ABSTRACT

Objective

Literature has reported that language is the most common barrier in a health care setting and a risk factor associated with negative outcomes. The present study reports the differences between nursing students who speak one language and nursing students who speak two or more languages (self-reported language proficiency) and their skills and learning needs in global health.

Method

An observational cross-sectional study was performed among nursing students from five Ontario universities. A survey was designed to measure knowledge, skills and learning needs in global health.

Results

Students who speak more than two languages are more likely to have more interest in learning global health issues, such as health risks and their association with travel and migration (p=0.44), and social determinants of health (p=0.042).

Conclusion

Language training is needed for nursing students to be able to face language barriers in health care settings and improve global health, locally and internationally.

Key Words:
Global health; health education; language; cultural competency; nursing; (source: MeSH, NLM)

RESUMEN

Objetivo

De acuerdo con la literatura, el idioma es el obstáculo más común en el contexto de la atención médica y un factor de riesgo asociado con resultados negativos. El objetivo de este estudio es presentar las diferencias percibidas entre los estudiantes de enfermería que hablan un idioma y aquellos que hablan dos o más (competencia lingüística reportada por ellos mismos) y sus habilidades y necesidades de aprendizaje en salud global.

Método

Estudio observacional de corte transversal entre estudiantes de enfermería de cinco universidades de Ontario. Se diseñó una encuesta para medir el conocimiento, las habilidades y las necesidades de aprendizaje en salud global.

Resultados

Se observó que los estudiantes que hablan más de dos idiomas tienen mayor probabilidad de interesarse más en aprender sobre problemas de salud global, los riesgos para la salud y su asociación con los viajes y la migración (p=0,44), así como sobre los determinantes sociales de la salud (p=0,042).

Conclusión

Es necesario que se brinde capacitación en aprendizaje de otros idiomas a los estudiantes de enfermería para que puedan afrontar las barreras impuestas por el lenguaje en los contextos de atención médica y mejorar la salud global, de manera local e internacional.

Palabras Clave:
Salud global; educación para la salud; idioma; competencia cultural; enfermería; (fuente: DeCS, BIREME)

The world is experiencing major political, economic and social changes as a result of globalization. The impact of these changes is most evident in terms of communication, transportation and human migration ¹1. Labonte R, Schrecker T. Introduction: globalization challenges to people's health. Globalization and health: pathways, evidence and policy, 2009.. Globalization has significant implications not only for health and international issues, but also for nursing practice ²2. Veras M, Pottie K, Ramsay T, Welch V, Tugwell P. How do Ontario Family Medicine Residents Perform on Global Health Competencies? A Multi-Insitutional Survey. Canadian Medical Education Journal, Vol. 4, No. 2, 2013.. Furthermore, it has created new challenges and opportunities for nursing and health care ³3. Davidson PM, Meleis A, Daly J, Douglas MM. Globalization as we enter the 21st century: Reflections and directions for nursing education, science, research and clinical practice. Contemporary Nurse: Transcultural Nursing, Vol. 15, 2003, pp. 162-174..

