As a research scientist who is devoted to ensuring that immigrant nurses have successful U.S. careers, the issue of internationally educated nurses’ (IENs’) cross-culture language competence has recently been both a sensitive and front-and-center issue pervading my work. In my more than 30 years in the health care sphere, the topic is now reaching a fever-pitch as IENs increasingly enter the U.S. health care workforce and play a critical role in its success. With immigrant nurses representing 15.6 percent of the total registered U.S. nurse workforce, and some states having higher percentages of immigrant nurses than others (e.g., California (37 percent), Nevada (34 percent), and New Jersey (32 percent)), the influx of IENs continues to grow because they are crucial to mitigating the U.S. nursing workforce shortage. In fact, as of 2022, one out of six U.S. nurses was internationally educated, and this diversity is cause for celebration. That said, against this backdrop, the increasing global and multi-language context of nursing makes accurate and effective communication more essential than ever for providing optimum patient care.

Context and under-recognized issue

This is what many people may not know: While much has been written regarding communication from culturally dominant English-speaking nurses addressing non-English speaking patients, I have repeatedly seen that less research exists for the reverse scenario: when highly educated and skilled IENs have limited English proficiency. In the latter case, acute and demonstrable risks include medication errors, lack of advocacy, and impaired or reduced teamwork effectiveness. Here’s my specific concern: There is current regulatory discussion surrounding relaxing English language proficiency (ELP) standards as part-and-parcel of welcoming otherwise highly-talented IENs (ELP is the ability to listen, talk, read, and write in English). For example, one non-profit article asks if ELP is “Crucial or Unnecessary?” and then argues that language competency is unnecessary since all nurses take a national nursing licensure exam. However, the opposite appears true: An extensive report from Ireland, which examined thirty-nine countries, reached the conclusion that strict language assessment standards and evidence-based regulation are absolutely needed to ensure patient safety. The study advocates for the development of language and communication competencies both before and after nurse migration.

While current federal law requires IENs from non-English speaking countries who seek U.S. employment to take ELP tests and achieve minimum scores, these ELP tests are designed for academic uses, not for health care settings, creating potential dangers for patients when otherwise competent IENs pass with minimum scores. Although some state licensure boards do require ELP testing with greater than the federal minimum scores as a requirement for licensure, others do not.

The purpose of ELP testing is to assess communication skills in a nursing context with patient safety as the primary goal, and attempts to weaken or otherwise erode ELP within the current policy debate is perilous, however well-meaning these attempts may be. The importance of language competency cannot be overstated: Language barriers can hinder a provider’s ability to gather crucial patient information, resulting in misdiagnosis, incorrect treatment, or the need for more tests to compensate for various communication gaps. In turn, when patients struggle to understand their diagnosis, treatment, or follow-up care due to IEN-centric language barriers, they may become uninvolved or simply not return for further care.

Health care team communication

While the patient-provider discordance has at least been recognized, less attention has been paid to language barriers within health care teams. Just as with patients, miscommunication between team members from different linguistic backgrounds can result in errors and adverse events, impacting patient safety. Not only do team members have different native languages, but their levels of proficiency in the shared language (English), and crucially (in medical language) can vary, leading to gaps in understanding.

Benefits of English language proficiency for nurses

Overall, patients fare better when IEN language competency improves. For example, a study on IENs working in cardiac care units found a high correlation between enhanced ELP and improved patient care. This included the enhanced writing of nursing notes, charts, and reports. Higher ELP enabled IENs to effectively perform patient handovers, listen to doctors’ daily rounds, and communicate clearly. Enhanced ELP improved nurses’ ability to solve clinical problems and to read updated nursing guidelines. These enhancements contributed significantly to the nurses’ professionalism and professional autonomy.

Solutions and calls to action

There are, again, some basic ELP standards already in place, at least for now. Under the Illegal Immigration Reform and Immigrant Responsibility Act of 1996 (IIRIRA), as implemented by the Health Resources and Services Administration (HRSA), foreign health care professionals are required to demonstrate English language proficiency on one of seven HRSA-approved tests to obtain an occupational visa to work in the U.S. In addition, as mentioned, state boards of nursing set their own English proficiency standards for licensure and practice. However, again, naysayers claim that high ELP testing standards should be eliminated. These naysayers also posit that test taking skills reflect American culture (standardized tests rather than essay format) and can therefore unfairly disadvantage nurses from foreign locales. Cost is also cited as a significant factor for eliminating or reducing language competency tests for IENs, as some activists assert that IENs may have difficulty affording these tests (taking the TOEFL alone costs approximately $225, for example). That said, the paramount argument for ensuring stringent ELP testing standards is focused on patient safety, quality of care, and patient outcomes as opposed to an arbitrary and unproven relaxation of standards. Moreover, meeting a more than minimum ELP helps nurses enhance their learning and boost their confidence.

Conclusion

Fully integrating IENs into the U.S. nursing workforce means upholding quality, common-sense ELP testing standards to ensure that ELP is a core element of clinical competence. On-the-job ELP training should also ensure that medical language is adequate. The broader debate should be reframed from activists’ “ELP is a barrier” to a more widely accepted view that ELP is the key to safe, effective patient care and safe health care teamwork. IENs are essential for American health care success, and ELP standards are a win-win component of that equation, especially for otherwise high-skilled IENs themselves.

Lynne Moronski is a research scientist.