Susan Bosher presented on communicative competence for nurses working in clinical settings. She discussed the five components of communicative competence: linguistic competence, textual competence, functional competence, socio-cultural competence, and strategic competence. For each component, she provided examples of language skills needed by nurses, such as asking questions, giving instructions, teaching patients, and understanding cultural differences. The presentation aimed to provide a framework for developing effective English language instruction and assessments for nurses.

1. Plenary 3
Susan Bosher
Professor and Director of ESL, St. Catherine University
St. Paul, Minnesota

2. 2016 Perspectives Symposium
2016 Perspective Symposium
Touchstone Institute
February 23, 20162016 Perspectives Symposium
2016 Perspectives Symposium
Susan Bosher, PhD
Professor and Director of ESL
St. Catherine University, St. Paul, Minnesota, USA

3. Communicative Competence
Definition: Knowledge that a native speaker has which
allows him or her to successfully interact with other
speakers (Savignon, 1976)
1) Linguistic competence: syntax, morphology,
phonology, orthography, and the lexicon
2) Textual competence: cohesion, coherence, deixis,
genre structure, and conversational structures
3) Functional competence: using language for a specific
purpose (e.g. teaching, warning, self-expression,
persuading, etc.)

4. 4) Socio-cultural competence: rules of appropriateness
and politeness, idioms and figurative language, non-
verbal communication, cultural knowledge and
references, knowledge of social contexts and
relationships
5) Strategic competence: planning for effective
communication in a given situation, avoiding
difficulties in communication, and recovering from
communication breakdowns (Pawlikowska-Smith, 2002)

5. Pronunciation (Bosher & Smalkoski 2002;
Cameron 1998; Hussin 2002; Seydow 2012)
Phonemes
Initial & final consonants
Common prefixes & suffixes
Phonemic contrasts
Words
Medical terminology
Diagnoses
Procedures
Names of drugs
Acronyms & abbreviations

6. Pronunciation (Continued)
Common words
 Numbers
 Words of frequency
Patients’ names
Stress & intonation
Misplaced word stress
Unstressed syllables
Tone

7. Vocabulary
(Cameron 1998; Hussin 2002; Marston & Hansen 1985;
Medlin 2009; Seydow 2012)
Medical/nursing terminology
Correct abbreviations & shortening of words
Words with different connotations
Appropriate medical terms
Paraphrasing of technical information; precise terms for
charting
Sub-technical vocabulary
Idioms & metaphors related to self, pain, emotion, etc.
Physical appearance & emotional states
Two- & three-word verbs used to describe health
Colloquial language
Word forms/parts of speech

8. Grammar (Cameron 1998; Hussin 2002, 2008;
Marston & Hansen 1985; Staples 2015)
Asking questions
Primary means of getting information
Key communicative behavior in clinical setting
Types of questions
 Open-ended
 Information
 Yes/no
 Elliptical
 Tag
 Intonation

9. Grammar (Continued)
Other purposes of questions
To confirm, evaluate, provide options
Imperatives or commands
To conduct assessments
Understanding instructions
Explicit vs. implicit
Tense & aspect
Future
Past vs. present (present progressive, present perfect
progressive, simple present)
Passive vs. active

10. Grammar (Continued)
Modal verbs
Reported speech in dialogue form
What-cleft & it-cleft constructions
Pronoun usage
Word order
Describing spatial relationships
Passive constructions
Prepositions of location
Using relative clauses

11. Grammar (Continued)
Describing procedures
3rd
person subjects
Imperatives
Passives
Expressions of time
Telegraphic style for charting
Adverbs of time & frequency
Prepositions
“I” statements

12. Functional Competence
(Bosher & Smalkoski 2002; Cameron 1998; Epp & Lewis 2008;
Hussin 2002, 2008; Malthus, Holmes, & Major 2005; Marston &
Hansen 1985; Seydow 2012)
How nurses spend their time (Epp & Lewis 2008)
With whom?
56% with clients
34% with other professionals
10% with family
Doing what?
22% asking for information
21% explaining
9% giving instructions

13. Functional Competence (Continued)
7% informing
6% responding to questions
6% suggesting
6% describing
5% making small talk
5% discussing
4% comforting
3% making/receiving phone calls
2% asking for help
2% offering to help
1% clarifying
1% apologizing

14. Giving Information (Cameron 1998)
To patients & families
Who one is
What one knows
Good/bad news
Available options
Educate patients about diagnosis & self-care
To other health-care professionals
Present cases
Advocate for patients