Specifically, the multicultural aspects of the Canadian population bring challenges for nursing practices, since Canada has a diverse population with a significant number of immigrants. Between 2001 and 2006, an annual average of 242 000 individuals were admitted as permanent residents into Canada ⁴4. Chui T, Tran K, Maheux H. Social and Aboriginal Statistics Division, S. C. 2006 Census: Immigration in Canada: A Portrait of the Foreign-born Population, 2006 Census: Findings. Avaliable at: Avaliable at: https://goo.gl/zpZcJm . Acessed on: May 12., 2010.
https://goo.gl/zpZcJm... , of whom 80 % came from Asia, South America and Africa ⁵5. Chui T, Tran K, Maheux H. Immigration in Canada: A portrait of the foreign-born population, 2006 Census. Ottawa: Statisticis Canada- Catalogue 97-557-XIE, 2007.. Most immigrants have a native language other than English or French and 3 % of the Canadian population reports a Chinese language as their native language ⁶6. Statistics Canada. Canada Language. Available at: Available at: https://goo.gl/R3uVdF . Accessed on march 10, 2012.
https://goo.gl/R3uVdF... . The city of Toronto, with 2.48 million people, is considered as one of the most multicultural cities in the world. In 2006 only, 47 % of the population was reported to have a native language other than English or French; in fact, there are over 140 languages and dialects spoken there ⁷7. City of Toronto. Toronto's racial diversity. Available at: https://goo.gl/XU9TjP. Accessed on march 11., 2012.
https://goo.gl/XU9TjP... . Diversity is evident even among Canadians, since nearly 25 % of them are Francophone and live mostly in Quebec, while only 4 % of people who live in other provinces outside of Quebec speak French as a native language. ⁶6. Statistics Canada. Canada Language. Available at: Available at: https://goo.gl/R3uVdF . Accessed on march 10, 2012.
https://goo.gl/R3uVdF...

Several studies have demonstrated differences in health conditions and use of health care according to immigrant status ⁸8. Dunn J, Dyck I. Social determinants of health in Canada's immigrant population: Results from the National Population Health Survey. Social Science and Medicine, Vol. 51, 2000, pp. 1573-1593.. Recent immigrants (less than 10 years) generally have a health status comparable to the Canadian population, although, their health status changes over time ⁹9. Newbold KB, Danforth J. Health status and Canada's immigrant population:1981-1995. Soc.Sci.Med., Vol. 57, 2003.. The process of acculturation has a significant impact on the diet, physical activity and stress levels of immigrants through multi-faceted pathways, not all of which are completely understood. However, it is unclear how these factors are affected by acculturation ¹⁰10. Sanou D, O'Reilly E, Ngnie-Teta I, Batal M, Mondain N, Andrew C, Newbold BK, Bourgeault IL, et al. Acculturation and Nutritional Health of Immigrants in Canada: A Scoping Review. Journal Immigrant Minority Health, Vol. April, 2013, pp. 1557-1912..

Additionally, poor language proficiency is associated with poor self-reported health ¹¹11. NG E, Pottie K, Spitzer, D. Official language proficiency and self-reported health among immigrants to Canada. Statistics Canada, Catalogue no.82-003-XPE- Health Reports, Vol 22, no.4, 2011.. A study using data from Statistics Canada's Longitudinal Survey of Immigrants to Canada (LSIC) shows that women after four years of arriving in Canada had a considerable increase in the prevalence of poor self-reported health. Another finding of this study is that persistent limited official language proficiency was associated with poor health among male and female immigrants who had previously reported good health ¹¹11. NG E, Pottie K, Spitzer, D. Official language proficiency and self-reported health among immigrants to Canada. Statistics Canada, Catalogue no.82-003-XPE- Health Reports, Vol 22, no.4, 2011.. Immigrants report more barriers to health care compared to non-immigrants, especially language barriers ¹²12. Bowen S. ¿Language Barriers in Access to Health Care. Ottawa: Health Canada. Available at: https://goo.gl/FQ1PrC. Accessd on March , 2001.
https://goo.gl/FQ1PrC... .

Furthermore, differences in health between people with different languages seem to exist not only between immigrants and Canadian-born people but also between English-speaking and French-speaking people in Canada. For example, Francophone men and women living in Ontario (where they represent 10 % of the population) are more likely to report being in poorer health condition compared to Anglophones and Allophones ¹³13. French Language Services Commissioner. Annual report 2011-2012. Available at: Available at: https://goo.gl/dNEewD . Accessed on march 19., 2013.
https://goo.gl/dNEewD... . Some explanations for differences in access to health care include barriers in terms of language, socioeconomic status, culture and social network ¹⁴14. Bentham G, Hinton R, Haynes R, Lovett A, Bestwick C. Factors affecting non-response to cervical cytology screening in Norfolk, England. Social Science & Medicine, Vol. 40, No. 1, 1995, pp. 131-135..

