Breaking Language Barriers: Improving Communication in a Multilingual NHS Trust Hospital

1.0 CHAPTER ONE

1.1 Introduction

The UK hospitals’ care settings are complex, fast paced and may be chaotic, especially at this time of COVID-19 pandemic. Nurses are required to converse with various people on various topics. According to Boissy et al (2016), their main function is to act as liaisons between physicians, patients, family members and other staffs. Furthermore, they must constantly remember the messages even as they multitask to fit within time constraints. Often, in such working environments, there are many interruptions and distractions. The working environments can be noisy, demanding, frustrating and busy. On the other hand, visitors and patients are often under tremendous stress and fear. The speech between laypeople and nurses can be influenced by many factors. For instance, according to Iwasa (2020), such factors may include the patients’ emotional well-being, physical health, functional abilities (e.g. sense of hearing), noisy and hectic hospital environment. Furthermore, the client’s cultural background, level of education, philosophical values and past experiences that have a relation with their present situation can affect their perception if the current situation and its meaning (Lundin et al, 2018). Technological innovation and advancement in interventions and therapies have contributed to an increased human lifespan. As people live longer, they become more predisposed to other age-related health problems and issues that require hospitalization and other forms of medical care (Meuter et al, 2015). In this regard, Pot et al (2020) predicted that in the next few years, hospitals will face increased cases of hospital admissions – especially among the old age (65 years and above) with chronic illnesses. Consequently, there will be an increase in job opportunities in the healthcare industry, opening chances of recruiting nurses straight from college. Recruit nurses who do not speak English as their first language will also seek those job opportunities in the UK healthcare market and they will therefore need to learn English or at least show a proficiency in the English language (according to the Nursing and Midwifery Council, NMC 2014 requirements) before they can be allowed to practice in the hospital environment. Furthermore, they cannot be registered as a nurse to work in the UK unless they meet the requirements of the NMC. This paper explores the subject of language barrier for recruit nurses in the UK and proposes a handbook that will help the nurses to translate key clinical terms in English during their practice. The paper is organized into chapters. The first chapter identifies the problem found in the specific organisation, introduces the topic by outlining its purpose, significance, scope, and definition of concepts. The project began as an attempt to fill the void of lack of specific materials assisting non-English speaking nursing recruits to translate key terms of clinical practice. It seeks to begin a conversation on the topic of language barrier within the context of clinical practice and to encourage others within the field to develop materials. Chapter two of the paper will give a theoretical background of the topic through a review of literature materials. This will include literature on the language of hospital setting, various aspects of culture and how they relate to patients in care situations, important forms of language and abbreviations, as well as the complex nature of culture and how it impacts patients’ response to illness, hospitalization, privacy, verbal/non-verbal communication and their conceptualization of health. Chapter three will explore project aim and objective while chapter 4 will evaluate the project plan and key project milestones. Chapter four will entail a breakdown of financial costs while chapter five will entail the project evaluation plan, monitoring, implementation and success evaluation.

1.2 Statement of the problem

The hypothetical organization is an anonymised NHS Trust hospital with a total of 36 nurses, 7 of whom do not speak English as their first language. Consequently, the hospital’s management experience several cases of miscommunication of treatment or diagnosis details. In one incidence, a patient visited the hospital and was diagnosed with rheumatoid arthritis (RA).

As per the standard treatment of RA, the patient received a prescription of 15 mg methotrexate once weekly and 5 mg folic acid twice weekly. However, because she could not move to the pharmacy, one non-English speaking nurse picked the drugs on her behalf. Unfortunately, due to language barrier the nurse failed to clarify that the methotrexate was to be taken on a weekly basis and not daily. Consequently, the patient consumed the 15mg methotrexate daily and for 11 days. On the 11th day, the patient presented with ongoing vomiting and a further examination revealed that she had ulcerative lesions and multiple erythematous. This incidence was taken seriously by the NMC and had serious implications for the NHS trust management.

Indeed, when communicating details of treatment and diagnosis, it is important to effectively convey the information in a way that is not likely to expose the patient to associated risk factors. More importantly, failure to highlight the seriousness of the negative consequences of wrong treatment may lead to various health implication such as the patient’s failure to comply with the treatment (Boissy et al, 2016).

There is evidence that practitioner miscommunication due to language barrier might occur when clinicians use an inadequately mastered second language and cannot convey the certain aspects of risk and certainty (Wyn, 1994). Furthermore, according to Ryder et al (2011), people from different cultural groups have different ways of describing specific terms (e.g. days or weeks), metaphors or expressions, even if they have a high language competency. Also, when clinicians lack the cultural and linguistic skills needed and interpreters are not available, patients may have to rely on their medically inexperienced relatives, non-medical staff or friends (Gany et al 2013). This compromises the quality of care and worsens health outcomes – as experienced in the case study above. The proposed project seeks to introduce a handbook that will be of value to non-English speaking nurses by acting as a personal guide to prepare nursing recruits for work in the UK or other clinical care settings. The handbook will consist of various chapters on the topics of patient care, body systems, basic life support, the nursing process, the legal language of healthcare, patient privacy, weights and measures.

For non-English speaking nursing recruits to effectively communicate with patients in UK hospitals, they need a language material that will act as their guiding companion to help them speak authentic English language that is embedded in a meaningful practice context, relevant to direct work and patient care situations. The material should also be standardized enough to act as a foundation for the English courses they might want to take to qualify for registration by NMC as practitioners in UK hospitals (NMC, 2014A).

Sharifi et al (2019) analysed culturally diverse students working in UK hospitals and found that the recruits encounter anxiety when communicating with clients about various medical procedures to be performed on them. The results of their study also revealed how the new recruits experienced difficulties in areas such as developing assertiveness with the patients, effective and clear communication, use of appropriate non-verbal communication skills (e.g. maintaining eye contact), understanding patient needs, asking for help from colleagues, charting appropriately with colleagues and navigating through cultural differences.

Recruit nurses from other countries wishing to study English and later practice in the UK come from different professional and personal backgrounds, and therefore it is important to conduct a needs assessment to design an effective language instruction or personal language translation reference material for them (Squires, 2018). According to Alghamdi et al (2019), one of the most important considerations to make when developing such a material is the nurses’ educational background. Countries have varying educational systems and therefore students might be accustomed to individual practice rather than group work. Therefore, the material ought to be flexible enough to help nurses with language translation both in individual and group work context.

Apart from reading and writing skills, nursing recruits need practice and instruction to help them learn best. For example, a recruit that has had an extensive educational and professional training in nursing might be comfortable with reading and writing English but may also need to practice verbal communication (Greene & Adam, 2020). The recruit nurses might have come from a wide range of socioeconomic background – some growing up in urban areas while others in rural areas, a phenomenon that influences their ability to effectively hold conversations within the clinical care context.

The proposed handbook will be used as personal guide to prepare nursing recruits for work in the UK or other clinical care settings. It may also be used as a reference text, an independent study resources or a teaching tool that helps individuals improve their communication skills and efficient interaction with patients at the workplace. Its contents will help reduce stress among non-English speaking nursing recruits who may feel overwhelmed by responsibilities and work in a clinical environment.

Before implementing the project, it is prudent to evaluate whether the project is feasible, whether the institution has the capacity to implement the project. According to Gurel & Tat (2017), this will help determine whether the project should be implemented. From a business perspective, there are various tools and techniques useful in creating an honest assessment of organization’s strengths and weaknesses and how they relate to the proposed project, and to give an insight into what is available, what are the limitations and whether there are any additional investments that the organization will have to make to implement the project.

A common problem for improvement teams is identifying what changes that can be taken improve a process of problem. According to Boissy et al (2016), one great method that can help break down the ideas is a tool known as the Fishbone diagram/the course and effect diagram. The figure below illustrates the cause and effect diagram to help identify some of the major causes of miscommunication between non-English speaking nurses and patients

1.3 The Fish-bone diagram

People

Language discrepancy

There is a growing number of patients and practitioners who do not speak English as their first language in the UK health system and therefore any language discrepancy that might cause miscommunication must be mitigated. This can be addressed by availing a handbook companion to help recruit nurses with translation

Cultural discrepancy

Nurse recruits might be coming from a different cultural background from the patients’ cultural background where some words may have different meanings depending on the context. This might cause poor communication. This can be addressed by availing a handbook companion to help recruit nurses with translation of specific terminologies in different contexts

Methods

The use of both family and proficient translators might prove to be medically inefficient and financially unaffordable. The hospital might not be able to control this factor

Equipment and materials

The use of translation technology and equipment might prove to be expensive and prone to translation errors. The hospital might not be able to control this factor.

