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Business English, Professional English, Legal English, Medical English, Academic English etc.
Online peer-reviewed Journal for Teachers

English for Specific Purposes World (ESP World)

English for Specific Purposes World

ISSN 1682-3257

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English for Specific Purposes: ESL and the Nursing Assistant

Matthew Currier

Kingsborough Community College


Between 2000 and 2030, the number of Americans over 85 is expected to double (Scanlon, 2001). As a result, nursing homes and home health organizations are being challenged to meet the caregiving needs of their clients. A large portion of this caregiving burden has, and continues, to fall on nursing assistants who are largely responsible for helping nursing home residents with daily activities. Not surprisingly, the profession of nursing assistant is identified as having strong growth prospects (U.S. Department of Labor [USDL], 2004a). The labor demand for nursing assistants, in addition to the nursing homes need to be cost effective, has caused many nursing homes to turn to immigrants as a cheap and renewable source of labor. This labor situation is potentially problematic when English is not a nursing assistants first language, which in turn could affect quality of care. Thus, it is important to develop a better understanding of the issues involved when nursing assistants are non-native English speakers (NNES). By exploring relevant research and integrating information gained from interviews with professionals in ESL (English as a Second Language) and nursing, it is hoped a clearer picture will emerge of the needs and challenges of NNES nursing assistants.

Review of the Literature

Previous research into how ESL and nursing intersect has focused largely on either foreign-born nurses working in the United States, or ESL learners training to become nurses (e.g., Bosher & Smalkoski, 2002; Guhde, 2003; Gay, Edgil, & Stullenberger, 1993). Few studies have directly investigated the specific challenges that face ESL nursing assistants as they train, or work as direct-care professionals in the nursing home setting.

Characteristics of Nursing Assistants

Nursing assistants are sometimes known as nursing aides, nursing assistants, orderlies, and Certified Nursing Assistants (CNAs). According to the USDL (2004a), the profession is both physically demanding and stressful; it involves helping residents in and out of bed, lifting residents onto toilet seats, bathing residents, making beds, taking temperatures, feeding residents, dressing residents, and record-keeping. Nursing assistants also report changes in residents conditions to nursing or medical staff.

Nursing assistants are largely women (National Clearinghouse on the Direct Care Workforce [NCDCW], 2004). The average age of a nursing assistant is thirty-seven. Half are white; one-third are African-American, and the rest are Hispanic and other ethnicities. Approximately half have high school degrees or GED equivalencies. Approximately one-quarter work without health insurance and 11.1% are reported to be non-native born workers (U.S. Department of Health and Human Services [USDHHS], 2002).

Working Condition and Turnover

Many nursing homes have high staff turnover rates, which in turn can affect quality of care (Anderson, Issel, & McDaniel, 2003; Atchison, 1998; Burnfeind & OConnor, 1992). Turnover is particularly high among nursing assistants and is seen in the fact that many facilities report turnover rates of 100%, and in some cases, 200%. An often cited factor in the high turnover rate of nursing assistants is poor pay. According to the USDL (2004b), the median wage of a direct care worker was $10.09. Low pay, especially when combined with high job stress, is a major factor in contributing to nursing assistant turnover. The effect of these two factors is evident in the following excerpt from an online forum dedicated to nursing assistant issues,

We were constantly on the go, and always had something to do, but this Water Buffalo with the name tag, and the power suit consisting of about 40 yards of polyester, always seemed to make it a point to be waddling around during breakfast, lunch and dinner, and she kept "Charmaigne" aka Nurse Florence Nightingale, LPN/DON on a tight leash. So they both seemed to love to make sure that for 9 measly bucks an hour, that we all did about $25/hr of work for 12 hours. Even her GD maintenance man got into it, he was brainwashed as well, and loved to remind us that the little pagers they assigned us were "350 dollars each" and we were reminded of this on a daily basis. I almost told them once, that for what they charged the patients, monthly to live there, that we should have no problems getting replacements. But as usual, I held my tongue. The bureaucracy became too much for my stomach. The poor, uneducated Guatemalans, they had slaving there had no choice because they needed a job, and compared to what they made in Central America, 9 bucks was big $$$.(Anonymous, 2005)

In an attempt to alleviate the turnover problem, many states have initiated programs to articulate beneficial long-term care policies (e.g., Iowa CareGivers Association, North Carolina Foundation for Advanced Health Programs, The Oregon Technical Assistance Corporation).


