Developing English language skills for nursing Dr Paul J.

Glew School of Nursing and Midwifery University of Western Sydney, Australia p.glew@uws.edu.au Cite this article as: Glew, P. J. (2012). Developing English language skills for nursing. Unpublished manuscript. School of Nursing and Midwifery, University of Western Sydney, Sydney NSW, Australia. Retrieved from http://www.scribd.com/doc/106032465/2012-Paul-J-Glew-DevelopingEnglish-Language-Skills-for-Nursing

This review of the literature examines the learning of nursing students from culturally and linguistically diverse (CALD) backgrounds and focuses on international students who use English as a second language (ESL) (Schneider, Whitehead, Elliott, Lodiondo-Wood, & Haber, 2007). There is a paucity of literature examining in-depththe major pedagogical issues specifically related to ESL students in nursing programs (Choi, 2005, p. 265). In particular, there is dearth of research into the andragogical approaches used to support the language learning of ESL students engaged in nursing studies in Australia. This review uses language learning as a conceptual framework in discussing the learning of ESL students for nursing studies. The theories of language learning offer a broad framework for the complexity and contradictions (Grant & Giddings, 2002, p. 22) of language learning and facilitate a critical and interpretive perspective in reviewing the literature (Taylor, Kermode, & Roberts, 2007). Introduction In 2010 there were more than 617,000 full-fee-paying international students enrolled for study in Australia on student visas (Department of Education Employment and Workplace Relations, 2010). International students in Australia represent some 195 countries (Froude, 2005) and generate $14.2 billion annually for the economy (Australian Education International, 2008). Their education contributes to higher education revenues with substantial benefits to Australian education providers (Cameron, 2002). One area of growth in international student numbers has resulted from a need for more qualified nurses in Australia. In addressing this demand, many Australian universities have increased their intake of full-fee-paying international students into nursing programs (Dickson, Lock, & Carey, 2007). International students may apply for admission into a nursing course to not only obtain a nursing qualifications but also to gain national nurse registration and an opportunity to apply for employment as a nurse in Australia (Wang, Singh, Bird, & Ives, 2008). However, for university entry in Australia international ESL students are typically required to demonstrate an English language proficiency in the areas of reading, writing listening and speaking for academic studies. As a result these students often undertake English language studies in Australia in preparation for examinations such as the International English Glew, 2012 Developing English language skills for nursing 1

Language Testing System (IELTS) (IELTS, 2007) in order to qualify for tertiary course admission (Andrew, Salamonson, & Halcomb, 2008; Univeristy of Ballarat, 2008; University of Western Sydney, 2009; UWSCollege, 2009). Tertiary education providers and the nursing registration board in Australia acknowledge the need for international ESL students to have an adequate proficiency in English for nursing. For direct entry into undergraduate studies in nursing, universities often require international ESL students to have an overall English proficiency score of 6.5 on the Academic IELTS (University of Western Sydney, 2011). Following graduation the English proficiency requirement for nurse registration is higher than for university entry. Non-resident and overseas applicants for nursing registration in Australia need to demonstrate English language proficiency on an examination such as the Academic IELTS with a minimum score of 7.0 in all of the components of reading, writing, listening and speaking (Nursing and Midwifery Board of Australia, 2010). In enforcing the need to have adequate English language for nursing, the Nurses and Midwives Board of New South Wales declined the registration of 50 international ESL nursing degree graduates in 2008 based on inadequate levels of English language and knowledge for nursing practice (The Lamp, 2008). It has been argued that in nursing, as in other health care professions, without the appropriate level of English language, safe patient care could potentially be compromised (Australian Resource Centre for Healthcare Innovations, 2009). English Programs Wang et al. (2008, p. 140) claim that universities that provide education for international ESL students may not fully appreciate the students needs and are therefore inadequately prepared to provide them with a tailored, quality educational experience. However, in requiring international students with less than adequate English to attend an English Language Intensive Courses for Overseas Students (ELICOS) program some universities are endeavoring to address the initial English language needs of these students (University of Western Sydney, 2009; UWSCollege, 2009). Students can attend ELICOS programs at private colleges, Technical and Further Education (TAFE) institutes, and universities in courses accredited by the National ELT Accreditation Scheme (NEAS) (Department of Education Science and Training, 2007a, 2007b; National ELT Accreditation Scheme Limited, 2006, 2007). Given that language has been identified as the primary barrier to learning in ethnically diverse students (Johnston & Mohide, 2008, p. 5), there has been much growth in ELICOS student numbers and diversification in ELICOS programs that provide preparatory pathways for university (English Australia, 2009). The majority of ELICOS student enrolments are aged between 18 and 30 years and are from Asian countries such as China, Malaysia, Indonesia, Singapore, Korea and Taiwan (Wang, et al., 2008). There are fewer students from Europe, South and Central America and the Middle East (English Australia, 2007). As a conduit into Australian education, ELICOS has become a precursor and pathway for an increasing number of these international students into undergraduate courses such as nursing (Australian Education International, 2006; English Australia, 2009). Despite the reliance of the tertiary sector on the additional funding gained from full-fee-paying students, universities maintain the requirement for international ESL students to meet a minimum English language requirement for course admission (Dwyer, 2003; University of Western Sydney, 2011). The increasing number of international students seeking admission into tertiary programs combined with the requirement for them to have adequate English has contributed to the proliferation of ELICOS programs in Australia. However, there remains a lack of knowledge within the broader education sectors about ELICOS as the norms of practice, and expectations about quality, curriculum and outcomes Glew, 2012 Developing English language skills for nursing 2

