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Defining Communicative Competence in Nursing

Susan Bosher

July 2016 | Assessment | Research | Teaching & Learning

Susan Bosher, researcher and medical English trainer, presents a model for developing materials for the nursing community.

A framework of communicative competence provides a helpful way to categorize the various tasks and skills that are essential for communicating effectively in the clinical setting. Such a framework can also be used to develop ESP materials as well as assessments for the healthcare setting. The framework described here (Pawlikowska-Smith, 2002) was developed, based on the work of previous researchers, by the Centre for Canadian Language. It was used to establish the Canadian Language Benchmarks, a descriptive scale of English language proficiency, which was then used to validate the CELBAN (Canadian English Language Benchmark Assessment for Nurses), a nursing-specific language proficiency test developed for use with internationally educated nurses seeking to re-enter the nursing profession in Canada (Epp & Lewis, 2008).

The framework consists of five competencies: linguistic, textual, functional, socio-cultural, and strategic. Although they are discussed separately (and in a slightly different order), there is considerable overlap between them. Examples that illustrate each competence are drawn from a variety of needs analyses and research studies in the field of English for Nursing (Bosher & Smalkoski, 2002; Cameron, 1998; Hussin, 2002, 2008; Malthus, Holmes, & Major, 2005; Marston & Hansen, 1985; Seydow, 2012).

Linguistic competence, the most established component of all frameworks of communicative competence, is based on knowledge of syntax, morphology, phonology, orthography, and the lexicon. Examples of the appropriate and effective use of pronunciation, vocabulary, and grammar in the healthcare setting include:

  • pronunciation of medical terminology and medications (Betadine vs. Pethidine)
  • abbreviations, both acronyms (ADLs and NPO) and shortened words (peri and pisi)
  • sub-technical vocabulary (administer, position, record); non-technical or layperson’s terms (heart attack vs myocardial infarction)
  • formation of various types of questions (How are you feeling today? When did the pain start? Are you in pain now?)
  • explicit vs. implicit commands (Give Mr. Davis his medication now vs. It might be good to…)
  • verb tenses (I’m going to take your pulse vs. She’s having an appendectomy)
  • relative clauses to specify a patient (The patient who is scheduled for surgery…)

Functional competence, or pragmatic competence, refers to how language is used to accomplish a particular task, or speech act. One study (Epp & Lewis, 2008) found that nurses in Canada spend over half of their time with clients (56%), compared with other professionals (30%) and the client’s families (10%). Half of their time is spent on three language tasks or functions: asking for information (22%), explaining (21%), and giving instructions (8%), followed by other functions at lower levels of usage: informing (7%), responding to questions (6%), suggesting (6%), describing (6%), engaging in small talk (5%), discussing (5%), comforting (0%), making or receiving telephone calls (3%), asking for help (2%), offering to help (2%), clarifying (1%), and apologizing (1%). Nurses must also be able to produce and understand a series of speech acts, as discussed in the next section.

Textual competence, or discourse competence, consists of understanding and producing contextualized stretches of language in spoken or written form. Set conversational structures, such as openings and closings, require textual competence, as do standard procedures. For example, taking vital signs consists of six steps, each consisting of a separate speech act: giving information to the patient, explaining the procedure, asking for cooperation, encouraging the patient, reassuring the patient, and giving feedback to the patient about their vital signs. Another example of textual competence is the use of SBAR, a framework used by healthcare providers in the U.S to organize their speech when communicating about a patient. Consisting of an easily remembered mnemonic: situation, background, assessment, and recommendation, SBAR helps to ensure that all the necessary information about a patient is provided in a consistent and predictable order, thus helping to ensure patient safety.

Socio-cultural competence, or sociolinguistic competence, refers to the ability to use language in ways that are appropriate to the context, the relationship between the persons involved, and the purpose of the interaction. Because so much of nursing involves establishing a relationship with patients, the nurse’s interpersonal use of English is particularly important. Many of the language tasks and skills essential for this type of communication require not only functional competence, but also socio-cultural competence, for example, in expressing empathy, offering reassurance, and interpreting nonverbal cues. In addition, ‘small talk,’ often considered a necessary first step to establishing rapport with patients, requires socio-cultural competence, including the use of greetings, introductions, and compliments; expressing personal feelings and opinions; and using reflective listening techniques.