15. Language Tasks in Clinical Setting
(Hussin 2002)
Taking nursing history of patient
Writing nursing care plans
Giving & receiving change-of-shift reports
Writing progress notes, discharge summaries,
incident reports, & referral letters
Making & receiving phone calls
Using language while providing nursing care
Teaching patients & families about health care & how
to provide care after discharge
Participating in team meetings about patients

16. Informational Skills (Hussin 2002)
Interacting with patients & families
Using interviewing techniques
Giving instructions
Asking for cooperation
Checking readiness
Explaining medical information in layperson’s language
Explaining procedures
Asking for permission
Giving feedback
Understanding colloquial language
Using teaching techniques

17. Informational Skills (Continued)
Interacting with colleagues
Giving & understanding instructions, explanations of
procedures, & directions
Asking for repetition & clarification
Asking for assistance & explanation
Checking for readiness
Understanding & presenting verbal information
Making & receiving telephone calls
Accurately conveying telephone messages

18. Informational Skills (Continued)
Interacting with colleagues (Continued)
Using appropriate medical terminology
Completing, reading, & interpreting routine forms,
charts, & instructions
Completing medical histories
Reading & interpreting medical records & histories
Writing, reading, & interpreting notes & summaries,
nursing care plans, letters, & reports

19. Interpersonal Communication Skills
with Patients (Hussin 2002)
Expressing empathy & offering reassurance
Interpreting nonverbal cues
Using attending behaviors
Using nonverbal communication
Using reflective listening techniques
Using clarification techniques
Paraphrasing & summarizing
Using assertive responses
Expressing personal opinion

20. Social Talk
5% of time spent with patients (Epp & Lewis 2008)
60% of time spent with patients (Malthus, Holmes, &
Major 2005)
Requires greetings, introductions, compliments,
showing interest, expressing likes and dislikes
Challenges of functional/pragmatic competence
Understanding implicit communicative intent
Inferencing skills required
Inferring patient’s emotional state
Inferring relevant social information

21. Textual Competence
(Bosher & Smalkoski 2002; Cameron 1998; Hussin 2002,
2008; Seydow 2012)
Conversational structures (opening and closings)
Series of speech acts
Producing sequence of speech acts (Ex: Transferring a
patient)
Offering assistance
Requesting help
Explaining procedure
Giving instructions
Checking readiness
Offering reassurance
Checking patient’s comfort level

22. Textual Competence (Continued)
Understanding sequence of speech acts
Identifying shift from one speech act to another:
Request, complaint, joke, set of instructions
Sequence can become convention or standard procedure
When people are expected to follow sequence
Taking vital signs (Example)
 Give information to patient
 Explain procedure
 Ask for cooperation
 Encourage patient
 Reassure patient
 Give feedback to patient about vital signs

23. Textual Competence (Continued)
Recounting what others have said
Narrating a sequence of events
Describing assessment & observations of patient
Using SBAR (Situation, Background, Assessment,
Recommendation)
Making and receiving telephone calls
Identifying numbers, letters, names of people
 Distinguishing intonation patterns for questions &
statements

24. Socio-Cultural Competence
(Bosher & Smalkoski 2002; Cameron 1998; Hussin 2002, 2008;
Malthus, Holmes, & Major 2005; Marston & Hansen 1985;
Seydow 2012; Staples 2015)
“Saying the right thing” to patients – nursing
students’ primary concern (Kotecki 2002)
Sociolinguistic behavior in the clinical setting
Topic choice
Directing interview
Renewing topic
Turn-taking
Interrupting politely
Communicating empathy and confidence

25. Socio-Cultural Competence (Continued)
Social/small talk
To establish rapport with patients
Necessary first step to social interaction
Non-task related
Topics included patients’ hobbies, likes, dislikes,
families
Other functions of social interaction
Greetings & leave taking
Giving compliments
Telling stories of personal experience

26. Socio-Cultural Competence (Continued)
Extending invitations
Making requests
Giving apologies
Using terms of address appropriately
Recognizing & deflecting inappropriate behavior
Using culturally appropriate nonverbal behavior
Using visual clues

27. Socio-Cultural Competence (Continued)
Speaking loudly enough
Using body language appropriately, e.g., smiling
Interpreting non-verbal cues appropriately
Adjusting speech based on audience and purpose
Using hedging or softening devices
Understanding cultural & dialectal variation
Being assertive and speaking up
Taking an active role in interactions
Asking questions of instructors and other
authority figures