are different from the formal school, vocational and higher education sectors (Department of Further Education Employment Science and Technology, 2005, p. 3). In particular, there is a gap in the literature about programs designed to prepare international ESL students for nursing studies in Australia (Dickson, et al., 2007; Giorgio, 2004; Wang, et al., 2008). Language and Learning Needs of International ESL Nursing Students International ESL students can face considerable challenges in English language universities, but little is known about the relationship between English-language acculturation and academic performance (Salamonson, Everett, Koch, Andrew, & Davidson, 2008). Although international ESL students can gain admission into a nursing course with a 6.5 score on the Academic IELTS and diligently engage in their studies, they may fail to meet the required standards of their academic courses and clinical placements because of difficulties with English (Giorgio, 2004). Having insufficient oral and written academic English is a cause of considerable anxiety among ESL nursing students (Choi, 2005, p. 265), and this may negatively impact on student learning and performance in nursing studies. Shakya and Horsfall (2000) explain that the poor achievements of ESL students in nursing studies is due to having to learn a new vocabulary, grammar and academic writing along with having to explore and understand concepts from nursing, the bio-sciences and social sciences (p. 165). Not only can these students experience difficulties in the usage of nursing terminology in English, but they may also be unable to adequately communicate in English with patients and effectively engage in interactions with nurses and other health care professionals in clinical settings (Johnston & Mohide, 2008). ESL students are expected to learn and deal with multiple complex clinical problems, often in a highly technological environment (Shakya & Horsfall, 2000, p. 169) and need to have an adequate command of English for the educational, clinical and social contexts in which they study. The work of nursing in Australia requires an ability to comprehend and use effective verbal and written communication with other health care professionals and in providing nursing care. For instance, in many clinical settings nursing care is highly dependent on accurate verbal communication, since much of the information and many orders are passed on verbally (Guhde, 2003, p. 113). Therefore, students on clinical placements are expected to communicate effectively with patients, the nurses they work with, and with other health care professionals (Shakya & Horsfall, 2000). However, the development of a level of English proficiency that is adequate for the work of nursing can take intensive instruction and practice over time for non-native speakers of English (Louey, 2007). Moreover, the use of effective communication skills in nursing involves having not only a sufficient command of English, but also knowledge of the culture and values specific to health care (Louey, 2007). International ESL students often lack exposure to the Australian healthcare system and especially, the Australian concept of nursing that is framed by the values, beliefs and expectations of a dominant western culture (Dickson, et al., 2007, p. 2). Consequently, programs that develop an understanding of the culture and values that influence nursing in Australian health care can enable these students to integrate this knowledge into their learning in nursing (Parker & Millan, 2008). The Cummins Model of cultural competence offers insights into the development of the interpersonal communication skills and the cognitive academic language proficiency that ESL students need for nursing (Choi, 2005). Guhde (2003) explains that international ESL students need a high level of English proficiency in speaking, listening, reading and writing for interpersonal communication in an Australian health care setting and that they require cognitive academic language proficiency and skills to analyse and evaluate abstract nursing Glew, 2012 Developing English language skills for nursing 3