Language is considered one of the most important barriers in any health care system and is a risk factor with adverse outcomes ¹⁵15. Quan H. ¿Language barriers: Use of regular medical doctors by Canada's official language minorities. Can Fam Physician, Vol. 58, 2012, pp. 709-716.. In linguistically diverse countries such as Canada, the United States and India, which provide equitable health care in many languages, care can be a challenge ¹⁶16. Canadian Medical Association. National physician survey: New data reflect multiculturalism's impact on medicine. Available at: Available at: https://goo.gl/SgCnSz . Acessed on March 2012., 2005.
https://goo.gl/SgCnSz... . A study conducted among resettling refugees aimed at exploring health access issues in the state of California, USA, identified language as the most important barrier to accessing health care. Language and communication affect all stages related to health care access ¹⁷17. Morris, M. D., Popper, S. T., Rodwell, T. C., Brodine, S. K., and Brouwer, K. C., Healthcare Barriers of Refugees Post-resettlement. Journal Community Health, Vol. 34, 2009, pp. 529-538. and compromise health care quality ¹⁸18. Cegala, D. J., Bahnson, R. R., Clinton, S. K., David, P., Gong, M. C., Monk, J. P. I., and Pohar, K. S.,et al. Information seeking and satisfaction with physician-patient communication among prostate cancer survivors. Health Communication, Vol. 23, 2008, pp. 62-69..

Communication between health professionals and patients is positively associated with improved health outcomes ¹⁹19. Aboul-Enein F, Ahmed F. Language is the most common barrier in any health care setting and has been found to be a risk factor with adverse outcomes. J.Cult.Divers. Vol. 13, No. 3, 2006, pp. 168-169.. The College of Nurses of Ontario states that nurses are responsible for developing an effective communication plan for their clients in order to facilitate their role as informed partners ²⁰20. College of nurses of Ontario. Practice guideline.Culturally sensitive care. Available at: https://goo.gl/Na7uMK. Accessed on march 2012, 2009.
https://goo.gl/Na7uMK... . Working with a multicultural multilinguistic population demands global health skills to address local and international health issues. In the absence of a definition for global health skills, they are defined here as "the skills required for developing health practice and research to promote health and achieve equity for all people in the world through interdisciplinary and collaborative action." Our definition incorporates the main elements of the global health definition by Koplan et al. and Beaglehole and Bonita ²¹21. Beaglehole R, Bonita R. What is Global Health?. Global Health Action. Vol. 3, No. 5142, 2010, pp. 1-2.^,2222. Koplan JP, Bond TC, Merson MH, Reddy KS, Rodriguez MH, Sewankambo NK, Wasserheit JN. Towards a common definition of global health. The Lancet, Vol. 373, No. 9679, 2009, pp. 1993-1995..

Some nursing programs in Canada have responded to this need and have added global health to their nursing curricula ²³23. Mill J, Astle BJ, Ogilvie L, Gastaldo D. Linking global citzenship, undergraduate nursing education, and professional nursing: curricular innovation in the 21 st century. Advances in Nursing Science, Vol. July/September, 2010, pp. E1-E11.. For example, in Ontario, the University of Toronto (Bloomberg Faculty of Nursing) has an international office for global health issues ²³23. Mill J, Astle BJ, Ogilvie L, Gastaldo D. Linking global citzenship, undergraduate nursing education, and professional nursing: curricular innovation in the 21 st century. Advances in Nursing Science, Vol. July/September, 2010, pp. E1-E11., and a pre-departure course for overseas experiences is offered to nursing students; the course covers preparation, placement expectations, support and post-trip debriefing ²⁴24. Chavez F, Bender A, Hardie K, Gastaldo D. Becoming a global citizen through nursing education: lessons learned in developing evaluation tools. International Journal of Nursing Education Scholarship, Vol. 7, No. 1, 2010, pp. 1-21.. McMaster University has a global health office which works in collaboration with all schools in the Faculty of Health Sciences, including Medicine, Nursing and Rehabilitation Science ²⁵25. McMaster University. Global Health Office. Available at: Available at: https://goo.gl/aAZW6a . Accessed on agosto 19., 2011.
https://goo.gl/aAZW6a... . However, many universities have not incorporated mandatory courses in global health and/or have not documented their experience. The Canadian Nurses Association highlights the lack of discussion and documentation of initiatives to include global health content into nursing curricula ²⁶26. Canadian Nursing Association. Nursing leadership: do we have a global social responsibility?. Available at: Available at: https://goo.gl/Cpjfeu 2008. Accessed august 16, 2009.
https://goo.gl/Cpjfeu... .Language fluency is also a barrier for internationally educated nurses working in Ontario and they represent 11% of the total nurse workforce ²⁷27. Kolawole B. Ontario's internationally educated nurses and waste in human capital. International Nursing Review, 2009, pp. 174-190..

