Contributor: Nadine Griffiths-Brooks, MSN, RN, NEA-BC

Let me begin with a little background to set the stage and hopefully you can walk in my world…I started my Nursologist career in South Africa, where I was born and raised. Back home, I was highly respected for my professionalism and clinical competence in adult acute care and midwifery, which led to me being recruited to work in Saudi Arabia, where I successfully practiced in a melting pot of cultures for over five years.

When my husband’s job moved us to the U.S, I was excited to start working and couldn’t wait to share knowledge and ideas for best practice with my American counterparts. In my initial days as a pre op nurse, my proficiency in IV insertions and patient care was quickly recognized by colleagues. However, the shock came when, shortly after starting my first job, a patient refused my care solely due to my “foreign” background. This was my first encounter with accent bias, a phenomenon that became a persistent theme throughout my career. You see, I was no stranger to racism or discrimination. I was raised in South Africa during Apartheid. My manager tried to advocate for me, even telling the patient that I was one of the best nurses she had ever worked with. It didn’t matter. The patient was undergoing a major surgery and she wanted everything to be perfect. A foreign-trained nurse with an accent she had difficulty understanding was not inspiring confidence in her healthcare team. I was confused, hurt … and embarrassed.

This happened a few times over the next few months and that was the beginning of almost 20 years fighting imposter syndrome. It crept up in the strangest of places. During challenging situations with patients and families, difficult conversations with physicians, staff meetings when I needed to speak up for my practice and my team, and opportunities for promotion or career advancement. I didn’t anticipate that even my colleagues would not have confidence in my nursing skills or be willing to give me their attention due to my noticeable African accent.

Accent discrimination affects linguistic minorities from diverse linguistic and ethnic backgrounds, including foreign-accented English speakers (Barrett et al., 2022). Foreign-trained nurses make up about 15% of the nursing workforce in the United States and will only increase with the nurse staffing crisis (Harrison, 2020). Research suggests that individuals with non-native accents may be perceived as less competent or less knowledgeable compared to their native-speaking counterparts (Iheduru, 2020). This bias can hinder opportunities for advancement, limit participation in decision-making processes, and erode confidence and morale among affected employees.

According to the 2020 State of the World’s Nursing report (SOWN), the national nursing shortage continues to impact healthcare delivery in the US, resulting in increased recruiting of experienced nurses from the international community (SOWN, 2020). One in every eight nurses practice in a country other than the one where they were born or trained. In 2020, the United States reported an estimate of almost 197,000 registered international nurses (OECD, 2020).

So, what did I do? I cultivated and worked on being more “American”. I replaced the words and phrases that caused people to be confused when I spoke, with the American equivalent. For instance, I started saying “trash” can instead of “rubbish bin”, and “pills” instead of “tablets”. Additionally, I consciously addressed my tendency to overly enunciate and articulate by endeavoring to soften my consonants and elongate my vowels. However, in this pursuit of conformity, I found myself sacrificing authenticity to conform to societal expectations.

When I first encountered DEI programs in the hospital, I was very excited about the potential to be included and eager to learn more about the programs that focused on bringing colleagues together towards a common goal. I eagerly anticipated having a space where I could connect with colleagues who shared similar experiences, fostering a sense of camaraderie and alleviating feelings of isolation. I attended several meetings where we discussed opportunities within the organization to ensure everyone felt like they were a valuable member of the team. I waited patiently for the discussions to circle around to foreign-trained employees and accent-bias. Nothing! I worked through it on my own and found comfort through conversations with other foreign nurses. Like the time one of our most respected and productive surgeons told me I was such a great nurse, if only I spoke better English. I jokingly but clearly informed him that I was fluent in four languages, English was my first language, and if speaking English with an accent was a measure of intelligence, I could say the same for him since he spoke with a heavy Texas drawl.

I mastered the art of finding humorous ways to gently educate anyone who was inclined to make assumptions about my education and experience. But I didn’t see many foreign nurses advocating for themselves. I saw them mostly working nightshift and weekends. I observed that when we peer interviewed foreign nurses, most of the questions centered around communication. “Tell me about a time you had difficulty communicating with another clinician. What was the situation and how did you work through that?” I heard leaders talk about how outstanding they were clinically, how dependable, reliable, and great team players they were and yet they were spending years in the same positions while others were promoted over them. These were good people who did not realize their implicit bias existed.