The training of nursing assistants occurs in two waysnamely, through on-the-job training and through coursework in state-sanctioned educational institutions. On the job training occurs in private nursing homes that do not use Medicare or Medicaid funds, and are therefore not beholden to Federal standards. On the other hand, nursing homes that are state-operated, or that receive funding through Medicare or Medicaid, must employ formally educated and certified nursing assistants. This formal education must at least sixty-five hours of coursework, which in turn can occur on premise, or, in a state-approved setting such as a college, vocation school, or other organization (i.e., The Red Cross). Upon completing the program, nursing assistants are required to pass a certification exam and register with a state maintained nursing assistant registry.

Certification exams can, and very often do vary between states. Many states contract with private testing services to administer and score tests. One company involved in nursing assistant certification is Promissor. Promissor tests knowledge in three areas: (1) physical care skills, (2) psychosocial care skills, and (3) the role of the nursing assistant (Promissor, 2004). Promissor (2004) uses a seventy question multiple-choice examination that consists of three partsPhysical Care Skills (hygiene, data collection and reporting, prevention), Psychosocial Care Skills (Emotional and Mental Health Needs, Spiritual and Cultural Needs), and Role of the Nurse Aide (e.g., communication, client rights). Students taking a Promissor test can take either a written or oral version of the examination.
 Communication in the Nursing Home

Therapeutic communication is an integral part of caregiving in the nursing home. Therapeutic communication can be characterized as involving trust, validation, empathy, honesty, and active listening (Delaune & Ladner, 2002). Studies suggest that when older adults relate closely with care providers, they live longer and more healthily (Estes & Rundall, 1992; Kiely, Simon, Jones, & Morris, 2000).

Guidelines for effective communication with nursing home residents recommend that nursing assistants should speak clearly, face the individual when speaking, maintain eye contact, use language the person can understand, and make messages brief, clear, and logical (Pullian, 1998).

While oral communication is a large component of on-the-job communication for nursing assistants, written communication is also important, and principally involves recording observations of residents (Pullian, 1998). Observations might include noting skin color of residents (e.g., a rash), smell (e.g., foul smell from a wound), lumps in the skin, fever, perspiration, wheezing, coughing, or patients own statements about how he or she is feeling (Pullian, 1998, p. 21).

When nursing assistants are NNESs, they face a number of communicative and cultural challenges in communicating with residents, coworkers, and management. For example, ESL nursing assistants might be told by a supervisor to dress the wound, but instead of applying a bandage, the assistants clothe the resident. In addition to miscommunications, there can also be cultural misunderstandings. For example, a manager may have a hard time understanding an employee who takes sick leave in order to tend to a sick family member. Culturally, the nursing assistant is behaving appropriately, but such behavior may be not in accordance with American work expectations.

Characteristics on Nursing Home Residents

Who are nursing home residents? According to the USDHHS (2002), over 70% of nursing home residents are women. More than ninety percent of residents are over sixty-five, and seventy-five percent of residents need assistance with three or more activities of daily living (ADLs). A significant number also have vision (27.1%) and hearing (21%) impairment (NNHS, Table 20).

Communicative Challenges of the Client Side

Williams, Ilten, and Bower (2005) investigated the distributions of speech acts between caregivers and nursing home staff. They divide speech acts into four categoriesADLs, nursing assessment, technical aspects of care, and personal social. ADLs are identified as speech acts relating to baths, hygiene, bed-making, toileting, etc. Nursing assessment, which included speech acts regarding health status and conditions comprised 6% of communicative activities. Personal-social, which included salutations, banter, idle chatter and jokes, fillers, small talk, etc., comprised 28%. And, technical speech acts, which included taking blood pressure, obtaining vital signs, weights and measures comprised 13% of the communication. Speech acts are linguistic events such as apologies, complaints, compliments and responses, refusals, requests, and thanks. What is socially appropriate can and very often does vary between cultures.

Communication Challenges on the Client Side 

Residents often suffer from at least one condition that impedes effective communication. Conditions often include senility, strokes, or hearing issues. A recent study found that some forty-two percent of nursing home residents were diagnosed with dementia (NNHS, 1999). It is therefore easy to see how ineffective communication between resident and caregiver (regardless of language spoken) is common problem.

Needs of ESL Nursing Assistants

Bosher and Smalkoski (2002) found that students enrolled in the Associate of Science (A.S.) nursing degree program had trouble with following: (1) being assertive with clients, colleagues and nursing instructors in clinical settings; (2) communicating clearly and effectively, using appropriate paralinguistic features of speech, particularly in a clinical setting; (3) using appropriate non-verbal communication skills, such as eyen contact; (4) making small talk with clients and understanding when clients are engaging in small talk with them; (5) understanding how cultural values influence their interactions with clients from cultural backgrounds different from their own.

