Running Head: English as a second language

HLT504
Issues in clinical education
Rebecca Sinyi
1137928

INTRODUCTION

The increasing number of immigrants has transformed Canada in a variety of ways, specifically, in the field of Nursing and Nursing education. The advantage, to this diversity of ethnicities, is that the different ethnic groups are instrumental in supporting the nursing profession to adequately provide culturally competent nursing care. The obstacle that Nursing is experiencing lies with the nursing students and the educators. The frequent challenges the students experience relate to language, academics, resources and culture, (Starr, 2009). The reality, however, is that the ethnic students who lack mastery of the English language experience more academic and clinical difficulty. According to Campbell, (2008) there is a ???2:1 ratio dropout rate for minority students compared to Caucasian students???.
The faculty or educators encounter several stumbling blocks when teaching ESL students. The compilation of literature reveals that we, as educators, are ill-equipped to provide the necessary strategies, interventions and resources that promote the culturally diverse student to succeed within the nursing curriculum. This reinforces the need for nursing programs to develop creative means to alter this tendency.
As a clinical instructor it is my mandate to ascertain the student possesses basic theory knowledge for the clinical experience, facilitate the application of principles and concepts related to patient care, promote critical thinking and problem solving skills and lastly to ensure advancement to the next level. This is increasingly difficult if the student has limited English. In view of my personal objectives, coupled with encountering ESL students, I felt it to be my obligation as an educator to equip myself with relevant literature that define the actual challenges and foster strategies that pertain to this very palpable clinical education issue.
The following annotated bibliography is based on literature found using the keywords, ESL nursing student??™s challenges, teaching nursing students whom ESL and educator barriers with ESL students. The database used was CINHAL.

ANNOTATED BIBLIOGRAPHY

Abriam-Yago, Katherine., Yoder, Marian., Kataoka-Yahiro, Merle. (1999). The Cummins model: A framework for teaching nursing students for whom English is a second language. Journal of transcultural nursing. 10 (2) 143-149.

The article discusses the need for specific teaching strategies in educating students for
whom English is a second language (ESL). The authors reflect on present teaching
strategies and recognize that they may not be practical for ESL students. They describe
the Cummins model of language acquisition and utilize the framework to develop and
interpret eleven teaching strategies that assist the ESL student in promoting critical
thinking skill. The strategies are well defined and constructive examples are specified.
The authors are either professors or assisted Professors in the school of Nursing in
various states. I find the article to be unbiased and an adequate account identifying the
various issues that are encountered with this topic.
I find this article to be quite informative and relevant to the issues of ESL students. As
an educator of many ESL students it is imperative to source out a variety of teaching
strategies and styles that foster the distinct learning needs of ESL students.

Campbell, Barbara E. (2008). Enhancing communication skills in ESL students within a community college setting. Teaching and learning in nursing. 3 100-104.

The article describes a program that was implemented at the author??™s college to improve
both oral and written communication skills for students with deficient English
proficiency. She describes the program in detail and gives a statistical analysis related to
the attendance and outcome of the sessions which are based on chi-square testing. The
workshops demonstrated a noteworthy difference in student??™s nursing grades.
Furthermore, the author recognizes the limitations of the study and provides
recommendations.
The author, a professor, teaches Nursing at a community college in a large Metropolitan
area. This project was funded by a Federal grant used for the development of academic,
career and technical skills in post-secondary institutions. This funding aids initiative that
improve oral and written communication skills in vocational students.
The author has presented this initiative at many events across United States.
The article is useful in that it demonstrates the obligation we have as educators to become
more cognizant of various learning styles and be aware and develop our own cultural
competence.

Carter, Kimberly F., Xu, Yu. (2007). Addressing the hidden dimensions in nursing education: Promoting cultural competence. Nurse Educator. 32 (4) 149-153.

This article provides a very thorough description of the process undertaken in implementing a culturally competent quality enhancement program within a nursing curriculum. The objective of the program is to identify the challenges with retaining students who speak English as a second language. The ultimate goal is to establish realistic strategies to ensure successful completion of the nursing curriculum. Additionally, the authors outline, in detail, the process involved in: establishing the program, examining the strategies and reviewing the outcome and finally the evaluation of the training program.
The authors are associate professors at two separate nursing schools, Radford,Va. and LV, Nev. respectively. This project was funded by a quality enhancement plan implementation grant.
I like this article because the author addresses the quality enhancement program that was developed based on the assessment data. In was an honest description of the feeling of the participants. It recognized the sensitive issues that can be encountered when staff neglects to respect and understand cultural diversity.

