What do we know about educating Asian ESL nursing students? A literature review.
Keywords Asian Nursing Students--English-as-a-Second Language Nursing Education--Cultural Variability--Language Barriers--Instructional Differences--Instructional Strategies
TRADITIONALLLY, ASIA HAS PROVIDED THE GREATEST SHARE OF INTERNATIONAL NURSING STUDENTS TO THE UNITED STATES. During 2008-2009, 62 percent of the 671,616 international students in the United States came from Asia (Institute of International Education, 2010), primarily Chinese, Asian Indians, Koreans, Taiwanese, Japanese, and Vietnamese. Despite diversity among these groups, there are certain commonalities among people of Asian origin. Asian students who speak English as second language (ESL) face cultural barriers their non-ESL peers may not experience.
For the purpose of this article, ESL students are defined as students who attended grade school outside the United States and use a language other than English in daily functions, or students raised in a non-English-speaking environment who continue to use their native language in the home while using English in environments where the native language is not used. Although most Asian students develop some English reading and writing skills before coming to the United States, they typically have few opportunities to speak English in their native countries or at home. Thus, they often have difficulty speaking and understanding English when they enter the US educational system.
Common difficulties with the English language are gender and tense; in some spoken Asian languages, such as Chinese, there is no need to differentiate gender and tense. There are also instructional differences at both the philosophical and classroom levels. For instance, in Asian educational systems, emphasis is placed on memorizing details of important facts. In contrast, reading widely and then synthesizing or critiquing is a common educational strategy in the United States. The large amount of required reading in most US nursing curricula can be overwhelming, causing Asian students to fall behind their peers (Abu-Saad, Kayser-Jones, & Tien, 1982).
There is very limited research on Asian ESL students in nursing. An extensive literature search indicated that there are no specific reported statistics on the attrition rate of Asian ESL nursing students. However, published articles (Abriam-Yago, Yoder, & Kataoka-Yahiro, 1999; Abu-Saad et al., 1982; Guhde, 2003; Kataoka-Yahiro & Abriam-Yago, 1997; Phillips & Hartley, 1990; Xu & Davidhizar, 2005) and anecdotal evidence revealed a concern over attrition rates among these students as both their numbers and proportion continue to increase in nursing programs across the United States.
This review synthesizes the existing literature on Asian ESL nursing students. Specifically, it reviews the conceptual frameworks used in studying Asian ESL nursing students and challenges encountered by these students. Research findings regarding academic strategies of Asian ESL nursing students published between 1980 and 2010 are summarized. The authors elaborate on the use of an evidence-based approach to apply the findings to Asian ESL nursing students in order to enhance their learning outcomes and educational experiences.
Method The authors conducted an exhaustive electronic search of studies published between 1980 and 2010. Some classic book literature, published before 1980, is discussed in this article. Key words used in this systematic literature search were retention strategies for ESL nursing students, teaching strategies for culturally diverse nursing students, and barriers to education of the ESL nursing student, with and without the term Asian. Databases searched included CINAHL, LexisNexis, Expanded Academic ASAP plus, Medline, Cochrane Database of Systematic Review, and PsychINFO.
This search identified more than 55 articles addressing culturally diverse nursing students. Although only eight articles specifically addressed issues with Asian ESL nursing students, it is believed that the recommendations for other ESL nursing students may be relevant if cultural differences are taken into consideration and modifications are made accordingly.
Synthesis of Findings CONCEPTUAL FRAMEWORKS A number of conceptual frameworks have been applied to understand and interpret behavioral differences observed in Asian students at the cultural level. Xu and Davidhizar (2005) attempted to use what they called "Framework of Cultural Variability" to shed light on the observed differences in Asian ESL students. The framework consists of two dimensions: individualism vs. collectivism (Triandis, 1995) and low-context vs. high-context communication (Hall, 1976).