Environment

The physical environment can make a significant difference in facilitating successful communication between the nurse recruits and patients, noise, lack of privacy, poor lighting and inadequate room size may add to the challenge of language barrier between nurse recruits and patients. To some extent, the hospital can control these factors by availing better lighting, reducing noise and partitioning the clinical rooms to make them more private

Chapter 2

2.0 Literature Review and Theoretical Background

2.1 Methodology

To effectively establish a theoretical background, this study relied on a systematic selection, evaluation and analysis of literature materials. The process involved identifying literature materials from online databases, evaluating the relevance of those materials through inclusion criteria, analysing and summarising their findings to develop concrete pieces of evidence that not only informs the proposed project but also identifies existing research gaps (Oztemel & Gursev, 2020).

2.2 The Search Strategy

The search strategy entailed an identification and evaluation of literature evidence that supports the project objectives. According to Snyder (2019), adopting a systematic approach to literature review ensures that there is enough and valid evidence to support a piece of research work but also to facilitate transparency and replicability of the results. In the following sections, we describe the systematic process of identifying and extracting evidence from existing literature materials for literature review.

2.3 Databases

The study relied on online databases (e.g. Proquest, and EBSCO) as sources of literature materials. Online as opposed to physical databases were selected to facilitate an easier identification and retrieval of literature material using relevant search terms. Online databases are relatively simpler to use that physical libraries because the latter rely on manual use of catalogues while the former only relies on search terms which are keyed in to retrieve literature materials (Rahma, 2020). Apart from the three online databases, a manual search was also conducted on search engines to identify any relevant piece of literature material.

2.4 Keywords

The study relied on various keywords such as language barrier, recruits, nursing, handbook, code of ethics, guidelines, qualification, language, patients, service users, and practice to conduct a comprehensive literature search. More importantly, as recommended by Reis et al (2018), the search strategy was customised to suit each online database. The customization was done through Boolean operators (AND/OR), which facilitated the combination and separation of the key words for easier retrieval of relevant pieces of literature materials (Mengist et al, 2020). For example OR was used to broaden the search by combining several unrelated words while AND was used to narrow the search by combining several related words.

2.5 Inclusion and Exclusion Criteria

Mengist et al (2020) pointed out that inclusion/exclusion criteria are useful in defining the relevance and scope of literature material during a literature review. In the current study, the literature materials were limited to those in full text, written in the English language and those regarded as academic papers. It was considered to include full text literature materials because they would facilitate comprehensive review of literature if they were in their full versions. The study also considered only the studies published after the year 2000 to ensure that the evidence is not too out of date. However, materials published before the year 2000 but had crucial pieces of evidence were included. Lastly, academic papers were considered for inclusion to ensure valid and reliable pieces of literature. A PRISMA chart was adopted to ensure that only the studies that met the inclusion criteria were retained for further review. Appendix 1 illustrates the PRISMA chart.

2.6 Data extraction

The researcher independently extracted data from each article (Appendix X). Key to the data extraction process was to identify various aspects of each journal article including the name of the author (s), the setting or location of each article, the year of investigation, the study sample size, methods of data analysis, main findings and conclusion.

2.7 Critical appraisal

A critical appraisal tool was adopted to ensure quality literature materials were included for review. According to Reis et al (2018), critical appraisal tools such as Critical Appraisal Skills Programme (CASP) and the Consolidated Standards of Reporting Trials (CONSORT) are conventional tools that researchers can use to evaluate the methodological rigour, validity and reliability of research articles as sources of evidence (Oztemel & Gursev, 2020). In the current study, the CASP tool was adopted to critically evaluate any RCT selected for review. According to Reis et al (2018), CASP evaluates research articles by examining their content and how there are relevant to the research topic under investigation. The critical appraisal process involves an evaluation of the studies’ strengths and limitations, as well as their relevance and reliability. Ultimately, the tool is organized into ten questions categorised under three thematic areas namely: what are the results of the study? Are those results valid? And do the results apply on a local context? Attached in appendix 5 is a CASP table highlighting how the studies scored across the 10 questions. Below the CASP table is the scoring system.

2.8 Literature review

The subject of Health Education England (HEE) English language can be explored from various perspectives. While one may conduct an ethnographic study on workplace hierarchies and socio-cultural dynamics, the other might transcribe conversations and conduct a discourse analysis on them. Medical terminologies, most of which contain Latin and Greek morphemes and grammatic elements of scientific writings can provide a rich platform for linguistic analysis. Even if one would like to study medical documents, they are vast enough to warrant the same because, for example, physicians’ conversation with patients entail a large portion of discourse that can be analysed. This section will explore the topic of language barrier from all these perspectives.

Roberts (2005) pointed out four major approaches used in studying and understanding the use of English language within the workplace context namely: interactional sociologistics, textual discourse analysis, ethnography and pragmatics. These approaches speak to the phenomenon of rule-governed speech, differences in communicative styles and misunderstandings, cultural and social patterns of interaction and the beliefs, assumptions and values that account for such interactions.

Against this backdrop, the proposed project focuses on what would help non-native English-speaking nurse recruits working in UK hospitals get through their shifts stress free and how to effectively teach them British English language. This may include one of the above approaches to language. However, this may first involve evaluating the language.

According to Clarke et al (2021), verbal communication may occur face to face, within a group discussion, over a telephone call, in-service lectures or through announcements over the internet. That aside, forms of written communication may include formal and informal messages and notes, specialised abbreviations and terms, reference materials, research articles, and clinical documents. In some situations, nurses must communicate nonverbally or interpret those non-verbal communications. However, in some cases, patients with cognitive impairments such as psychosis, delirium, dementia, brain injury, or psychological stressors may impair nurse’s communication process with them (Cook, 2017). Furthermore, according to Harding et al (2018), individual life experience, temperament and psychological orientation can also influence how they communicate with others.

Out of the wide range of literature material on HEE English language for nursing (Health Education England, 2021) three major areas are of great interest to this report: elements of English for Specific Purposes (ESP), cultural aspect of patient care, and the hospital environment language. First, according to Hoskins & Reynolds (2020), the topic of ESP has been selected as an area of interest because it is a specialized form of the English language as a second language for adults interested in the topic hospital English.

Secondly, because English in a hospital environment is a content to be taught, it is important to understand the student and design content that best meets their need (Shevchenko, 2017). Elements of content content-based learning and learner motivation are a fundamental factor to consider when developing learning materials like the one targeted by the proposed project. Just as instructors must clearly understand the subjects they intend to teach; a linguistic analysis of this content will increase the knowledge on the language forms that help explain these rules to learners (Beilousova, 2017). The main goal of producing instructional content is to help the nurses achieve effective communication in the hospital.

Finally, culture influences how one responds to hospitalization and illness (Nalimova & Voronina, 2017). The environment within which nurses work entails people from different cultures who interact in stressful circumstances. Therefore, according to Hoskins & Reynolds (2020), it is important that when nurses communicate in such environments, they should be sensitive to potential areas of misunderstanding that may cause a communication breakdown. This justifies why nurses are taught to maintain therapeutic communication throughout their areas of practice. Therefore, an awareness of culture and how it affects their interaction with patients can facilitate more therapeutic and effective communication. The sections below address each of these topics.

2.8.1 English for Specific Purposes

English for specific purpose (ESP) is an English special language (ESL) for an occupational field, workplace situation of speech community. According to Hoskins & Reynolds (2020), the main aim of ESP is to teach the language using a subject matter or content. The teaching of HEE English language would fall in this category: occupational or workplace ESL. Beilousova (2017) observes that ESP is taught in the UK under the stewardship of the British Council, which covers topic areas such as workplace ESL for international nurses working in the UK.