Caffee and Pineiro (2005) identify the following needs for health professionals: (1) comprehensible pronunciation and prosody of speech; (2) active listening skills, asking for clarification; (3) confidence in communication; (4) assertiveness skills; (5) politeness and pragmatics of oral communication; (5) bridging professional and lay language.


Linguistic professionals are uniquely positioned to inform the nursing discipline. Further quantitative research into communicative activities between nursing assistants and nursing home residents would benefit curriculum design and inform educators in ESL and nursing. More specific research into the extent that communication between native and non-native English speakers is a problem in the nursing home would also be of interest. Additionally, how to more effectively address communicative issues NNES nursing assistants educations would be beneficial.

Anderson, R., Issel, I. M., & McDaniel, R. R. (2003). Nursing homes as complex adaptive systems: Relationship between management practice and resident outcomes. Nursing Research, 52, 12-41.

Atchison, J. (1998). Perceived job satisfaction factors of nursing assistants employed in Midwest nursing homes. Geriatric Nursing, 19(3), 135-8.

Bosher, S. & Smalkoski, K. (2002). From needs analysis to curriculum development: Designing a course in health-care communication for immigrant students in the USA. English for Specific Purposes, 21(1), 59-79.

Burnfiend, J. D., & OConnor, S. J. (1992, August). Employee turnover and retention rates as predictors of nursing home code violations. Paper presented at the annual meeting of the Academy of Management, Las Vegas, NV.

Cameron, R. (1998). A language-focused needs analysis for ESL-speaking nursing students in class and clinic. Foreign Language Annals, 31(2), 203-218.

Delaune, S. C., Ladner, P. K. (2002). Fundamentals of Nursing: Standards and Practices (2nd Ed.). Delmar: New York

Duff, P. A., Wong, P., & Early, M. (2000). Learning language for work and life: The linguistic socialization of immigrant Canadians seeking careers in healthcare. Canadian Modern Language Review, 57(1). Retrieved November 5, 2005, from

Estes, C. L., & Rundall, T. G. (1992). Social characteristics, social structure, and health in the aging population. In M.G. Ory, R.P. Abeles, & P.D. Lipman (Eds.), Aging, health and behavior (pp. 299-326). Newbury Park , CA: Sage.

Gay, J. T., Edgil, A. E., & Stullenbarger, E. N. (1993). Graduate education for nursing students who have English as a Second Language. Journal of Professional Nursing, 9(2), 104-109.

Guhde, J. A., (2003). English-as-a-Second Language (ESL) nursing students: Strategies for building verbal and written language skills. Journal of Cultural Diversity, 10(4), 113-117.

Kiely, D. K., Simon, M. A., Jones, R. N., Morris, J.N. (2000). The protective effect of social engagement on mortality in long-term care. Journal of the American Geriatrics Society, 48, 1367-1372.

National Clearinghouse on the Direct Care Workforce. (2004, Sept). Who are direct-care workers? Retrieved from

Promissor. (2004). NNAAP Nurse Aide Practice Written Exam Packet. Retrieved December 17, 2005 from

Pullian, J. (1998). The nursing assistant (2nd Ed). New Jersey: Prentice Hall.

Scanlon, W. J. (2001, May). Nursing workforce: Recruitment and Retention of Nurses and Nurse Aides Is a Growing Concern, U.S. General Accounting Office. Retrieved from

U.S. Department of Health and Human Services (USDHHS). (2002, June). (The National Nursing Home Survey: 1999 Summary. Publication No. PHS 2002-1723). Retrieved November 9, 2005, from Centers for Disease Control and Prevention via:

U.S. Department of Labor, Bureau of Labor Statistics (2004a). Occupational Outlook Handbook, 2004-2005. Retrieved from

U.S Department of Labor, Bureau of Labor Statistics (2004b). National Occupational Employment and Wage Estimates. Retrieved from

U.S. General Accounting Office (2001). Nursing Workforce: Recruitment and Retention of Nurses and Nurse Aides Is a Growing Concern. Statement by William J. Scanlon, Director, Health Care Issues (GAO-01-750T) May 17, 2001.

Williams, K. N., Ilten, T., & Bower, H., (2005). Meeting Communication needs: Topics of talk in the nursing home. Journal of Psychosocial Nursing & Mental Health Services, 43(7), 38-45.


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