Regarding nursing education, the majority of nursing undergraduate programs lack essential global health issues in their curricula ²⁸28. Ervin NE, Bickes JT, Schim SM. Environments of care: A curriculum model for preparing a new generation of nurses. Journal of Nursing Education, Vol. 45, 2006, pp. 75-80.. Although there is an increased inclusion of elective global health experiences in nursing programs ²⁹29. Kirkham SR, Hofwegen L, Pankratz D. Keeping the vision: Sustaining social conciousness with nursing students following international learning experiences. International Journal of Nursing Education Scholarship. Vol. 6, No. 1, 2009, pp. 1635-1636., the role of the nurses in these international experiences has received little attention ²⁴24. Chavez F, Bender A, Hardie K, Gastaldo D. Becoming a global citizen through nursing education: lessons learned in developing evaluation tools. International Journal of Nursing Education Scholarship, Vol. 7, No. 1, 2010, pp. 1-21.. There is also a growing interest in health communication ³⁰30. Candlin C, Candlin S. Health care communication: A problematic site for applied linguistics research. Annual Review of Applied Linguistics. Vol. 23, 2003, pp. 134-154., especially when patients and caregivers do not share the same native language ³¹31. Robinson M. Communication and health in a multi-ethnic society. Bristol: Policy Press., 2002., but few studies have investigated communication among nurses and their perception of language barriers in their care ³²32. Isaacs T, Laurier MD, Turner CE, Segalowitz N. Identifying Second Language Speech Tasks and Ability Levels for Successful Nurse Oral Interaction with Patients in a Linguistic Minority Setting: An Instrument Development Project. Health Communication. Vol. 26, No. 6, 2011, pp. 560-570.. Moreover, no studies have investigated if there are differences between language abilities (bilingual or multilingual) of nurses and global health skills. This study aims to address this gap in the literature.

To investigate if there are differences between nursing students who speak one language and nursing students who speak two or more languages and their skills and learning needs in global health.

METHOD

This paper is part of a large study to assess perceived knowledge, skills and learning needs in global health in nurses, family physicians residents, physiotherapists and occupational therapists students in Ontario. This paper describes the results of the survey applied to the nursing programs of Ontario in relation to nursing skills and learning needs in global health and their association with students' abilities to speak one or two or more languages (self-reported language ability).

Study population and setting

A total of 906 nursing students from five universities of Ontario, Canada were invited to participate in the online survey. The universities are geographically representative of the province. The inclusion criteria for participants were: a) being a final year undergraduate nursing student, considering that at that point most of the course load has been completed and students have more practical, hand-son experience with patients; b) being a student from Canadian Universities in Ontario; c) being 18 years or older, and d) signing an online informed consent.