Linguistic competence in English is important for non-English speaking nurses working as registered nurses in the UK. According to Crawford & Candlin (2012), nurses who lack such competence experience issues of miscommunication and social misunderstanding and this poses a potential risk to patient outcomes and safety. Therefore, ensuring that recruits have the necessary language is a great responsibility for hospital managers whose job descriptions is to recruit competent and suitable clinicians (Edgecombe et al, 2013).

The UK is a major host of internationally educated student nurses (England, 2013) and have established various mechanisms to ensure that any internationally educated nurse is eligible to practice (RCN, 2014a). according to NMC (2014A), These mechanisms are manifested in the variety of practice, language and registration requirements for all applicants educated outside the European Economic Area and the European Union. Thus, mandatory English language proficiency testing through the International English Language Testing System emerges as one of the most used approach for testing English proficiency in the UK.

By effect, non-English language speaking recruits are required to show evidence of proficiency in English. On the other hand, according to NMC (2011) the employers have the right to require evidence of English language proficiency to ensure that they employ nurses who can effectively communicate. However, despite all these mechanisms to ensure English proficiency among non-English speaking nurses, according to RCN (2014a) it is not clear whether they guarantee enough cultural and nuanced competence in the context of clinical practice.

In a recent UK study of internationally educated nurses through to have a considerable proficiency in English, it was found that the participants did not have the right language skills and proficiency for working successfully in a clinical setting (Stephenson, 2014; NNRU, 2014). That said, Crawford & Candlin (2012) noted that a language skill deficiency can also impede professional development. Nurses require skills that not only involve technical competence in spoken and written English but also clinical and social competence across different contexts of practice (Harris et al, 2013).

The rationale for the proposed project is supported by existing literature on English and clinical practice. For instance, Likupe (2013) noted that supporting non-English speaking nurses in developing effective communication skills is important for their successful integration into the British healthcare system. On the same note, the RCN (2005) acknowledged that helping or providing non-English speaking nurses with the necessary English language skills such as handling telephone conversations with patients can help them feel included and facilitate a smooth communication between the staff and patients.

However, literature by Edgecombe et al (2013) highlighted that non-English speaking nurses need more than technical competency in English, they also need the linguistic competency for specific social and clinical contexts of nursing. This justifies the need for the proposed handbook project because it will contain translations of various topics relevant to various contexts of clinical practice including emergency care, patient privacy, healthcare legal language and the nursing process. This will ensure that on top of the academic English proficiency, the recruit nurses will have specific communication skills for different contexts of practice. A similar project was successfully conducted by Medlin (2009) in the US. This illustrates that the proposal is evidence-based. However, the project by Medelin (2009) had methodological limitations that are worth noting. For instance, the project was implemented in a United States hospital. Yet, each country has its own laws, regulations and standards of healthcare practice, meaning that the communication needs and contexts in the study by Medelin (2009) might not be fully practicable to the communication needs and contexts in the proposed NHS Trust hospital. Moreover, the supplies and equipment used in each individual hospital may vary, there are may be different clinical speciality areas, and each hospital may have its own unique policies and procedures. Therefore, the operational modalities in the project by Medelin (2009) creates the notion that because the project was implemented and succeeded in their target hospital does not mean that the proposed one will succeed. The implementation environments differ.

But O’Neill (2011) argue that in their line of practice, nurses may need to make language use choices that necessitate them to relinquish their long held cultural concepts. According to Lum et al (2014), these communication skills might also involve the ability to engage in small talk with both patients and colleagues (cultural competency) as well as various sociocultural aspects of communication such as sarcasm, jokes, and non-verbal behaviours. Thus, the competency involves not only what is said but also how to best say it (Allan et al, 2009).

Much as there are various transitional programs aimed at facilitating English language development among non-English speaking nurses who would like to practice in the UK, there is minimal evidence on their success (Edgecombe et al, 2013). furthermore, such programs are often taken long before the nurses begin to practice, rather than those who are currently practicing and have already identified their practical language challenges (Allan et al, 2009). Furthermore, according to Likupe (2013), non-English speaking nurses may find it challenging to develop their language skills “on the job” due to discrimination processes.

Several years ago, a UK study by Allan and Larsen (2003) dubbed ‘We need Respect’ acknowledged the significance of communication difficulties for non-English speaking nurses by noting that communication seemed to be the most challenging areas in clinical practice for non-English speaking nurses not only because they took time to orient to local dialects but also because they could not easily be accepted by patients and colleagues due to their unique accent and dialect.

Against this backdrop, communication challenges for non-English speaking nurses can also distinguish them as ‘different’ especially in the context of ongoing disadvantaging of black and minority ethnic groups and institutionalised racism (Edgecombe et al, 2013). In short, non-English speaking nurses not only face communication challenges but also poor organizational response to the challenges they encounter due to language barrier. As such, the proposed project addresses this challenge helping the Trust to respond to communication challenges encountered by non-English speaking recruit nurses.

Crawford & Candlin (2012) argued that difference in cultural norms, nursing practices and communication styles can delay non-English speaking students a successful transition into their host countries. This is a major concern not only with regards to supporting internationally registered nurses to practice within the host country but also those trying to get registration. It has also been argued that this form of language barrier can impede upward occupational mobility for the recruit nurses, especially those who are recruited as nursing assistants (Allan et al, 2009). Contrastingly, with the requirements to register as a practicing nurse in the UK, there are no specific nationality requirements for becoming a healthcare nurse assistant – only some employers require numeracy and literacy skills. Therefore, non-English speaking nurses who might find it problematic to speak English, healthcare assistant position might be the most accessible opportunity for them.

While there is a dearth of evidence on any NHS Trust hospital that has implemented the handbook intervention to ensure that their internationally trained nurses are competent communicators, there are several pieces of evidence highlighting similar projects that have attained significant success in both healthcare and other professions. For instance, Medlin (2009) launched a similar project targeting American English nurses. The author identified a need for internationally trained nurses working in America to have specifically language material that would be useful in both practice and instruction of American English for use in American hospitals. The entire project was based on the concepts of English for Special purposes (ESP), cultural aspects of patient care and hospital language; covering specific topics such as medical abbreviations and terminologies, content-based language instruction, and the influence of cultural background on patient’s response to illness (Medlin 2009). Medlin’s (2009) project created a prototype handbook that could be used by internationally trained nurses in America as a language companion. The handbook consisted of ten chapters ranging from basic life support, glossary of terms, weights and measures, patient care, body systems, legal healthcare language and recommended language resources. Preliminary project evaluations revealed successful use of the handbook as a language guide for non-English speaking nurses during practice (Medlin, 2009).

As hinted above, language handbooks have not only been used by nurse professionals but also by other professionals such as social workers assigned to provide personalised social care to foreign individuals and communities. For instance, Kozelka (1980) developed a Ewe (for Togo) language handbook for social work practitioners, teachers and students that presented a list of vocabularies and samples of Ewe conversational language in various contexts that social work practitioners could refer to when delivering personalised services to the Awe community in Togo. Some of the contextual language translations covered topics such as injuries, diseases, relationships between men and women, body parts, clothing, cultural practices and taboos. Hanchey and Francis (1979) also developed a similar handbook for social workers practicing in Mauritania. From these three pieces of evidence, it is plausible to claim that a language handbook would be useful for internationally trained nurses to be good communicators.