concepts. To develop these communication and academic language skills for nursing, international ESL students can benefit from participation in intensive classes on the use of technical and conversational language for nursing (Shakya & Horsfall, 2000). These classes are one method of actively engaging international ESL students in programs that can facilitate adjustment to the different educational, social and cultural aspects of a foreign learning environment (Wang, Singh, Bird & Ives, 2008). Without effective interventions these students could remain disadvantaged in their learning as their understandings and learning experiences are culturally different to those which guide teaching and learning processes and curriculum content (Parker & McMillan, 2008, p. 144). Through nursing programs that build learner capacity in English language and cultural knowledge, international ESL students can develop the skills to engage fully in learning in their classrooms and clinical settings (Wang, et al, 2008). For instance, nursing students from Asian backgrounds may be unfamiliar with communication norms and teaching styles in Australia, and this could limit them from engaging in classroom learning (Parker & McMillan, 2008). Wang, et al. (2008) discuss how Asian nursing students can benefit from nursing programs that focus on developing independent learning skills rather than depending on structured, instructor-guided learning. The use of learning and teaching approaches that facilitate independent learning, functional communication skills in English and cultural understanding build the capacity of learners to enter new experiences, gain insights and experience change (Richards & Rodgers, 2001). International ESL students in nursing can experience different learning and language development needs to native English speaking Australian students and these need to be addressed through their studies (Dickson, et al., 2007). Giorgio, (2004) questions how international ESL students are to succeed in their studies if nurse education providers do not meet their language and learning needs. It is arguable that a holistic and student-centered approach to language and learning needs to be embedded in nursing programs to develop the needed skills and proficiency of international ESL students for their studies (Giorgio, 2004; Wang, et al., 2008). This could involve developing programs with specialist ESL teachers for nursing who can incorporate language learning and teaching approaches into courses to meet the needs of ESL students. Teachers play a vital role in implementing curriculum content and approaches to learning through their teaching that can help international ESL students to cross learning barriers and fully engage with the language and culture (Rogers, 2000c). A study by Giorgio (2004) found that specialist ESL teachers with sufficient nursing knowledge are able to provide effective instruction to students on language form and meaning that can advance their written and spoken communication skills for nursing. Specialist ESL teachers in nursing can also act as role models that help ESL nursing students to develop their linguistic and communicative competencies for classroom and clinical settings (Wang, et al., 2008). These approaches to learning and teaching for international ESL students respond to the invocations of Ostroff, OToole and Kropf (2007), and Forbes (2003) who suggest there is need for a holistic approach to education programs that foster the development of the full potential of the learner. Wang (2008) argues for a program framework and strategies to facilitate the learning of ESL nursing students using concepts from the Cummins Model. This model recommends that ESL students be provided with English language for professional nursing communication and support classes for clinical language development (Wang, 2008). The structural, interactional and functional views of language learning are relevant to programs for ESL nursing students. These views are underpinned by learning theories that inform the approaches to language Glew, 2012 Developing English language skills for nursing 4

