ANAHEIM, CALIFORNIA—An accent modification class for internationally educated nurses improved pronunciation and confidence in speaking to patients and coworkers, according to research presented at the Oncology Nursing Society (ONS) 39th Annual Congress.

Nurse shortages led the University of Texas MD Anderson Cancer Center in Houston to supplement their staff with internationally educated nurses. Patient surveys indicated that 18% of mixed or negative comments about nurses were related to difficulty in understanding the accents of the internationally educated nurses.

“Communication is considered one of the most important aspects in performing nursing duties,” said researcher Julieta Fajardo, RN, BSN, CHPN, of the University of Texas MD Anderson Cancer Center, during a podium session. “It is central to nurse–patient relationships and has become a focus in patient satisfaction.”

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Fajardo stated that prior research shows that both employers and internationally educated nurses need to address issues surrounding language and communication, particularly the pronunciation of American English, as ineffective communication is known to be one of the main causes of severe adverse events.

“In our study, nursing directors chose accent modification class when accents became an issue because previous research has shown positive effects in addressing linguistic and sociocultural problems in communication,” she said.

Fajardo and colleagues included 22 internationally educated nurses in their pilot project. Participants attended a 10-session accent modification course. The instructor was a speech therapist who specialized in English as a second language. The results were examined by surveying patient satisfaction, through self-assessments by the participants as well as instructor assessments.

Of 22 participants, only 17 completed demographic questionnaires. A majority (59%) were educated in India, while the remainder were educated in the Philippines, Ghana, and other countries. Eighty-eight percent held a bachelor’s degree in nursing.

Nineteen of the 22 participants attended preassessment and 17 completed the postassessment session. Among the main reasons for missing classes were scheduling conflicts with school, work shifts, and jury duty, among others.

Results showed that 94% of participants strongly agreed that the content in accent modification course was well presented and that the information and training were useful. They also said the course satisfied and positively met their expectations. All participants also strongly agreed that the instructor knew the content well and that they would recommend the course to their colleagues.

Additionally, although all participants expressed satisfaction with the accent modification course, they experienced challenges along the way, according to Fajardo. For instance, some nurses were concerned about leaving their floors understaffed, attending the course after a long shift, and expectations from their managers to attend the courses on their days off.

According to both the participants’ and instructor’s assessments, an increase in participants’ skills in pitch and linking syllables that enabled them to pronounce words effectively was particularly important. They felt this improved pronunciation gave them confidence in speaking to both patients and coworkers.

Evaluating the participants’ progress later on will be of interest, Fajardo noted.

“Although participants’ skills and confidence during and right after class improved, it will be interesting to learn if they will be able to sustain it and if patients and colleagues will notice in the long run,” Fajardo said, noting that no studies have evaluated this to date.

Further, because of the overwhelmingly positive response, the course has been recommended to roll out a 10-session course available to any internationally educated nurse or those who are assessed by their manager as lacking competence, with accent as a contributing factor, at MD Anderson. Incentives and a certificate of completion will be offered.

“Improving nursing communication is critical to an institution’s strategic goal and is essential to patient safety,” Fajardo said. “Nursing communication is also the foundation of relationship-based care. Oral communication training may prove useful for internationally educated nurses to improve effectiveness in the clinical setting.”


Fajardo J. Maintaining patient safety: Accents of international nurses as an oral communication barrier to patient satisfaction with nursing communication. Presented at: Oncology Nursing Society (ONS) 39th Annual Congress. May 1-4, 2014; Anaheim, CA.

Prepared by Kathy Boltz, PhD, and Melissa Foster