Chapter 3

3.0 Project Aims and Objectives

3.1 Aim

To enhance communication for nursing recruits whose first language is not English, by introducing a language companion handbook. This will be achieved through the following objectives

3.2 Project objectives

• To reduce cases of treatment and diagnosis communication errors attributable to language barrier among recruit nurses by 25% within the first 12 months of implementation from the current 25 cases (per year) of errors attributable to language barrier in the proposed NHS Trust.
• To reduce patients’ exposure to the risk of adverse events (by 20-30%) attributable to ineffective conveyance of medical information by non-English speaking recruit nurses within the first 12 months of implementation, from the current 20 cases per year.
• To increase patient’s compliance with medical treatment by 20-30% through effective communication between non-English speaking recruit nurses and patients within the first 12 months of implementation, compared to the current 65% compliance rate

Chapter 4

4.0 Project Plan and Milestones

4.1 Initiation and planning activities

4.1.1 Executive leadership

To effectively implement the proposed project, the change agent will need to get approval and buy-in from the Trust’s leadership. As suggested by Radujković & Sjekavica (2017), getting an endorsement from the hospital’s leadership will ensure that the project runs smoothly and launch it more quickly. Furthermore, considering that the Trust’s leadership might be distracted by other projects (especially the COVID-19 vaccination programs) it will also be important to give them enough time to give their input. Therefore, the following action plans will be executed to get executive leadership’s buy-in:

First, the project manager will get the hospital leadership’s idea of a successful project i.e. what they would consider a successful implementation of the proposed handbook and compare it with the project’s own ideas of success. The project manager will then reconcile these two ideas to ensure a management buy-in. The next process in getting the management buy-in is getting their budgetary approval after receiving the project costings. Furthermore, this stage of the project plan will also include determining the best timing for the launch of the handbook – considering the various events and initiatives yet to be launched by the Trust’s leadership. More importantly this stage of the implementation process will seek clarification from the leadership about any significant policy considerations to be made by the handbook, any strategic communications that the leadership might require before launching the handbook and identifying the overall leadership’s involvement in the entire project management process (Ika et al, 2020). To facilitate an easier approval by the leadership, the following SWOT analysis highlights the internal and external factors that may facilitate or hinder the project implementation:

Gürel and Tat (2017) one of the most popular tools for analysing project feasibility is SWOT (strengths, weaknesses, opportunities and threats), which places strengths and opportunities side by side, weaknesses and threats – so that project managers can use the strengths and opportunities to eliminate any weaknesses or threats against the successful completion of projects. Th following section highlight a SWOT analysis of the hypothetical NHS Trust with respect to its ability to implement the proposed project to introduce an English language handbook for internationally trained nurses.

Strengths

The hospital has established an effective clinical leadership model with clearly demarcated roles that would help in a systematic implementation of the proposed project. Through effective and well-coordinated leadership, according to Sabbaghi & Vaidyanathan (2004), it is easier to harness teamwork and promote optimum resource utilization leading to a successful implementation of the project. The other strength of the Trust is the availability of nurse performance metrics useful in monitoring the performance and delivery of plans, projects and strategies across the organization. This will ensure that all the KPIs of the project are assessed at board level to ascertain their progress and necessary resource adjustments are made to ensure project success (Helms & Nixon, 2012).

Weaknesses

The increase levels of emergency activities and occupancy caused by COVID-19 will impede the effectiveness of the proposed project. The current focus on COVID-19 patients and other related factors might inhibit a successful implementation of the project both from the financial and human resources perspectives. the Trust’s leadership might be too focused on COVID-19 related issue to pay attention to the proposed project. Similarly, the currently overwhelmed recruits might be too focused on attending to COVID-19 patients to learn how to be involved in the project. Related to overwhelmed hospital capacity is the issue of underlying financial constraints, which might impede an optimum implementation of the project.

Opportunities

Currently, the Trust has an opportunity to increase nurse involvement in the project since only a portion of the nurses are non-English speaking. Furthermore, the Trust has effective technological HRM systems to facilitate shift rescheduling. More importantly, the Trust recently received funding from the government to facilitate employee development (The Kings Fund), which can be used to fund the project.

Threats

Regardless of the funding opportunities from the government, the Trust still faces several emergency needs (occasioned by COVID-19) that might drain on the available funds and render the project financially impossible.

4.2 Project stakeholders and human resource

This step in the project planning process will include an identification of the people involved directly or indirectly in the project. Also termed as the people who directly or indirectly ‘own’ the project Ika et al (2020), the project stakeholders will span from the recruit nurses to top leadership in the target Trust. Here, the Trust’s leadership will be responsible for the overall ratification of the project as well as the roles identified in the ‘Executive Leadership’ section above. Within the stakeholder analysis matrix, the Trust leadership are considered high power less interested stakeholders. They are high power because without their ratification, the project cannot be rolled out within the Trust hospital. However, they are considered ‘low interest’ because they did not initiate the project, neither are they directly involved in the use of the proposed handbook. Nonetheless, the Trust’s leadership must be satisfied with the project (through the project proposal) to enable them to release the necessary funding.

On the other hand, the recruit nurses will be direct stakeholders because they are the population the proposed handbook will be designed for. They will be involved in different capacities at different stages of the project including the initial project implementation stage to conduct a needs assessment, and the final project stages to confirm the effectiveness of the handbook (Silvius 2017). The internationally educated nurses are considered ‘high power high interested’ stakeholders who must be fully engaged and satisfied. They are the target audience for the project and will be directly involved in using the handbook to improve their communication within the clinical care setting.

Meanwhile, the other direct stakeholders in this project will be the project team, consisting of the lead project manager (i.e. the author) and outsourced freelances who will be contracted to design and edit the proposed handbook. They are considered ‘low power high interested’ stakeholders who must be adequately aware of the project to ensure that all the challenges faced during the development and implementation of the proposed handbook is addressed. While they have little power as far as the project implementation is concerned, they are highly interested in the project because they want to see a practice improvement.

The other important stakeholders are the English-speaking nurses and the recruits’ colleagues who will be called upon to assist with the implementation of the project. Their role will be to provide any language assistance to the new recruits in case they encounter any problem with the handbook. They are considered low power, less interested stakeholders because they do not face any challenges with the English language and will not be required to use the proposed handbook. The project lead will only monitor them to see any opportunity for them to assist with the implementation of the handbook. The following stakeholder analysis matrix illustrates the level of interest by each stakeholder:

4.3 Legal considerations

This stage of the project planning process will be concerned with all the laws involved in handbook publication, including the UK’s copyright laws (e.g. The Copyright, Designs and Patents Act 1988). While the project manager will contract a freelancer to help with the design and publishing of the handbook, the project manager will familiarise with all the legal requirements of producing and using such a material in the care setting. In detail, the project manager will work with the Trust legal experts in identifying the specific kind of intellectual property the handbook will represent and how to communicate those rights to readers and other potential users. The legal experts will also advise on the items to consider when developing the content so that the handbook does not infringe on other author’s intellectual property rights. Such infringements may lead to costly and time-consuming litigations that might prove detrimental to the economic and public relations wellbeing of the Trust.

The other important legal consideration to be made is engaging with the Royal College of Nursing and the Nursing and Midwifery Council (NMC) to gain their approval for the handbook. Ideally, the project manager would like to ensure that all the content is in line with the practice guidelines (NMC, 2015). Furthermore, getting the NMC and RCN’s approval will add on to the credibility of the handbook, facilitating its acceptance by the internationally trained nurses.

4.4 Marketing and communication

Once the handbook has been produced, a marketing and communication strategy will be launched within the Trust hospital to sensitize all staffs about the book and why they should embrace it as part of the organizational practice materials. A lot of groundwork for marketing and communication will be done by the freelance designer, including writing and editing summaries of the handbook with a conversational tone. Similarly, the freelancers will help with developing the images, graphics, and other branding activities to support the handbook’s design. Because the handbook will be printed, this stage of the planning process will determine the timeline required to do all the designs.

The project manager will work with the freelancers to coordinate the launching and distribution of the handbook to all the recruits and identify other opportunities such as upcoming, events and newsletters that might provide an opportunity to notify the other practitioners about the handbook. As such, the following strategies will be used to launch the handbook and attract potential users towards it:

• Develop a launch notification for the new employee handbook and ask the target audience to sign up for either hard or soft copy versions of the handbook
• Develop an invitation template for future new recruits
• Develop an online reminder template to remind employees in case they handbook is complete and ready for distribution
• Develop a communication messaging for any future changes made on the handbook

Ideally, these communication strategies are meant to create an anticipation for the handbook.

4.5 Project milestones

4.5.1 Project foundation

The first item under this milestone will be to obtain the leadership’s approval for the project within the first week after the project conceptualization. The project foundation task will be completed by the project manager. The second item will be to identify and contract publishing freelancers, an activity that will be done by the project manager and completed within two weeks of the project conceptualization. The penultimate item in this milestone is to complete all the necessary legal and financial paperwork, including making the initial payments and commissioning the freelancers. This will be done within one month after the project conceptualization.

4.5.2 Content creation editing, review and approval

This will arguably be the lengthiest and most variable section of the entire project. Ideally, the timings under this milestone will be based on the project team’s current workload, motivation and the volume of changes to be made along the process. Nonetheless, the first item in this milestone is the creation of new and edited content. Here, several important features will be borrowed from the analysis of other hospital English books and existing (HEE) English language guidelines.