Chiang, Vico., Crickmore, Barabra-Lee. (2009). Improving English proficiency of post-graduate international nursing students seeking further qualifications and continuing education in foreign countries. The journal of continuing education in nursing. 40 (7) 329-336.

These authors, through a literature review, identify that international nursing has become a form of continuing education that enhances skills and augment qualifications. However, they recognize that proficiency in English was crucial for nurses being clinically placed in an unfamiliar environment. To that end, the article describes the course that was developed and offered, by and Australian University school of nursing, to aid in the transition of international nursing students in a cross-cultural environment. The authors describe in detail the transition course and the theoretical framework utilized for the program. They identify the Likert scale as an evaluation tool for the student??™s development of communications skills throughout the course.
Both authors have doctorates and are teaching consultants, one in China the other Australia. Collaboratively, their experience in this area has afforded them insight into the barriers encountered with this issue.
I found this article to be detailed in its account of the course however, very specific to the Australian culture. I think that the transition course would be valuable in many colleges or universities settings as it assists the ESL student to acclimatize to the culture, language and specific practices.

Donnely, Tam Troung., McKiel, Elaine., Hwang, Jihye. (2008). Factors influencing the performance of English as an additional language nursing students; Instructor perspective.

It is important to recognize that the University where this study was conducted has replaced ESL (English as a second language) with EAL ( English as an additional language). The University felt that the term ???second??™ denoted inferiority.
The Canadian author specifically describes a qualitative research method that was undertaken to identify, from an instructors perspective, the difficulties encountered in educating EAL students. They recognize that the sample size is small but feel the analysis is valuable. The analysis of the study revealed five themes. From these themes came recommendations for universities to establish policies and programs that address the specific learning need of the student and establish effective teaching strategies for the instructors to enhance best practice.
The credentials of the authors are not presented.
I liked this article because it was very complete. It gave great detail with regards to the analysis. I liked the comments that supported the themes that emerged from the study. I find the information useful to my practice as a clinical educator. It reinforces the need to utilize and collaborate with colleagues in order to create an ongoing supportive learning environment.

Donnely, Tam Troung., McKiel, Elaine., Hwang, Jihye. (2009). Challenges and motivators influencing the academic performance of English as an additional language (EAL) nursing students: The perspective of the students.
This article is a sequel to the previous article. The authors describe the descriptive, exploratory, qualitative research design undertaken to examine various problems encountered by EAL students. It is important to note that they used maximum variation purposive sampling, which includes average people thereby making the study more reliable. The authors present the themes that emerged from their findings and provide detailed breakdown of the challenges the students face using quotes. Additionally, recommendations are presented.
I liked this article for its detail. I found that reading some quotes were similar to what I encounter in my own clinical setting. The strategies presented, can be utilized by an educator to facilitate and promote the success of the EAL student.

Guhde, Jaqueline A. (2003). English-as-a-second language (ESL) nursing students: strategies for building verbal and written language skills. Journal of cultural diversity. 10 (4) 113-117.

This author clearly identifies the many educational and language barriers, within the nursing curriculum, encountered by ESL nursing students. To that end, she reveals studies that support this issue. The author outlines a tutoring program that was instituted to further assist the ESL student to develop and strengthen English proficiency. The strategies are clearly outlines with examples and rationale for use. The author reports and evaluates theses strategies based on a case study utilizing an ESL student, from China, enrolled in the nursing curriculum. Through the evaluation she identifies how the template can be adapted to the progression of the student and to various clinical placement encountered by the nursing student.
The author recognizes that financial constraints inhibit the institution of a similar program in many institutions.
The author is an instructor at the University of Akron Ohio. She has her Master and is a Clinical Nurse Specialist.
Overall, the article was very thorough and informative regarding this topic. I like that she points out that language skills is divide into four categories. The author gives many examples and rationales on how to supplement the learning of the ESL student and what component of the learning process it will develop.

Malu, Kathleen F., Figleas, Mary R. (2000). Six active learning-based teaching tips: Promoting success for ESL nursing students. Nurse Educator, 26 (5) p 204,208

Through a qualitative research study the authors identify and analyze one problem nurse educators and ESL nursing students face within the curriculum: language development.
The authors briefly describe six teaching techniques to promote meaningful learning, in the area of language development, for nursing students whom English is a second language (ESL). They utilize a case study to present the evidence to support their findings.
The author determines that the active learning model, as opposed to the transmission model of teaching, is the rationale for the success of the ESL student. The author does not, however, elaborate on the either model or why one model is preferred.
Although the article had some valuable information I did not find it to be as thorough as other articles. I did like that they identified the two types of language development: basic interpersonal communicative skills (BICS) and cognitive academic language proficiency (CALP). I also like the use of case studies because it shows the practicality of certain strategies.