teaching (Richards & Rodgers, 2001; Rodgers, 2001) and determine the instruction strategies and program content. The structural and most traditional view of language offers a theory of language as a system of related and coded elements with the goal of language learning being mastery of these elements (Richards & Rodgers, 2001; Rodgers, 2001). In contrast, the interactional view of language focuses on the learner negotiating meaning, using patterns of communicative exchange and engaging in interpersonal verbal interactions (Richards & Rodgers, 2001; Rodgers, 2001). Also, the functional view of language focuses on organising teaching content based on meaning and language function. An example of this view is found in the notional-functional syllabus, which incorporates the planning of course content based on language function and the communicative needs of learners to address elements of grammar and lexis, as well as notions, topics and concepts the learner is to communicate about (Richards & Rodgers, 2001; Rodgers, 2001). An interactional and functional program for ESL nursing students could promote learning in which students relate information to previous knowledge and experience (Kiger, 2004, p. 15) and have opportunity to learn from others, express opinions and ask questions. This would supports learner application of knowledge and skills to address specific problems and situations (Malouf, 2003) and engage learners in constructing their own learning experience (Tuijnman, 2002, p. 18). This approach involves the teacher guiding the learning process and fostering a supportive learning environment in which the learners are encouraged and facilitated to develop (Kiger, 2004, p. 81). The androgogical approaches embedded in a program for ESL nursing students need to incorporate theory on language learning, teaching and curriculum design, and reflect understanding of second language acquisition by drawing on knowledge from linguistics and language development (Larsen-Freemam, 2000). For example, language learning theory addresses factors that impact on learning such as social-cultural influences and student learning styles (Abriam-Yago, Yoder, & Kataoka-Yahiro, 1999; Cummins, 1991; Guhde, 2003; Larsen-Freemam, 2000). Moreover, the approaches used in the teaching of language include the structuring of content to improve learner comprehension through sequencing learning and using a degree of redundancy to review key concepts. This type of programming draws on language learning theory to develop, implement and evaluate content and uses elements of behaviourist, cognitive and humanist learning (Kiger, 2004; Rogers, 2002a). For instance, Blooms taxonomy (Bloom, 1956; Krathwohl, Bloom, & Masia, 1964), illustrates that teaching and learning involves the cognitive, psychomotor and affective domains and may engage more than one domain at a time to move through a hierarchy from lower to higher levels of skills. Choi (2005) suggests that in nursing studies ESL students benefit greatly from an instructor who proceeds from cognitively easy tasks to cognitively challenging tasks (p. 265). Within the cognitive domain the levels of learning proceed from knowledge of concepts and facts, to comprehension, application, analysis, synthesis and evaluation (Kiger, 2004; Richards & Rodgers, 2001). Traditional approaches and methods for language learning, based on behaviourist theories, involve the teacher directing the selection of the stimuli, reinforcing approved responses and discouraging other responses (Rogers, 2002c). This does not reflect the complexities of language learning and teaching that is informed by knowledge of the subject matter, language and culture, and the learner (Larsen-Freemam, 2000). A program for ESL students uses cognitive and humanist learning theories that place emphasis on learner thinking to process information and solve problems (Rogers, 2002b). Although cognitive learning theories involve hierarchies of learning with strategies for high and low-level learning, humanist learning theories do not contain distinctive hierarchies of learning. Humanist learning Glew, 2012 Developing English language skills for nursing 5

theories claim that stimuli in learning involve social contexts and that the variety of our responses is dependent on individual experiences and personalities (Rogers, 2002a, p.10). These theories are evident in learning that focuses on learner motivation and interest with movement of the learner towards increased autonomy and competence (Rogers, 2002a). Similarly, cognitive theories incorporate learner perception and how learners view and respond differently to stimulus due to factors such as experience, cultural expectations and personal characteristics (Kiger, 2004). Importance is placed on the learner being inquisitive and engaging in learning that is meaningful. Conclusion Although full-fee-paying international ESL students may complete an ELICOS program and have an IELTS score to meet university admission requirements, they can have difficulty in meeting the demands of nursing studies in Australia. They not only require a sufficient command of English, but also a cognitive academic language proficiency and cultural knowledge to achieve success in their studies and clinical placements in health care settings. To provide a holistic approach to learning in nursing, university programs need to meet the learning and language needs of these full-fee-paying ESL students by embedding approaches to learning and teaching strategies in their programs that can improve English proficiency, academic language skills and cultural understanding. Drawing on the knowledge and skills of ESL specialists to integrate English language skills, academic language and cultural knowledge into the curriculum and its delivery are strategic learning and teaching approaches that may effectively meet the learning and language needs of international ESL students. These approaches may successfully build the capacity of these learners in their use English for nursing, facilitate achievement in their academic studies and serve to improve their language to meet more than the minimum English proficiency standards for nurse registration in Australia.

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