Triandis (1995) conceptualized cultures around the globe along two constructs: individualism and collectivism. According to Triandis, individualism is defined as "a social pattern that consists of loosely linked individuals who view themselves as independent of collectives; are primarily motivated by their own preferences, needs, rights, and the contracts they have established with others; give priority to their personal goals over the goals of others; and emphasize rational analyses of the advantages and disadvantages to associating with others" (p. 2). The United States, Australia, and most Northern European countries are examples of individualistic cultures.
In contrast, collectivism is a social pattern consisting of closely linked individuals who see themselves as part of one or more collectives (family, co-workers, tribe, and nation) and where "we" comes before "I." Individuals in collective cultures are "primarily motivated by the duties and goals of the members of these collectives over their own personal goals" (Triandis, 1995, p. 2). The cultures of African, Arab, Asian, Latin, and Southern European countries are predominantly collectivistic (Xu, Lippold, Gilligan, Posey-Goodwin, & Broome, 2004). In addition, the concept of self in many Asian cultures is a relationship-based concept where the self is rarely considered independent or separate from a group (Xu et al.).
Triandis's framework of individualism vs. collectivism offers a broad and robust theoretical framework at the cultural level. For instance, it can shed light on many Asian ESL nursing students' behaviors, such as respect for authority figures and preserving interpersonal harmony as priorities. However, such culture-based behaviors present a challenge when there are conflicts. Often, "quietness" among Asian ESL nursing students is interpreted as having no views at all or an inability to formulate an opinion. The tendency for cooperation could be interpreted as overdependence.
Another useful conceptual framework was developed by Hall (1959), who proposed the idea that "culture is communication and communication is culture" (p. 217). Hall conceptualized world cultures along a low-high continuum in terms of context dependency. A culture is described as a low-context culture if communication is explicit and direct; all information is found in the coded, explicit, transmitted part of the message. According to Hall, mainstream US culture tends to be low context. In contrast, communication in a high-context culture is indirect, implicit, internalized, or more dependent on physical and psychosocial contexts. Based on Hall's criteria, all Asian cultures are high context. Hall further suggested that culture determines what an individual takes in and leaves out in terms of information processing.
Hall's conceptualization offers another powerful explanatory framework for Asian ESL nursing students' behaviors, especially regarding communication patterns and styles. For example, Asian students assess verbal and nonverbal clues to make a decision as to whether to approach an American faculty or an American classmate. At times, because of a different cultural lens to filter information, they may be incorrect in interpreting clues, and misunderstanding is not uncommon. In addition, people from high-context cultures (e.g., Asian ESL nursing students) have higher expectations--they expect that their needs could be perceived before they are made known. Such expectation is unrealistic in most situations in the low-context US culture because it requires knowledge of "cultural programming," an automatic mechanism formulated through one's primary socialization in a given culture.
The third conceptual framework is the Model for Enhancing Intercultural Communication conceptualized by Xu and colleagues (2004) based on their empirical experiences. This model is predicated on the assumption that perception is subjective. Because of differences in personal experiences, cultural influence, situation-based contextual factors, and the inherent ambiguity of language, people may perceive the same event or situation with different and even conflicting interpretations that could lead to misunderstanding and impaired communication. This model proposes that a third party can serve as a "mirror" to validate the independent perceptions of different parties involved and help interpret or bridge the perceptual differences. While this model was based upon real cultural encounters of a male Asian American faculty and his American colleagues, it can be applied to intercultural communication between Asian ESL students and their American faculty to validate perceptions and improve communicative effectiveness.
The final conceptual framework is the Cummins Model of Second Language Acquisition (cited in Abriam-Yago et al., 1999). This model maintains that there are two types of language proficiency: basic interpersonal communication skills (BICS) and cognitive academic language proficiency (CALP). CALP requires students to communicate in more cognitively demanding oral and written situations, such as class discussions and lectures. Educational research suggests that it takes ESL students approximately two years to become proficient in BICS and four to seven years to achieve competence in CALP (Abriam-Yago et al.). This model could explain how ESL students learn language for social and academic purposes and sheds light on the process and challenges associated with second language acquisition. In addition, research has shown that linguistic and communicative competence is also related to the length of time in a new host culture/country. Most individuals require a period of four to eight years to reach a level of language competence needed for scholastic achievement (Abriam-Yago & Kataoke-Yahiro).