Survey

The instrument was adapted from: (a) a validated questionnaire used to measure actual and perceived resident physician knowledge of underserved patient populations in the United States and adapted to the Canadian population ³³33. Wieland ML, Beckman TJ, Cha SS, Beebe TJ, McDonald FS. Resident physicians' knowledge of underserved patients: A multi-institutional survey. Mayo Clin Proc. Vol. 85, No. 8, 2010, pp. 728-733.; b) items from a global health competency skills survey for medical students ³⁴34. Augustincic, LP. Global Health Competency Skills: A Self-assessment for Medical Students. MSc.Dissertation., Vol. University of Ottawa, 2011., and c) the Canadian Medical Education Directives for Specialists (CanMEDs) competencies ³⁵35. Frank JR. The CanMEDS 2005 physician competency framework. Better standards. Better physicians. Better care. Ottawa: The Royal College of Physicians and Surgeons of Canada, 2005.. The survey was assessed for validity, reliability and pretesting in a prior study. No floor or ceiling effects were found for the overall rating score.

Good internal consistency was demonstrated with a Cronbach's alpha >0.8. Factor analysis was conducted using principal factor analysis with varimax rotation and five factors accounted for 95 % variance ³⁶36. Veras M, Pottie K, Welch V, Labonte R, Eslava-Schmalbach J, Borkhoff CM, Kristjansson EA, Tugwell P. et al. Reliability and Validity of a New Survey to Assess Global Health Competencies of Health Professionals. Global Journal of Health Science, Vol. 5, No. 1, 2013.. The validated survey contained 30 questions classified in four sections: 1. Knowledge in global health and health equity (self-assessment); 2. Global health skills (self-assessment) for working with patients who have different linguistic, educational, socioeconomic, and cultural backgrounds, and; 3. Learning needs about global health, and 4. socioeconomic and demographic questions.

Survey administration and data collection

Students were recruited by e-mail through the directors or coordinators of their respective programs. They received a brief explanation about the study and a web link to access the online survey and consent form. Online surveys have demonstrated to be superior compared to postal surveys in several ways, mainly in response speed, response rate, and cost efficiency ³⁷37. Sheehan KB. E-mail Survey Response Rates: A Review. Journal of Computer-Mediated Communication, Vol. 6, No. 2, 2001, pp. 0.^,3838. VanGeest J, Johnson TP. Surveying Nurses: Identifying Strategies to Improve Participation. Evaluation & the Health Professions, 2011.. Reminders were sent after two and four weeks. Data were collected from April 2011 until October 2011.

Data analysis

Descriptive statistics were computed to describe the sample. Chi-square statistic was used to compare frequencies for descriptive variables between nursing students who speak one language and nursing students who speak two or more languages. The three main factors of the survey -confidence level in global health issues, global health skills and learning needs in global health- were analyzed separately. A total score for each factor was calculated and compared by income per year (less or equal to $80 000, $80 001 or more, don't know), number of languages (1,2,3 or more), country of origin (Canada vs. others), background (white vs. non-white) and global health activity (non-active, active, neutral). Scores did not have normal distributions, therefore non-parametric statistics were used (Kruskal Wallis and Mann Whitney U tests). Bonferroni correction was used for multiple comparisons. A significance level of p<0.0056 was established. STATA 11.2 and SPSS were used.

Ethical considerations

This research received approval from all the universities involved.

Participants' characteristics

The survey was sent to 906 students from five universities and was completed by 97 students (response rate: 10.70 %). Partially completed surveys were not included in the analysis. Overall, the sample was predominantly female, mean age of 25 years, white, from the University of Ottawa, with a parent income of 80,000 Canadian dollars or more and able to speak two or more languages (Table 1). More than 50 % of the participants were Anglophones and 38 % reported proficiency in both Canadian official languages, namely, English and French. Additional languages reported were: Romanian, Chinese, Vietnamese, Polish, Dutch, Punjabi, Hindu, Amharic, Tigrigna, Polish, Tagalog (Filipino), Spanish, German, Korean, Somali, Croatian, Urdu, Hindi, Bosnian, Russian, Belarusian, Lithuanian, American sign language, Twi (Akan language which is widely spoken among the people of Ghana), Kinyarwanda, Hungarian and Russian.

