In any professional setting, clear and effective communication is key, but even more so in healthcare. For non-native English-speaking nurses navigating the complexities of the U.S. healthcare system, proficiency in English—and proficiency in practical English—can significantly impact the quality of care their patients receive.

Nina Ito and Chris Mefford recognized this need and used their work with international students and healthcare professionals to develop their collaboration, “Take Care: Communicating in English with Health Care Workers.” In July 2023, the book was reissued, taking into consideration the effect of COVID-19 and its impact on the healthcare system.

Inspiration and Development

Ito recalls one particular experience working with students from Yokkaichi Nursing and Medical Care University in Japan, who visited California State University Long Beach’s campus for intensive language training. This experience, coupled with their prior work on cruise ship training programs together, revealed a gap in the available materials for healthcare communication.

“We thought that that was a good opportunity to make some materials for them, because we had already been making materials for the crew members on the ships,” Ito said.

Both Ito and Mefford described seeing loved ones go through the healthcare system and witnessing the different levels of care they received.

Their collaborative effort resulted in a resource addressing real-world challenges faced by non-native English speakers in healthcare.

To ensure the book’s relevance and accuracy, the authors consulted with healthcare professionals, including nursing students and practitioners. This input was crucial in creating realistic and useful scenarios.

Patient Safety and Quality of Care

Nurses are often the primary point of contact for patients, responsible for interpreting medical histories, explaining treatment plans, and providing emotional support. Misunderstandings due to language barriers can lead to medication errors, incorrect treatments, and compromised patient safety. As noted by The Joint Commission, a U.S.-based nonprofit organization that accredits more than 22,000 US health care organizations and programs, “communication failures are the leading root cause of sentinel events in healthcare settings.”

In addition, research by the National Institutes of Health (NIH) found that patients who perceived their healthcare providers as proficient in their preferred language were 39 percent more likely to follow prescribed treatments and attend follow-up appointments.

Key Strategies

“Take Care” addresses two main categories of communication strategies: formulaic phrases and pragmatic phrases. These strategies help healthcare workers navigate complex interactions with patients, colleagues, and supervisors.

“Formulaic phrases are used to deal with communication breakdown, and…pragmatic phrases or speech acts are used in situations to complete tasks,” Mefford said. “And an example of that would be communicating with colleagues. In the section of the book about working with doctors and supervisors, you have polite ways to agree and disagree. We tried to choose the ones that are more pertinent to that particular situation where they can practice in that contextualized situation throughout the book.”

Nonverbal communication is another critical component of communication Ito and Mefford address. Understanding cultural differences in body language, gestures, and other nonverbal cues can significantly impact the effectiveness of interactions in a healthcare setting. Ito emphasized the importance of this, noting, “We have some specific exercises about how to say, for example, ‘I can’t hear you’ by using your hand behind your ear to help someone communicate a message without interrupting verbally.”

Role-playing and Cultural Awareness

Role-playing exercises are a standout feature of the book, providing learners with the opportunity to practice and internalize the communication strategies. Playing out real-life scenarios is a practical way for nurses to improve both their verbal and nonverbal communication skills.

After each section of role-playing and learning, readers can expect to find a culture point.

“The culture point is a little story, a little scenario, and some of those are based on nonverbal language. For example, smiling doesn’t always mean that someone is happy; it could mean that they’re embarrassed. That’s not always the case in other cultures. In some culture points there are scenarios that deal with the nonverbal language and a little bit of potential conflict between cultures and how to navigate that,” Ito said.

Applicability Beyond Healthcare

While “Take Care” is tailored for healthcare professionals, its communication strategies are universally applicable. It can benefit anyone in customer service roles, emphasizing clear, efficient, and polite interactions. Mefford shared an anecdote about a student who found the confirmation techniques from the book useful in a restaurant setting, illustrating the book’s broad applicability.

Increase in Demand for Communication Courses

Healthcare staffing shortages will continue to be met by international nurses in years to come. The Bureau of Labor and Statistics shows a 6% increase in jobs for nurses between now and 2032, which is faster than the national job growth average.

As demand for medical English training grows, Ito and Mefford hope their book will become an integral part of nursing programs, especially in community colleges with diverse student populations. They advocate for the inclusion of communication courses in nursing curricula to ensure non-native English-speaking nurses can perform their duties effectively.

To learn more about how MET can help nurses certify their English, visit our MET page.


“Take Care: Communicating in English with Health Care Workers,” revised edition, by Nina Ito and Chris Mefford was published in July 2023 by the University of Michigan Press.

About Nina Ito

Nina Ito is the former academic coordinator of the American Language Institute at California State University, Long Beach and previously taught at the University of Southern California International Academy.

About Chris Mefford

Chris Mefford is the director of Study Abroad @The Beach at California State University, Long Beach, and associate professor of English as a Second Language at Coastline Community College.