Sanner, Susan., Wilson, Astrid. (2008). The experiences of students with English as a second language in a baccalaureate nursing program. Nurse education today. 28 807-813.

The authors describe a qualitative research study that was undertaken because faculty had identified specific and ongoing difficulties ESL students were encountering in the nursing program. The method, data collection and analysis and results were discussed. Various themes are identified and illustrated using participants comments. The findings were predominantly the perception of the participants involved in the study and it related to cultural experience, meanings based on previous learning and family and prior learning experiences.
I found this article useful in that it pointed out the learning styles that the ESL students were familiar with and the difficulty encountered being taught with different teaching styles. It made me realize that to be an effective educator whether academically or clinically I must utilize a variety of teaching methods to impact the different learning students gravitate towards.

Shearer, Jessica B. (2008). English as a second language among licensed practical nurses: Implications and relevance in practice. Journal of practical nursing. 58 (1) 26-27.

Through varied research the author identifies that accurate communication is integral within the nursing profession. She identifies that there is a direct link between poor communication and patient??™s litigation complaints, healthier patient outcomes, and the promotion of trust between the nurse and patient. The article is purely a very brief synopsis of literature relating to language and communication.
The author is a professor of the Practical Nursing program at a community college in Sanford, Florida.
I did not find this article to be very informative especially after reading the previous annotations. Her thoughts were brief and scattered.

Starr, Kimberly. (2009). Nursing education challenges: students with English as an additional language. Journal of nursing education. 48 (9) 478-487

The author combined ten qualitative studies that addressed challenges faced by nursing students with English as an additional language. They describe Noblit and Hare??™s ethnographic metasynthesis model to coordinate this study. The article illustrates the break down of the studies identifying how the themes emerged and recurrent issues that were revealed. In detail they describe the two main categories that are manifested, challenges of the EAL students and reinforcement that encourage success. The recommendations and implications are clearly defined.
The author is a Nursing Education independent contractor from Lamar Colorado.
I found this article to be very useful. The author is very detailed in her literature review and the synthesis of the material. She indicates what databases she used for the literature search and all are credible. The information regarding intervention to assist in successful education is presented well

INTRODUCTION

Within the practice of nursing, it is essential to have the ability to communicate accurately and effectively in both oral and written form, (Campbell, 2008). Academic difficulties are experienced, to a large extent, with students whom English is a second language (ESL). Furthermore, patient safety, patient satisfaction and effectiveness of care can all be compromised by poor English, (Carter 2007).
As stated by Campbell, there will be 1.2 million nursing vacancies within the United States by 2014. It is expected that the racially and ethnically diverse nursing student will occupy a large percentage of those positions. Furthermore, the American Association of College of Nurses annual report, 2001, has publicized that the minority representation constitutes 10.5% of the baccalaureate nursing programs. In Canada, two million people, or 6.3% of the population, are immigrants, (Statistics Canada, 2006). These statistics demonstrate that ESL within the nursing program is an escalating concern internationally.
Language acquisition is a very complex process. It involves understanding syntax, phonetics and mastery of a sizable vocabulary. There are two types of language proficiency, basic interpersonal communication skills (BICS), and cognitive academic language proficiency (CALP). BICS are language skills used in everyday conversation. CALP refers to formal academic learning. It not only includes the basic ability to listen, speak, read and write about a subject but to analyze, compare, and evaluate the material. The content of nursing programs is academically demanding for most students, but specifically for students whom English is a second language. To that end, the ESL student often has acquired the BICS but not the CALP leading to comprehension and retention difficulties, resulting in poor academic and clinical performance.
Language and communication is the most significant challenge ESL students and educators encounter. The objective of this paper will serve to identify the challenges faced by faculty and ESL students, and define effective strategies to overcome this hurdle.
FACULTY CHALLENGES
Among the literature reviewed, there are recurrent themes that emerge that identify the prevailing challenges that educators are confronted with. First and foremost, educators identify that English proficiency and communication difficulties are among the greatest concern with ESL students
From a clinical perspective, patient safety has been an apprehension communicated by many instructors, (Donnelly et al, 2008). Specifically, the language difficulty leads to incorrect charting. Charting requires an organized thought process and a good grasp of medical terminology. Poor charting leads to misguided information and is often contradictory. Misunderstanding orders for medications and procedures leads to errors and compromises patient safety. Many ESL students have difficulty communicating and interacting with clients and colleagues. The consequence of poor communication stems from the reluctance of the ESL student to feel comfortable clarifying the instruction or assignments. The inability to participate in meaningful interpersonal interaction compromises nurse-patient relationship as it relates to trust and confidence. Collaboratively, these inferior practices can lead to endangering the client??™s safety health and wellbeing. Donnelly et al, 2009, state that given these clinical issues there is a concern that the ESL student may have difficulty advocating if a dilemma were to arise.
Since English proficiency includes reading and writing, educators must be familiar with various teaching styles in order to include student??™s various learning requirements. Students whose primary communication skill is BICS are more apt to memorize facts as opposed to understanding concepts and ideas, thereby having difficulty applying concepts in the clinical setting, (Starr, 2009). Additionally, academic and clinical work requires more time if the student is thinking and processing information in their native tongue then mentally translating. This leads to a failure to complete assignments and examinations in a timely fashion.