Perceived knowledge in Global Health and Global Health Skills

Table 2 shows the results concerning the differences in income, language, country, ethnicity, global health activity and language. The Kruskal-Wallis and Mann Whitney U tests were conducted to evaluate whether the sample medians on a dependent variable were the same across all levels of a factor. After Bonferroni correction, the results showed that there was a significant difference in the median learning need in global health across language ability [nursing students who speak one language, two languages and three or more languages (p=0.0049)]. Differences were observed in "global health skills" across levels of global health activities (being active, non-active and neutral) and global health skills (p=0.004).

Learning needs in Global Health

Nursing students who spoke two or more languages were more likely to consider health risks associated with travel and migration as a very important and extremely important (68.2 % and 78.6 %, respectively) issue to learn in global health compared to nursing students who spoke one language (31.8 % and 21.4 %, respectively) (p=0.044). Moreover, nursing students who spoke two or more languages were more likely to rate the correlation between health and social determinants of health (SDH) as extremely important (71.1 %), and how SDH varies across world regions compared to nursing students who spoke one language (extremely important=28.9 %) (p=0.042).

Regarding learning needs in global health related to cultural competency (understanding how cultural background, socioeconomic status and language barriers can influence access to care and health outcomes), 100 % of the participants who spoke one language considered this as not at all important in contrast with none of the nurses who spoke two or more languages (p=0.018). Furthermore, more than 70 % of the participants who spoke two or more languages reported that learning about the correlation between access to clean water, sanitation, and nutrition on individual and population health were extremely important for global health when compared to participants who spoke one language (25.5 %) (p=0.009) (Table 3).

DISCUSSION

The response rate obtained in this study is comparable to similar surveys with nursing students and health professional students described in the literature ³⁹39. Hamshire C, Willgoss T, Wibberley C, Wibberley C. Should I stay or should I go? A study exploring why healthcare students consider leaving their programme. Nurse Educ Today.Sep 7., 2012.. Although there is an increased interest in global health among students and faculties ⁴⁰40. Izadnegahdar R, Correia S, Ohata B, Kittler A, Kuile S, Vai-llancourt S, Saba N, Brewer TF, et al. Global health in Canadian medical education: current practices and opportunities. Acad Med, Vol. 83, No. 2, 2008, pp. 192-198., a low response rate was observed. The survey was representative for some universities in Ontario, although low participation from other universities affected the overall response rate. More than 90 % of our sample was constituted by female students, since historically, nurses have been predominantly female ⁴¹41. Cockrell EDS. Prenursing students' perceptions of the nursing profession. A Thesis. Louisiana State University and Agricultural and Mechanical College. Northwestern State University, 2002.. According to the College of Nurses of Ontario report, in 2011, 90.9 % of new registered nurses in Ontario were female while 9.1 % were male. This data is also compatible with gender imbalance in other Canadian jurisdictions (female 91.0 %; male 9.0 %) and internationally (female 85.0 %; male 15.0 %) ⁴²42. College of Nurses of Ontario. Trends in General Class New Members 2011. Available at: Available at: https://goo.gl/RWKMgV . Accessed on february 24, 2013.
https://goo.gl/RWKMgV... . Indeed, the "feminization" of the health workforce is well documented in the literature ⁴³43. Frenk J, Chen L, Bhutta Z, Cohen J, Crisp N, Evans T, Fineberg H. et al. Health professionals for a new century: transforming education to strengthen the health systems in an interdependent world. The Lancet, Vol. 376, No. 1923, 2010, pp. 1958..