Because cultural expectations are often embedded in communication differences in style can lead to cross-cultural misunderstandings and negative evaluations. For example, nursing instructors and supervisors from Western backgrounds expect students to be self-directed and assertive (Seydow, 2012); however, Bosher and Smalkoski (2002) found that ESL students often have difficulty being assertive. If ESL students lack initiative and assertiveness in ways that are expected by their instructors and supervisors, they may be viewed as lacking in clinical reasoning and problem-solving skills (Hussin, 2008).

Finally, there is strategic competence, which includes both cognitive and linguistic strategies: cognitive strategies to plan for effective communication and assess its effectiveness, and linguistic strategies to ensure mutual comprehension, including the following:

  • asking for repetition (Could you repeat that, please?)
  • asking for clarification (What did you say we need to order from the pharmacy?)
  • checking comprehension (Was that ‘s’ for Sam or ‘f’ for Fred?)
  • demonstrating understanding (OK, I’ll call the kitchen and ask if Mrs. Green can have meals that are low in salt and fat.)

While usually last in the list, strategic competence is often cited as the most important area of communicative competence. In one study (Seydow, 2012), five of six nursing instructors interviewed emphasized the importance of nursing students asking when they don’t understand in contrast to Bosher and Smalkoski’s (2002) finding that asking for clarification as well as asking for assistance were two of the most challenging tasks for ESL nursing students. Given that 70% of errors that result in patient injury or death are caused by communication breakdowns, according to the Joint Commission on the Accreditation of Healthcare Organizations (JAHCO) in the U.S., and given that English is increasingly being used as a lingua franca in the healthcare setting by non-native speakers, both among healthcare professionals and with patients, the importance of strategic competence in ensuring safe, effective, and mutually intelligible communication should not be underestimated.

Susan BosherSusan Bosher (PhD) is Professor and Director of ESL, St. Catherine University in St. Paul, Minnesota (USA). She has conducted several needs analyses of ESL students in nursing programs and published two ESL for Nursing textbooks: English for Nursing, Academic Skills and Talk like a Nurse, a communication skills workbook.


Bosher, S., & Smalkoski, K. (2002). From needs analysis to curriculum development: Designing a course in healthcare communication for immigrant students in the USA. English for Specific Purposes, 21, 59-79.
Cameron, R. (1998). Language-focused needs analysis for ESL-speaking nursing students in class and clinic. Foreign Language Annals, 31, 203-218.
Epp, L., & Lewis, C. (2008). Innovation in language proficiency assessment: The Canadian English Language Benchmark Assessment for Nurses (CELBAN). In S. Bosher & M. Dexheimer Pharris (Eds.), Transforming nursing education: The culturally inclusive environment (pp. 285-310). New York: Springer Publishing.
Hussin, V. (2002). An ESP program for students of nursing. In T. Orr (Ed.), English for Specific Purposes (pp. 25-39). Alexandria, VA: TESOL.
Hussin, V. (2008). Facilitating success for ESL nursing students in the clinical setting: Models of learning support. In S. Bosher & M. Dexheimer Pharris (Eds.), Transforming nursing education: The culturally inclusive environment (pp. 767-386). New York: Springer Publishing.
Malthus, C., Homes, J., & Major, G. (2005). Completing the circle: Research-based classroom practice with EAL nursing students. New Zealand Studies in Applied Linguistics, 11(5), 65-89.
Marston, J., & Hansen, A. (1985). Clinically speaking: ESP for refugee nursing students. MinneTESOL Journal, 5, 29-52.
Pawlikowska-Smith, G. (2002). Canadian language benchmarks 2000: Theoretical framework. Ottawa: Centre for Canadian Language Benchmarks.
Seydow, A. (2012). Describing communicative competence in a college nursing degree program. Unpublished capstone, Hamline University, St. Paul, MN.