STUDENT CHALLENGES
The difficulty with English skills has many negative implications for ESL students. (Donnelly, Mckiel and Hwang, 2009). Academic performance appears to be the biggest challenge for ESL students. ???Difficulty understanding textbooks, lectures, teacher??™s expectations and the wording of written examinations, writing papers in APA style and expressing thoughts in grammatically correct sentences???, (Donnelly et al, 2009 p. 135), interfered with the learning process. Because the English language has many colloquialisms this further compounds confusion when processing verbal information.
The North American learning environment encourages students to question and present different perspectives as a form of interactive learning. This form of assertiveness is in direct contrast to many cultures of the ESL student. Moreover, the inadequate language skills, prevents them from participating in class and asking questions which may be regarded as being unmotivated to learn. The reality stems from wanting to avoid feeling alienated because of their accent and poor articulation in English, (Donnelly et al, 2009).
STRATEGIES/RECOMMENDATIONS
There have been a variety of recommendations formulated based on qualitative studies completed in the literature reviewed to enhance the learning of the ESL student. The suggestions and strategies are primarily the responsibility of the institution and faculty; however, it is not the sole responsibility of the educator to ensure the development of English proficiency. The student needs to be accountable to embrace opportunities and resources that are available to them. The suggestions and strategies are in keeping with the language and communication challenges discussed.
The program described by Campbell, 2008, describes a ten-week workshop designed to improve oral and written work. The oral workshop involved pronunciation of medical terminology, conversational rules and role-playing. The written workshop included writing nurses notes, care plans and summaries of patient??™s medical histories.
According to Donnelly et al, 2009, it is important to have a thorough screening process to ensure language proficiency and success within the nursing program. Furthermore, it is recommended that ESL student take a mandatory English course as part of their electives.
Australia University initially provided an orientation package for international students but found that the orientation was not sufficient, (Chiang & Crickmore, 2009). As illustrated by Chiang & Crickmore, 2009, the university instituted a full semester transition course that facilitated the development of communication skills, adapting to foreign cultures and reduce culture shock. The evaluation of the program indicated it was successful in enhancing clinical communication skills and cultural competence.
Gudhe, 2008, describes a nurse tutor program that was undertaken by the University of Akron Ohio. This program incorporated exercises that covered the four areas of language. One exercise was reading aloud to address verbal skills, pronunciation and encourage clarification. The second exercise evaluated written skills, specifically nursing notes. The nurse tutor ensures correct grammar, spelling and appropriate medical terminology. The third exercise is reading a list of words heard on a tape. This enhances pronunciation and comprehension of various words. The last exercise is utilized to develop listening skills. The student listens to a taped report of two patients and jots down pertinent information. The tutor reviews the data collected by the student to evaluate the ability to extrapolate and differentiate information that is needed to know as opposed to ???nice to know???. The evaluation of the program as stated by the students was very useful.
Malu and Figlear, 1998, specifically address approaches that improve language development. They suggest that nurse educators prepare a handout with problem words and it is the student??™s responsibility to update the list as various difficult words are encountered. Another recommendation was keeping a vocabulary notebook with definitions, synonyms and personal connections the student has with the word. This enables the student to ???build a concept map, categorize words and connect interrelated concepts and abstractions???, (Malu and Figlear, 1998).

CONCLUSION
Barriers within the nursing curriculum are encountered from the ESL student??™s perspective as well as the educators. Teaching strategies and cultural awareness must be examined in order to meet the needs of this growing diverse population. It is the professional responsibility of universities and educators to facilitate the success of ESL students by revising course objectives to accommodate their learning needs. Additionally, institutions must be made aware of the ESL student??™s particular need for furthering their grasp of the English language and establish the corresponding strategies to effectively overcome this barrier to learning.

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