28. Strategic Competence
(Bosher & Smalkoski 2002; Cameron 1998; Hussin 2002,
2008; Seydow 2012)
Strategies to ensure mutual comprehension
Clarifying meaning
 Ask for repetition
 Ask clarification questions
Checking comprehension
 Paraphrase & reflect back
Demonstrating understanding
 Repeat key words
 Paraphrase instruction in response

29. Strategic Competence (Continued)
 Use expansion statements
Statements that add information
 Use elaboration questions
Questions that ask for more information
Interactive repair
Recognize verbal & nonverbal cues of understanding &
misunderstanding
Repairing or rephrasing unclear messages
Expressing non-understanding
Making direct and indirect appeals for help

30. Strategic Competence (Continued)
Planning for effective communication
SBAR (situation, background, assessment, and
recommendation)
Determine who the audience is, what they need to
know
Evaluate whether communication goal was met
Interacting with difficult patients requires
assessment, planning and goal setting
Maintain control of conversation
Deal with patients with communication barriers
Regain authority and reestablish communication

31. Conclusion
Framework of communicative competence
(linguistic, textual, functional, socio-cultural,
strategic) helps to understand the various
components of using language effectively in the
clinical setting
Framework provides useful structure for
developing instructional and assessment materials
that address all aspects of communicating
effectively in English in the clinical setting

32. References
Bachman, L. (1990). Fundamental considerations in language testing.
Oxford: Oxford University Press.
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, 59-79.
Brown, S. (1994). Communication strategies used by an expert nurse
Clinical Nursing Research, 3(1), 43-56.
Cameron, R. (1998). Language-focused needs analysis for ESL-
speaking nursing students in class and clinic. Foreign Language
Annals, 31, 203-218.
Canale, M. (1983). From communicative competence to
communicative language pedagogy. In J. C. Richards & R. W. Schmidt
(Eds.), Language and Communication (pp. 2-27). London: Longman.
Canale, M., & Swain, M. (1980). Theoretical bases of communicative
approaches to second language teaching and testing. Applied

33. References (Continued)
Celce-Murcia, M., Dörnyei, Z., & Thurell, S. (1995). Communicative
competence: A pedagogically motivated model with content
specifications Issues in Applied Linguistics, 6(2), 5-35.
Crystal, D. (1987). The Cambridge encyclopedia of language.
Cambridge, U.K.: Cambridge University Press.
Donahue, M., Miller, M., Smith, L., Dykes, P., & Fitzpartrick, J. (2011).
A leadership initiative to improve communication and enhance safety.
American Journal of Medical Quality, 26(3), 206-211.
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.
Hedge, T. (2000). Teaching and learning in the language classroom.
Oxford: Oxford University Press.

34. References (Continued)
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. 363-386). New York: Springer
Publishing.
Kotecki, C. (2002). Baccalaureate nursing students’ communication
process in the clinical setting. Journal of Nursing Education, 41(2), 61-
68.
Krautscheid, L. (2008). Improving communication among healthcare
providers: Preparing student nurses for practice. International Journal
of Nursing Education Scholarship, 5(1), 1-15.
Marston, J., & Hansen, A. (1985). Clinically speaking: ESP for refugee
nursing students. MinneTESOL Journal, 5, 29-52.

35. References (Continued)
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(1), 65-89.
Medlin, L. (2009). English for Specific Purposes (ESP): Nursing in the
U.S. hospital. Unpublished project. California State University, Chico.
Pawlikowska-Smith, G. (2002). Canadian language benchmarks
theoretical framework. Canada: Centre for Canadian Language
Benchmarks, 1-108.
Savignon, S. (1976). Communicative competence: Theory and
classroom practice. Central states conference on the teaching of foreign
languages. University of Illinois, Urbana-Champaign. 23 April 1976.
Keynote Address.
Staples, (2015). Examining the linguistic needs of internationally
educated nurses: A corpus-based study of lexico-grammatical features
in nurse-patient interactions. English for Specific Purposes, 37, 122-136.

36. References (Continued)
Seydow, A. (2012). Describing communicative competence in a college
nursing degree program. Unpublished capstone, Hamline University,
St. Paul, MN.
Tuohy, D. (2003). Student nurse-older person communication. Nurse
Education Today, 23, 19-26.
Yates, L. (2004). The ‘secret rules of language’: Tackling pragmatics in
the classroom. Prospect, 19(1), 3-21.

37. Plenary 3
Susan Bosher
Professor and Director of ESL, St. Catherine University
St. Paul, Minnesota