Design-wise, the printed copy will be 5.5” x 8.5” Booklet size. Furthermore, the printed handbook will contain a table of content, appendices and index to facilitate an easier location of content by the reader. However, the soft-copy version will not have the index. More importantly, the book will have a separate glossary apart from the ones included throughout the texts to enable a quicker and easier location of text.

That said, the handbook will contain real life and workplace situation dialogues with accompanying meanings and recordings for the hard and soft copy respectively. The freelance designers will be tasked to develop an easy to navigate, consistent, attractive and clearly organized handbook that will make it pleasant to use. Indeed, a self-help book needs to be attractive and pleasant especially for nurses who may feel stressed at work and may need assistance with colloquial language to communicate with patients and colleagues.

The handbook will also contain various medical prescription templates and forms that frequently appear in the context of British medical practice and conversation. These templates will draw from examples and exercises taken from real life practice situations. Nonetheless, the handbook will contain important nursing topics such as basic conversational skills in British English, descriptive terms, authentic language grammar points and dialogues based on the British hospital context. Because the handbook aims to address the issue of language barrier in the context of British hospitals, it will also be useful as a guiding text for instructors and supervisors as a nursing reference material in the hospital. Appendix 3 contains all the 8 chapters from the proposed handbook and justifications for the inclusion of such content.

The next item under this milestone is a request for feedback from all the stakeholders (i.e. leadership, recruit nurses and all the other nurses in the target hospital). A further review will be requested from the Trust’s legal team to ensure the published version complies with all the UK publishing legal requirements. The previous steps will be repeated until a final approval is obtain from all the stakeholders. We expect all the activities in the content creation milestone to take 3 -4 weeks.

4.5.3 Preparation for distribution

This stage will likely involve the printing company. The task will take between two to three days depending on the workload the company might be having. Nevertheless, the activities in this milestone will begin after determining the audience for the handbook to ensure they can successfully access the handbook after the launch. For the soft-copy version of the handbook, the project team will coordinate with the HR department to synchronise with the employee list, set up a single line sign-up for the handbook.

The other item in this milestone is to identify whether the launch mail is well messaged and that it will be successfully delivered. All the software useful in delivering the launch mail will also be updated at this stage. These milestone activities will be completed within two weeks – tasks to be completed by the project team in collaboration with the IT department.

4.5.4 Content design and implementation

This milestone will mainly involve the project team working as the marketing and communication lead for the project. the first item involved in this milestone include sending branding and content guidelines to the freelance designer and reviewing the resultant design with the project team. Moreover, this milestone will involve circulating the handbook cover page design to the leadership for final approval as well as repeating any of the previous steps if necessary. At the end of this milestone, the final handbook should be ready for the launch.

In preparation for the launch, the project team will send the first reminder email one week to the launch while the second email reminder to all the staffs will be sent on the launch date while a couple of mails will be sent a few days after the due date to remind those who might have missed out on getting their copies. Appendix 5 illustrates a Gantt chart for achieving the project milestones.

4.5.5 Risk Management

The main risk that might hinder a successful implementation of the handbook project. for example, the increase levels of emergency activities and occupancy caused by COVID-19 might impede the effectiveness of the proposed project. The current focus on COVID-19 patients and other related factors might inhibit a successful implementation of the project both from the financial and human resources perspectives. For instance, budget constraints and lack of enough personnel to include in the team might hinder a successful implementation of the project To manage this risk, the project team intends to begin an early preparation for the project and get an early approval from the Trust’s management so that it becomes part of the planned cost areas. This will ensure that regardless of the COVID-19 activities currently undergoing, the project does not get side-lined.

The project manager will maintain a risk log to ensure all apparent risks are identified and managed early enough. According to Willumsen et al (2019), a risk log can be a simple way of identifying risk issues, record them and evaluate them regarding the potential consequences they might have on the project. The risk log typically records the risks on a scale of low, medium and high, then the factors are combined to determine the overall risk. Besides recording the risks in a risk log, an action plan will be developed to mitigate the eminent risks – identifying who and when those risks are mitigated. The following activity log illustrates some of the risks that the project is likely to encounter. The potential impact of risk is rated between 1-5, whereby 1=highly unlikely, 2=unlikely, 3=possible, 4=likely, 5=highly likely.

The potential impact if often populated by a score rating between 1-5, whereby 1=low, 2=minor, 3=moderate, 4=major and 5=serious

4.6 Project leadership and team management

The project team will consist of the project lead, one publishing freelancer and the Trust hopsital’s human resource manager. The project lead will be responsible for the overall implementation of the project, providing leadership and for the other team members. The publishing freelance will be responsible for all the publishing technicalities involved in developing and publishing the handbook. He or she might need the help of other freelancers, whom he/she will contact based on the needs. Lastly, the Trust hospital human resource manager will be responsible for organizing and coordinating any in-house resources needed for the successful implementation of the project. This will include coordinating with the Trust hospital’s leadership to endorse the project and providing any necessary approvals during the project implementation. Nonetheless, the three individuals will work as a team in making various decisions pertaining to the project.

To effectively implement the project, the project manager will need to develop and implement various leadership skills while working with the project team. According to Pritchard (2020), project managers then need to apply their leadership skills by inspiring and motivating their teams to achieve the project objectives and complete the project milestones within the specified time.

In the proposed project, the project manager will develop and implement essential leadership skills such as listening, negotiating, communicating, team building and influencing skills that will help in motivating the project team towards achieving the project objectives. Regarding motivating and inspiring, the project manager will develop and endeavour to communicate the project goals so that the team can be enthusiastic to work on the vision (Floris et al 2020). Furthermore, the project manager intends to encourage the project teams to accomplish the project milestones with self-satisfaction.

The other leadership item that will be of great interest to the project manager is team building. According to Ekechukwu & Lammers (2020), the leadership role of team building entails giving the team members the necessary support and resources to help each other. Therefore, in the proposed project, the project manager will facilitate the team members to cooperate towards achieving the project goals.

This implies that the project lead will adopt democratic leadership style by forging consensus through collective participation. Therefore, the project lead will always ask the question ‘what do you know’ when brainstorming over a decision item; and adopt a collaborative team leadership that is characterised by effective communication. The aim of adopting a collaborative leadership style will be to build a buy-in from all the stakeholders.

The other effective leadership role that the project manager will play is to communicate and negotiate with the team members towards helping one another, considering that all members of the team have common goals (Pritchard, 2020). Negotiation is especially important in ensuring that the team members, as well as other stakeholders reach a compromise before making any collective decision. Against this backdrop, the project manager will create an environment where team members can be open and honest in communicating with each other and ensuring that all the stakeholders understand each other’s’ communication style as they communicate freely with project stakeholders.

Lastly, the project manager will be keen on listening and influencing. In doing so, as recommended by Ekechukwu & Lammers (2020), the project manager will consider and understand each team members’ perspective before making any decision that will affect the entire team. Lastly, through negotiation and influencing, the project manager will get the project team and other stakeholders to cooperate and collaborate with each other towards achieving the project goals.

4.7 Ethical considerations

Considering the project objectives, there are several ethical considerations that will be made in the proposed project to ensure that it remains within the ethical principles of non-maleficence, beneficence, autonomy, informed consent, confidentiality and justice. For example, upon producing the books with financial assistance from the proposed funders, the project team will not accept any payments or any other form of compensation that do not conform to the NHS Trust regulations and code of conduct. This is aimed at ensuring that the project team do not have any unfair advantage for themselves as project initiators – abiding by the non-maleficence principle. Regarding the beneficence principle, improved communication will benefit both patients and nurses by reducing risks of adverse events, reducing stress for nurses and increasing patient satisfaction

During the content development and editing, the project team will ensure that any research or similar activities are conducted in a manner that is unbiased, fair and appropriate, and will maintain accurate, appropriate and complete records of such research activities for referencing purposes. Related to this, the project manager will ensure that during the content development, the team will maintain and respect the intellectual property and rights of others, by recognizing the content contributions from other authors.

More importantly, the project manager will strive to enhance the project team’s professional capabilities, knowledge and skills; and will truthfully and accurately acknowledge their professional contribution to the project. that said, the project manager will ensure that the handbook’s content resonate and adhere to the NMC and RCN’s professional guidelines of practice.

