurse and clinical team manager, adult mental outpatient services, general division and the emergency psychiatric consultation team at North York General Hospital in Toronto. Fern Quint is a registered nurse and a member of the emergency psychiatric consultation team. Linda Rosenbaum is a freelance writer specializing in health and medical issues.