Approximately 30 % of nursing students reported an ethnicity other than white, which is also representative of the multicultural population in Canada. Several studies report the benefits of cultural and linguistic competencies on health outcomes ⁴⁴44. Goode TD, Dunne MC, Bronheim SM. The evidence base for cultural and linguistic competency in health care. Commonwealth Fund.pub no.962, 2006. and support the hypotheses that minority health professionals are more likely to serve minorities and disadvantaged populations when compared with non-minority health professionals ⁴⁵45. U.S.Department of Health and Human Services and Health resources and Services Administration. The Rationale for Diversity in the health professions: A review of the evidence. Boreau of Health Professionals, 2006.. Diversity in the health care workforce can improve quality, communication and trust of the health care delivery system among minority and disadvantaged populations by providing them with an opportunity to see a health professional with a similar background ⁴⁵45. U.S.Department of Health and Human Services and Health resources and Services Administration. The Rationale for Diversity in the health professions: A review of the evidence. Boreau of Health Professionals, 2006.. Ethnicity and language concordance are associated with better patient-practitioner communication and relationships. Ethnicity concordance occurs when patients and practititioners have the same ethnicity ⁴⁶46. Stepanikova I. Patient-physician racial and ethnic concordance and perceived medical errors. Soc Sci Med, Vol. 63, 2006, pp. 3060-3066., while language concordance occurs when patients and practitioners speak the same language ⁴⁷47. Manson A. Language concordance as a determinant of patient compliance and emergency room use in patients with asthma. Med Care, Vol. 26, 1988, pp. 1119-1128.. Both concordancies may also increase the probability of the patient receiving appropriate care ⁴⁵45. U.S.Department of Health and Human Services and Health resources and Services Administration. The Rationale for Diversity in the health professions: A review of the evidence. Boreau of Health Professionals, 2006..

This study shows that participants reported language ability in many other languages besides English and French. However, we are unable to know if these language abilities are a result of foreign language training in Canada or of working, studying overseas, growing up in a setting where another language was spoken or having parents who speak another language at home.

Language abilities are required for nurses who intend to work in international settings as well as in Canada, which is a bilingual country with an increasing immigrant population. Our research revealed that nurses who speak two or more languages are more likely to be interested in learning about global health issues, but despite the demographic changes and the increasingly diverse population in Canada, nursing students who spoke one language considered that cultural competency was not important. The American Nurses Association's Code recognized the need to provide culturally competent care ⁴⁸48. American Nurses Association. Code for Nurses. Washington, DC: ANA Publishing; 2001., while the Aboriginal Nurses Association of Canada, the Canadian Association of Schools of Nursing and the Canadian Nurses Association highlight the importance of providing culturally competent care ⁴⁹49. Aboriginal Nurses Association of Canada. Cultural Competence and Cultural safety in First Nations, Inuit and Metis Nursing education: An Integrated Review of the Literature. Available at: Available at: https://goo.gl/zQ94Qs . Acessed on march 30., 2009.
https://goo.gl/zQ94Qs... .

Lack of culturally competent care can increase the stress experienced by patients and result in inappropriate care by health professionals, therefore, nurses must have expertise and skills to provide culturally competent nursing care ⁴⁹49. Aboriginal Nurses Association of Canada. Cultural Competence and Cultural safety in First Nations, Inuit and Metis Nursing education: An Integrated Review of the Literature. Available at: Available at: https://goo.gl/zQ94Qs . Acessed on march 30., 2009.
https://goo.gl/zQ94Qs... . The practice guideline of the College of Nurses of Ontario highlights the need for culturally competent care between nurses and patients, and states that when communication barriers exist, nurses are responsible to develop a communication plan which encompasses working with interpreters, preferably with a professional interpreter ⁵⁰50. College of Nurses of Ontario. Practical Guideline: Culturally Sensitive Care. Available at: Available at: https://goo.gl/fBAWpt . Accessed on march, 30., 2009.
https://goo.gl/fBAWpt... . Cultural competency is an important global health component in nursing practice due to the increasing complexity of health issues that arise in a globalized world. These additional issues often relate to language and equity issues and require a better understanding of the influence of cultural background in health outcomes.