Chapter 5

5.0 Financial costs and Rationale for funding

5.1 Health benefit analysis

Miscommunication attributable to language barrier is life threatening. The increasing number of foreign-trained staff and migrant patients means that there is likely to be communication errors between healthcare nurses and the patients when they interact – because they both speak English as a second language. This calls for an intervention initiative that facilitates easier communication between non-English speaking nurses and patients across different care settings. The growing number of patients and practitioners who do not speak English as their first language use the UK health system and therefore any language discrepancy that might cause miscommunication must be mitigated through various approaches (e.g. through translators) that might prove to be medically inefficient and financially unaffordable.

Furthermore, the language barrier created by such situations and medically significant communication errors may lead to psychological stress among patients who are already anxious about their health situations. Moreover, the language barrier might not only act as a barrier to equitable healthcare. Therefore, it is critical for both non-English speaking nurses and patients to understand the language that is frequently used in the diagnosis and treatment. This presents a proper justification for the proposed handbook, confirming that the project is worth the human and financial resources that might need to be invested. By using the proposed handbook as a language guide during various care settings, recruit nurses will be able to mitigate or minimize cases of miscommunication that might lead to medical adverse events, patient dissatisfaction and even lawsuits. Therefore, from a healthcare perspective, the project is worth investing in.

5.2 Cost-benefit analysis

Communication breakdowns associated with language barrier can lead to various healthcare malpractices that are detrimental to the health and well-being of patients. According to Medlin 2009, poor communication abilities of internationally trained nurses can lead to the miscommunication of important information about patient condition or symptom, or poor documentation of patient details. These issues may lead to poor decisions being made or treatment delays when the severity of the patient’s condition is misunderstood.

Apart from risking patient safety, poor communication by internationally trained nurses my cause long delays of treatment within the various stages of treatment within the hospital (Allan et al, 2009). Many of these delays often result from poor communication between the staff as well as poor communication between the staff and patients. Inability to effectively speak in English can cause a communication barrier that affects the patient throughput, increased hospital stays, and consequently poor patient satisfaction.

However, with the proposed handbook, clinicians will not only be able to effectively communicate among themselves but also effectively communicate with patients within the care setting. The handbook will help the nurses to carefully understand what patients tell them, verbally and non-verbally, and gather information, communicate important medical advice and reassure patients. Also, because most patients do not have an extensive understanding of medical language, the handbook will help internationally trained nurses to understand any piece of communication between them and the patients.

The proposed handbook will also address the issue of poor communication between the clinicians and patients which may lead to miscommunication and misunderstandings about medical instructions, which may lead to poor hospital outcomes, patient harms and hospital readmissions. It will also help in avoiding other legal issues such as inadequate informed consent that may lead to malpractice litigations.

While the whole process of content development was conducted by the project manager, a publishing freelancer will be contracted to help with all the designs and edits. A total of 40 handbooks will be printed, enough for all the 36 nurses in the Trust Hospital, leaving some spare copies for recruits. That said, all the cost items pertaining to design and edits, promotion, author tools and formatting of one handbook are as follows:

Every book, regardless of its physical size, requires a professional cover, which acts as the first impression to any reader. Therefore, it is worth investing in a professionally designed cover that will not only become appealing to readers but also ensuring that the handbook does not become a failure. Similarly, regardless of the level of care and perfection the handbook will be produced, the final version will still need some professional editing before finally releasing it for use. That said, it is also important to format the book especially for the paperback version. While most designers include formatting as part of the cover page design costs, others might charge it separately. Therefore, it is important to allocate some finances for formatting. The promotion costs are apportioned for each handbook.

Even if the handbook is targeted for recruit nurse just within the proposed Trust hospital, some finances will need to be set aside for launching and subsequent marketing activities aimed at making all the staffs aware of its existence. Therefore, some money will be needed for promotion. Lastly, the author will need some money to access textbooks and guide sites for reference resources. A total of 36 books will be printed, at the cost of £100 per copy, all published in the English language. Because the handbook will have a user guide embedded on the cover page, no training will be needed for nurses on how to use it.

5.3 Project Funding

With the current COVID-19 situation and the much-needed funds to facilitate programs related to it, it might be challenging to internally or externally acquire funds to facilitate the proposed handbook project unless the project team a presents a good case for the project that convinces the funders. Nonetheless, the project team believes that the potential impact of the proposed project to the delivery of quality healthcare is reason enough to acquire funding from strategic sources such as the Imperial Health Charity.

Briefly, The Imperial Health Charity gives grants to small projects that can make a difference in patients’ stays in the hospital (Imperial Charity, 2020). The Charity has a Small Grant Program that funds bright ideas to support staffs in improving patient care experience across Trust hospitals. According to (Imperial Charity, 2020), Trust staff can apply for funding of up to 10,000 pounds to finance projects that improve patient care in the wards or towards staffs’ amenities. The proposed project is believed to be well-organized enough to convince the Imperial Health Charity for a grant. Other possible external sources of funding that the project will seek funding from include the welcome.org (10,000 pounds), and bartscharity.org.uk (10,000 pounds).

Chapter 6

6.0 Project evaluation plan

This section describes an evaluation strategy for the project i.e. the extent to which the project will achieve its overall aims and objectives. It identifies the goals set by the project at different stages and how the evaluation data will be collected and analysed. The chapter will highlight the project evaluation plan in stages namely: clarifying the project objectives, developing project evaluation questions, developing project evaluation methods, setting project evaluation timeline, setting up interim and final progress reporting mechanisms, as well as the methods of disseminating the findings to project stakeholders.

6.1 Clarifying project objectives

The aim of the proposed project is to create a professional language guide handbook that will be useful to non-English speaking nursing recruits during their interaction with patients and other hospital staffs. Through the handbook, the project manager aims to reduce cases of treatment and diagnosis communication attributable to language barrier among recruit nurses, reduce patients’ exposure to the risk of adverse events attributable to miscommunication by non-English speaking nursing recruits, to promote patients’ exposure to the risk of adverse events attributable to ineffective conveyance of medical information by non-English speaking recruit nurses, to equip non-English speaking nurses with different ways of describing specific medical terms to patients, and to present a reference material for English speaking nurses acting as guide to prepare nursing recruits for work within the clinical care setting.

6.2 Handbook evaluation questions

While there are numerous evaluation tools for handbooks and other kinds of textbook content, a common option often used by publishers the Textbook Evaluation Checklist developed by Robinett (1978, pp251). The questions range from 8-10 evaluating various aspects of the handbook depending on the book’s objective. The following are the evaluation questions borrowed from Robinett (1978) that will be used to evaluate the proposed handbook:

• Will this textbook help meet your medical language translation needs?
• Does the book fit the background of your practice?
• Does the book’s theoretical background fit the institution’s philosophy?
• Does the book integrate the four communication modes of reading, writing, speaking and listening?
• How would you assess the handbook’s quality?
• How well is the book’s content sequenced?
• Is the book’s vocabulary effectively and relevantly presented?
• Is it British-style English dialect?
• How useful and the accompanying materials?

These questions are mainly based on the international English language teaching standards formulated by the tesol International Association (Tesol, 2021).

6.3 Project Evaluation methods

The study will therefore rely on questionnaire surveys to gather data from all the non-English speaking recruits who will sign up for the handbook. The questionnaires will adopt the above-mentioned questions. The questions will be closed -ended to facilitate the acquisition of objective response that can statistically be analysed. All the evaluation questionnaires will be distributed a few days (3 days) after the launch and four weeks after the full distribution. This will enable the gathering of information regarding the first impression of the handbook and how useful or useless it has proved to be one week after use. The survey responses will then be statistically analysed by the project manager and action taken by the project team based on the feedback. The data analysis process will be conducted manually Microsoft excel. The results of the survey will then me published and reported to all project stakeholders, including the funders. Nonetheless, to evaluate the proposed project objectives, the project will rely on the hospital’s annual reports and measure them against the desired outcomes.

Chapter 7

7.0 Project Mainstreaming

Ultimately, the proposed handbook will permanently be adopted as one of the hospital’s reference materials after evaluation and ascertainment of its effectiveness. Each nurse recruit will be required to use the book a s practice companion to avoid miscommunication within the nursing care setting. It will be part of the hospital’s tradition that each non-English speaking nurse must carry the handbook when attending to all patients under their care.