So, I decided to be the change! I started by reviewing the literature for research focusing on the experiences of foreign-trained nurses and accents, but outside of accent modification interventions, there was nothing. I made the decision to enroll in a doctoral program and spent the last several years talking to foreign born nurses who speak English with an accent they perceive others cannot understand.

Leininger’s Culture Care Theory emphasizes the significance of culturally congruent care in nursing practice, acknowledging that individuals’ cultural beliefs, values, and practices profoundly influence their health-related behaviors and perceptions of well-being. This theory underscores the importance of understanding and respecting diverse cultural perspectives to provide holistic and effective care. In the context of accent bias, which refers to the tendency to perceive individuals with non-native accents negatively or as less competent, Leininger’s theory holds relevance. Utilizing this theory as a framework for accent bias involves employing the established principles to guide the process to assist, support, facilitate and enable cultural care (nursology, 2018). By recognizing and valuing cultural diversity, nurses can mitigate accent bias by fostering inclusive care environments where all patients are treated with dignity, respect, and sensitivity to their unique cultural backgrounds and communication styles.

I spoke to nurses from the Philippines, Asia, India, and Africa and felt overwhelmed by the significance of the gap in resources and the magnitude of the work that needs to be done. I also spoke to foreign-trained nurses from Australia, Canada, and Europe. It was interesting that their experiences differed from their African and Asian counterparts. Anglo nurses of western origin did not feel the same level of isolation. I chose to tackle this challenge gradually, starting with addressing African accents and proceeding step by step from there. There needs to be heightened awareness that accents are not a measure competence, knowledge, or skills. Organization leaders must acknowledge that foreign-trained nurses can be the solution to the staffing crisis, but there must be resources available to help them assimilate into the workplace, to include education of their native counterparts. Overall, accent bias can undermine diversity, equity, and inclusion efforts within the workplace, impeding organizational effectiveness, innovation, and employee well-being. Addressing accent bias requires proactive measures, including awareness training, cultural competence initiatives, and policies promoting fair treatment and equal opportunities for all employees, regardless of accent or linguistic background.

I now embrace my accent. I say the words I was raised with and encourage people to ask about my accent and embrace their curiosity about my background. I seek out opportunities to discuss how diversity enriches the workplace by fostering creativity, innovation, collaboration, and inclusivity. I will gladly make this my life’s work so that every nurse can practice with the same level of support and opportunities. Through culturally congruent care, organizations can bridge communication gaps, build trust, and promote positive health outcomes, transcending linguistic barriers and biases to deliver an equitable and employee-centered environment for all.

References

Barrett, R., Cramer, J., & McGowan, K. B. (2022). English with an accent: Language, ideology, and discrimination in the United States. Taylor & Francis.

Harrison, R. (2020). Hospitals with internationally trained nurses have more stable, educated nursing workforces. Retrieved from New York University, September 2023. Hospitals with Internationally Trained Nurses Have More Stable, Educated Nursing Workforces (nyu.edu)

Iheduru, A. K. (2020). Accent bias: A barrier to Black African‐born nurses seeking managerial and faculty positions in the United States. Nursing Inquiry, 27(4), 1–15. https://doi-org.ezp.twu.edu/10.1111/nin.12355

Organization of Economic Co-operation and Development (OECD)(2020) Contribution of migrant doctors and nurses to tackling COVID-19-19 crisis in OECD countries, OECD, Paris, page 3. https://read.oecd-ilibrary.org/view/?ref=132_132856-kmg6jh3kvd&title=Contribution-of-migrant-doctors-and nurses-to-tackling-COVID-19-19-crisis-in-OECD-countries

Nursology. (2018). Madeleine Leininger: Cultural care diversity and universality theory. Nursology. https://nursology.net/nurse-theorists-and-their-work/madeleine-leininger/

State of the world’s nursing 2020: investing in education, jobs and leadership. Geneva: World Health Organization. Retrieved from https://www.who.int/publications-detail-redirect/9789240003279

About Nadine Griffiths-Brooks

I have been a nurse for over 25 years, born and raised in South Africa. I moved to the US in 2006 where I have since practiced in various clinical and leadership roles. I currently serve in an executive role where I support nurses in all areas of the hospital. My mission as a leader is to foster a culture of inclusivity, where every nurse can feel valued and find joy in their work. I am currently in a PhD program at Texas Woman’s University. My research interest is Foreign Nurses experiences in the United States.