An exploratory survey to identify the perception of nurses about global health competencies applied in nursing faculties from the United States, Canada, Latin America and Caribbean countries found that additional global health competencies, cited by both English and Spanish respondents, were "need for a second language" and "fluency in second language", respectively ⁵¹51. Wilson L, Harper DC, Tami-Mauri I, Zarate R, SALAS S, Farley J, Warren N, Mendes I, Ventura C, et. al. Global health competencies for nurses in the Americas. Journal of Profesisonal Nursing, Vol. 28, No. 4, 2012, pp. 213-222.. In Canada, some universities encourage students to take language courses prior to beginning their elective subjects⁵²52. The University of Western Ontario. Language Training. Available at: Available at: https://goo.gl/525nD6 Acessed on march 23., 2012.
https://goo.gl/525nD6... , while others require a mandatory language course (the Dalhousie University Faculty of Medicine). Learning or improving a foreign language is one of several benefits of working in global health ⁴⁰40. Izadnegahdar R, Correia S, Ohata B, Kittler A, Kuile S, Vai-llancourt S, Saba N, Brewer TF, et al. Global health in Canadian medical education: current practices and opportunities. Acad Med, Vol. 83, No. 2, 2008, pp. 192-198.. Research has shown that, among the students who took international electives, less than 30 % attended preparation training for their international experience ⁵³53. Heck J.E, Wedemeyer D. International health education in US medical schools: trends in curriculum focus, student interest, and funding sources. Fam Med, Vol. 27, No. 10, 1995, pp. 636-640..

In our survey, less than 30 % of the nursing students were able to speak French. The inequalities reported in the literature related to minority Francophones in Canada ⁵⁴54. Bouchard L, Gaboury I, Chomienne MH, Gilbert A, Dubois L. La santé en situation linguistique minoritaire. Healthcare Policy 2009;4(4):33-40. who are affected by the inability of health professionals to speak French suggests the need for health professionals to use both Canadian official languages in their practices. The lack of French language knowledge in a health care setting can result in poor self-perceived health for Francophones, especially for those who live outside Quebec ⁵⁴54. Bouchard L, Gaboury I, Chomienne MH, Gilbert A, Dubois L. La santé en situation linguistique minoritaire. Healthcare Policy 2009;4(4):33-40.. The same problem is found in Anglophones in predominantly French settings. This study also shows that nursing students who are involved in activities related to global health develop more skills to work with global health, although the kind of activities related to global health that influenced them positively in their global health skills are unknown.

The educational implication of this study is that there are gaps in awareness about global health and cultural competency that may have negative consequences on the nurses' ability to practice. Knowledge in cultural competency, for example, is important to prevent misunderstandings regarding diagnoses and alternative and Western treatments that can lead to inappropriate medication use and poor health outcomes. This suggests a greater focus on global health and that cultural competence is needed in nursing programs. Also, it was possible to identify that nursing students who spoke only one language were significantly less aware of global health issues, which adds to a better understanding of language abilities and knowledge and skills in global health.

The strengths of this study are the use of a validated survey tool, and the sampling of five universities representative of the province of Ontario. However, this study has some limitations. First, it was a cross-sectional survey, thus causality cannot be established. Second, the response rate was relatively low, limiting the level in which these results can be generalized to other groups. Student recruitment was the main challenge of this study and some universities were more represented than others. Several reasons might have influenced the low response rate, including that the survey was delivered to some universities during the exams period. Additionally, some director/coordinators of the nursing programs were more committed and interested in the results of the survey than others, which may have influenced the students' motivation to participate. Third, our results are defined based on self-reported language ability.

The sample size was not sufficient to compare bilingual (English/French) Canadian students and multicultural nursing students and their knowledge and skills in global health. Future research could elucidate whether there are differences in global health awareness between these groups. Furthermore, a self-report assessment of nursing professionals is also important to identify gaps in their education in relation to global health, and whether they also differ according to language abilities.

In conclusion, this study suggests that nursing students who speak more than two languages are more likely to have an increased interest in global health issues. Students that are actively involved in activities related to global health in their programs may develop more global health skills. Based on the results of the survey, the following are three policy recommendations suggested to address this issue.

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