By adapting the handbook as part of the hospital’s reference materials, the hospital shall promote the delivery of quality care, patient satisfaction and general positive care outcomes. While the first batch of the handbook will be given for free, the subsequent batches (if successful) will be given to new recruits at a fee that caters for the printing. However, in case it becomes a challenge for the nurses to pay for the handbook, the project team will resort to the soft-copy version, which is cheaper to produce. Similarly, the soft copy version, because it is more appropriate and easier to carry into the wards, will be marketed to other Trusts and ultimately in the entire UK.

This workbook will give facilitate the understanding of English language for nurse recruits speaking English as their second language. Proper understanding of English in a workplace context is important in facilitating adequate communication and eliminating the negative impact of inadequate communication such as increased psychological stress to the patient, significant medical communication misunderstanding and errors that might be detrimental to the patients’ health and well-being. Furthermore, the handbook would aim to facilitate the nurses’ understanding the cultural elements of interaction to prevent serious health risks that might arise in communication discrepant interactions.

While some scholars claim that professional medical interpreters can be an effective strategy for situations of language discrepancy during the interaction between clinicians and patients, earlier research by Flores (2005) and Ngo-Metzger et al (2007) indicate that professional medical translators are seldom used due to high costs and logistical challenges that they present. In some cases, bilingual family members have been used as interpreters and yielded effective results (Flores et al 2012). However, the use of bilingual family members to communicate with the patient within the medical care setting has been associated with more medical errors (Karliner, 2007). As a language guide, the handbook will have a better way of effectively engaging with their patents as they seek to influence their patients’ health and well-being thereby delivering a patient-centred care while evading all the shortcomings associated with professional medical interpreters and bilingual family members. Similarly, the handbook will facilitate patient-centred care by acting as a language guide for the nurses.

Chapter 8

8.0 Reflexivity

This section of the project proposal offers my reflection on the general outlook of the project and its implication on nursing practice. In the entire reflection, I will analyse my learning and deep understanding of the proposed project, evaluate what I have gained in understanding and development while acknowledging any complexities arising from the project. I adopted the DIEP (describe, interpret, evaluate, plan) reflection model for this reflection.

The most interesting thing I have learned from the entire project formulation process is that technology has brought a significant change and new opportunities of how we can identify and manage scientific evidence. Through just a desktop research, I could have access to published research and articles from numerous journal articles to help me develop an entire project proposal. However, I have also realised that despite having all the options from where to source research evidence and other reference material, finding the right information can be challenging. But, with continuous practice and on how to identify, retrieve, synthesize and apply the evidence, one can become a good evidence-based practice expert.

This realization may have important relevance for two significant reasons. First, it implies that the key to developing a good evidence-based project is identifying and clearly defining the research aim and objectives. With clear and concise objectives, I can begin to search for evidence.

Secondly, the key to developing a good evidence-based project proposal is to appropriately synthesize the retrieved evidence by identifying the strongest and highest quality of evidence from each of the articles. Having realised that, I intend to develop synthesizing and appraising skills by participating in various journal clubs or engaging in projects that offer an opportunity to discuss journal articles.

The other interesting thing I have learned from this proposal is the need to understand the process groups, their relevance and roles. Ideally, the process groups refer to the steps through which the project progress from initiation to completion. These process groups majorly entail five steps of the project management namely project initiation, project planning, project initiation, project controlling and closing phase. To this end, I have understood that these five process groups represent the project life cycle, each representing a set of important activities. the following are some of the items that I have learned about these five process groups:

The project initiation phase

I have learned that this is the phase that triggers all the other phases in the process groups. It ensures that the project can begin working after the primary stages of the project such as preparation of all the necessary documentation.

The project planning

Based on my understanding of the entire project progression, this phase ensures that all the necessary action plans are predetermined for a smooth project execution. I realise that without a proper project planning phase, the entire project can crumble down due to lack of an elaborate plan. Therefore, the project planning forms the fundamental basis of the entire project and charts the direction to which the project should take from initiation to completion.

Implementation stage

One thing I have realised is that this phase entails the delivery of the planned work. It is where all the project plans come into action based on the budget and schedules.

Project monitoring and evaluation

Based on my understanding, I believe that this phase of the project interacts with all the other phases of the project to ensure that each phase fulfils its part in achieving the overall project objectives. More importantly, I have realised that this phase is guided by the project planning phase because it evaluates whether everything has been carried out according to the plans. The following figure illustrates my comprehension of the entire project framework:

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Appendix 2: critical appraisal Results

Author	Study Aims	Research methods	Target population	Findings	Conclusion
Ali & Watson (2018)	The aim of this study was to explore nurses’ perspectives of language barriers and their impact on the provision of care to patients with limited English proficiency from diverse linguistic background.	A qualitative descriptive approach was used. Using individual interviews and focus group discussions, data were collected from 59 nurses working in tertiary care hospitals in England. A thematic analysis was used to analyse the data.	Tertiary hospital nurses	Three themes: ‘multi-ethnicities and language barriers’; ‘the impact of language barriers’; and ‘communicating via interpreters’, were identified. Communication was identified as the most important aspect of care provision and an essential component of a nurse’s professional role regardless of the clinical area or specialty. Language barriers were identified as the biggest obstacles in providing adequate, appropriate, effective and timely care to patients with limited English proficiency. Use of professional interpreters was considered useful; however, the limitations associated with use of interpretation service, including arrangement difficulties, availability and accessibility of interpreters, convenience, confidentiality and privacy related issues and impact on the patient’s comfort were mentioned.	Language barriers, in any country or setting, can negatively affect nurses’ ability to communicate effectively with their patients and thereby have a negative impact on the provision of appropriate, timely, safe and effective care to meet patient’s needs.
Kawi & Xu (2009)	This integrative review identifies facilitators and barriers encountered by internationally trained nurses as they adjust to foreign health-care environments.	Based on Cooper’s Five Stages of Integrative Research Review, a systematic search of eight electronic databases was conducted, combined with hand and ancestral searches. Two authors independently reviewed each qualified study for relevance and significance. Subsequently, facilitators and barriers were identified and categorized into themes and subthemes.	Clinical nurses	Twenty-nine studies conducted in Australia, Canada, Iceland, UK and the USA were included in this review. Findings indicated that positive work ethic, persistence, psychosocial and logistical support, learning to be assertive and continuous learning facilitated the adjustment of INs to their new workplace environments. In contrast, language and communication difficulties, differences in culture-based lifeways, lack of support, inadequate orientation, differences in nursing practice and inequality were barriers.	The review findings provide the basis for the development and testing of an evidence-informed programme to facilitate the successful adjustment of INs to their new work environments.
Goodman et al (2008)	To compare the willingness to study or work abroad and the perceived barriers and benefits of doing so, amongst students in England and Spain.	Third year nursing students completed a 15 item questionnaire on work and study abroad.	Nursing students	Spanish students were younger than UK students, had fewer family commitments, and better language skills. There was little difference between Spanish and UK students in wanting to study abroad, UK students named English speaking countries as likely destinations. Spanish students named Italy; the UK and USA were also popular. Perceived barriers for UK students were funding, family, and language. Family commitments were not a major problem for Spanish students. Spanish were more likely than English students to see language as a problem.	UK and Spanish Nursing students are equally enthusiastic about studying or working abroad but UK students have limited language skills, are less able to access Socrates funding for European destinations, and given their age and family commitments, funding is a barrier for ‘non-Socrates’ destinations.
Newton et al (2012)	To comprehensively review recent literature related to the migration and transitioning experiences of internationally educated nurses (IENs).	A database search of CINAHL, Medline, Scopus and Web of Science, and a hand-search of key nursing journals produced 239 combined hits, with 21 articles meeting the inclusion criteria.	Internationally educated nurses	Five common themes were extracted and synthesized including: (1) reasons for and challenges with immigration, (2) cultural displacement, (3) credentialing difficulties and _deskilling_, (4) discriminatory experiences and (5) strategies of IENs which smoothed transition.	Although major reasons for migration are related to improved income and professional stature, these have overwhelmingly shown to erode upon relocation. Cultural displacement appears to largely stem from communication and language differences, feelings of being an outsider and differences in nursing practice. The deskilling process and discrimination are also key players which hinder transition and demoralize many IENs.
Edgecombe et al, 2013	to identify factors that may impact international nursing students' clinical learning with a view to initiating further research into these students' attributes and how to work with these to enhance the students' clinical learning	Literature review	international nursing students	Issues commonly cited as affecting international students are socialisation, communication, culture, relationships, and unmet expectations and aspirations. International student attributes tend to be included by implication rather than as part of the literature's focus.	The review concludes that recognition and valuing of international nursing students' attributes in academic and clinical contexts are needed to facilitate effective strategies to support their clinical practice in new environments
Allan and Larsen	To study English language skills requirements for internationally educated nurses working in the care industry and hostheyact as barriers to registration	Literature review	internationally educated nurses	Providing internationally educated nurses currently working as healthcare assistants, and who wish to register as qualified nurses, with supplementary language skills and cultural competency training, would appear to be a simple, low-cost, and common sense way of enabling them to meet the language requirements for registration/transfer courses in their host countries	There is a need for more research on the career trajectories of internationally educated nurses, particularly those who are employed as unqualified healthcare assistants in their host countries, on the language skills/cultural competency support they receive, and its outcomes
Likupe (2013)	This paper explores Black African nurses' experiences of equal opportunities, racism, and discrimination in four NHS trusts in northeastern England	Survey	nurses from sub‐Saharan countries	This study suggests that Black African nurses experienced discrimination and racism from White colleagues and other overseas nurses, managers, and patients and their relatives as well as lack of opportunities in their workplaces	Although much progress has been made in valuing and embracing diversity in the NHS, this article highlights areas in which more work is required.
O’Neill (2011)	Understanding the journey these nurses experience as language learners and professionals highlights ways in which they could be better supported in their adaptation and integration into the Australian workforce.	By means of semi-structured interviews, the nurses' narratives were explored and documented. Thematic analysis was used to interpret their experiences as they move from the English language classroom to the clinical setting.	There were six female participants and four male. Five participants were Indian, four Chinese, and one, Nepalese.	In exploring their experiences, themes of identity and belonging, safety and competence and adapting to new roles and ways of communicating are revealed. In their own words, these nurses reveal the challenges they face as they concurrently manage the roles of language learners and professionals.	The journey from language classroom to clinical setting is a process that goes beyond the notions of language proficiency; these nurses are constructing new cultural and professional identities. Bridging the gap between preparation and practice involves making complex linguistic, cultural and social choices, often unsupported. Understanding their experience will better inform approaches to preparation and facilitate their adaptation and integration.
Crawford & Candlin (2012)	To identify the language needs of culturally and linguistically diverse students, and evaluate the English language support programme to develop appropriate strategies and assist academic progression and clinical communication skills.	An action research approach was adopted and this paper reports findings from the first round of semi-structured individual interviews. The strategies suggested by the participants will subsequently be implemented and evaluated during the first cycle of action research.	Eight second and third year students who have a primary language other than English.	Four strategies emerged from initial student interviews. The English language support programme to be conducted during semester breaks, ongoing focus on reading and writing but also to include some International English Language Testing System exam strategies and practice, increase the use of nursing specific language and context in the English language support programme, and informing or reminding lecturers of the impact of their lecture delivery style on learning for students from diverse backgrounds.	Themes emerging from the initial round of interviews inform both the implementation of the English language support programme and teacher delivery. It is hoped that implementing these strategies will support the English language development of nurses from diverse backgrounds.
Kozelka (1980)	A book of language and cultural material for teachersand students of Ewe presents vocabulary lists and samples of Ewelanguage in various contexts, including letters, essays, andnewspaper articles	Literature review	Teachers and students of Ewe presents vocabulary	N/A	N/A

Appendix 3: The proposed handbook’s content by chapters

Chapter	Content
Chapter 1: Body Systems	Systems: neurological, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, and integumentary. Sample “normal” nursing assessment within each category. Sample greetings and expressions for initial patient contact and assessment. Word roots for deciphering meaning of medical terms. Names of disorders and conditions. Translations of conditions and procedures into lay terms. Reference page numbers for definitions, visuals, and discussion. The language of nursing assessment, documentation, care plans, and patient.
Chapter 2: Patient Care	Conversational language and colloquial translations of medical terms and phrases. Activities of daily living (ADLs), which include exercise, eating, and bathing. British and terms. Terms used to describe intravenous sites and devices. Expressions for describing pain and feelings. Reference pages in the Oxford Picture Dictionary and Taber’s for definitions, visual aids, and discussion upon acquiring copyright material.
Chapter 3: Weights and Measures	Measurements and conversions of volume, temperature, and length. Intravenous medication flow rate calculations. Hemodynamic formulas. Reference pages in Taber’s and the Oxford Picture Dictionary provide visual aids upon acquiring copyright material.
Chapter 4: Glossary of Terms	Two hundred forty-six terms that are frequently spoken, heard, read or written in the course of work. Alphabetical listing. Some cross-references. Most frequently used terms in acute care settings.
Chapter 5: Basic Life Support	The language of a Cardiopulmonary Resuscitation (CPR) class. Elements of the lesson plan are a listing of goals, language functions, objectives, possible materials to use, vocabulary and grammar. Format following an Effective Instructional Sequence (EIS). The A-B-C-D sequence of CPR. Sample communicative task using a transcript of a 911 call. Sample multiple choice exam questions.
Chapter 6: Medical Transcription Templates	Sample document formats that hold key information. Outlines for a history and physical, radiology report, operative report, physician’s progress note, and a patient discharge summary. A listing of items with brief narrative phrases.
Chapter 7: Nursing Diagnosis	(P_E_S_) format: problem, etiology, signs and symptoms. Steps in the nursing process: assessment, nursing diagnosis, planning, implementation, and evaluation. A list of helpful websites.
Chapter 8: Recommended Books and Websites	A list of 20 books and ten websites that the author personally finds helpful.

Appendix 4: a copy of certificate of ethical approval

Appendix 5: CASP Tool

Article	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10	Score
Ali & Watson (2018)	1	1	0.5	1	1	0.5	1	0.5	1	1	8.5
Kawi & Xu (2009)	1	1	1	0.5	0.5	0.5	1	1	1	1	8.5
Goodman et al (2008)	1	1	1	1	1	1	1	1	1	0.5	9.5
Newton et al (2012)	1	1	0	1	1	0.5	1	1	1	0.5	8
Medlin (2009)	1	1	0.5	1	1	0.5	1	1	1	1	9
Edgecombe et al, 2013	1	1	0.5	1	1	0	1	1	1	1	8.5
Allan and Larsen (2003)	1	1	0.5	1	0.5	0	1	1	1	1	8
Likupe (2013)	1	1	0.5	0.5	1	0.5	1	1	1	1	8.5
O’Neill (2011)	1	1	0.5	0.5	1	0	1	1	1	0.5	7.5
Crawford & Candlin (2012)	1	1	1	1	1	0.5	0.5	0.5	1	1	8.5
Kozelka (1980)	1	1	1	0.5	1	0.5	0.5	0.5	1	1	8
Hanchey and Francis (1979)	1	1	0	1	1	0.5	0.5	0.5	0.5	1	7
Medlin (2009)	1	1	0	1	1	0.5	0.5	0.5	0.5	1	7

The CASP Grading system

Yes- 1 Point; Unsure- 0.5 Point; and No- 0 Point
High quality paper- between 9 and 10
Moderate quality paper- between 7.5 and 9
Low quality paper- Less than 7.5
Exclude: Less than 6

Appendix 5: Project Gantt Chart

Period (Weeks)	Activity
1 week	Project foundation Obtain the leadership’s approval Identify and contract publishing freelancers Complete all the necessary legal and financial paperwork Make initial payments and commission the freelancers
6 Weeks	Content creation editing, review, and approval Creation of new content Editing Cover page design Copyright approval Tentative copy printing Gain stakeholder approval Final copy printing
2 Weeks	Preparation and distribution Coordinate with the HR department to synchronize with the employee list Set up a single line sign-up for the handbook Identify whether the launch mail is well messaged and that it will be successfully delivered Update all the useful software