LANGUAGE AND COMMUNICATION The literature highlighted a number of barriers that have the potential to lead to attrition of Asian ESL nursing students. Communication in its broad sense may be the greatest barrier to success among these students. Communication difficulties, acting alone or in combination with other barriers, such as cultural differences, affect learning outcomes and educational experiences.
A review of the nursing literature by Xu and Davidhizar (2005) indicated that a number of challenges affected Asian ESL nursing students. Language barriers and cultural differences are identified as the leading cause of a myriad of academic and psychosocial issues, and often result in communication and adjustment difficulties in social and academic environments. Specifically, second language acquisition is a lengthy process, and communication patterns and styles are largely determined by culture (Xu & Davidhizar; Xu et al., 2004). Perhaps the most significant finding is that culture influences communicative behaviors subconsciously or unconsciously, particularly regarding nonverbal communication (Xu & Davidhizar).
A number of authors who examined communication (Guttman, 2004; Malu & Figlear, 1998; Memmer & Worth, 1991; Phillips & Hartley, 1990) described how effective communication is critical in nursing education. These authors offered various educational approaches to improving student success, including assessment of English proficiency via a valid instrument prior to admission to a nursing program and remediation as a requirement if prescribed entry scores are unmet. Orientation programs containing details of program matriculation and support services were recommended as an opportunity to answer questions and clarify mutual expectations.
By far, the largest cluster of studies on ESL nursing students focuses on language acquisition and its effects on learning outcomes and educational experiences, especially NCLEX-RN[R] pass rates. In an examination of NCLEX-RN pass rates, Johnston (2001) reported that pass rates for students whose first language was English ranged between 67.7 percent and 95 percent, while pass rates for ESL students fell between 33.3 percent and 47 percent
Johnston concluded that language skills are a key factor in passing the licensure exam.
According to the Cummins Model (Abriam-Yago et al., 1999), increased comprehension of the English language by ESL students comes from articulating specific ideas in their own language. Today, ESL students are encouraged to explain their lessons to family members or others of the same ethnic community. When they can express a clear understanding in their own language, they are more easily able to learn and articulate this level of comprehension in English. This, in turn, facilitates the transition from BICS to CALP for an ESL student (Choi, 2005).
The literature also indicates that competence in English can be strengthened by the integration of basic skills and rules of communication in listening, speaking, reading, and writing. Educators can enhance students' language development by encouraging the use of dictionaries, thesauruses, and taping of lectures. Practicing test questions in a variety of formats will also strengthen vocabulary and improve speed and stamina during testing.
SUPPORTIVE ENVIRONMENT AND INFRASTRUCTURE Mutual respect for cultural differences between student and educator enhances learning. A number of studies illustrate teaching strategies that proved effective in helping culturally diverse ESL students have a more positive educational experience (Abriam-Yago et al., 1999; Abu-Saad et al., 1982; Kataoka-Yahiro & Abriam-Yago, 1997; Klisch, 2000; Xu & Davidhizar, 2005). A summary of these strategies includes: faculty acknowledging individual differences in cultural values, thus reinforcing confidence in the student; pairing students with a professional mentor, student groups, and host families of the same cultural background, providing students with a sense of belonging; and eliminating items in lectures and test banks that discriminate against students from diverse cultures. Workshops and seminars to enhance educators' own intercultural competence are also effective. An ESL adviser as a certified transcultural nurse could serve as a consultant to faculty and students on cultural competence issues. Pairing ESL students with native volunteer English-speaking nursing students facilitates the practice of English, provides exposure to cultural variability, and enhances appreciation of cultural diversity.
INSTRUCTIONAL STRATEGIES The search of the literature uncovered a number of learning and teaching strategies recommended to improve the learning outcomes and educational experiences of Asian ESL students. (See Table.) Although most of these strategies do not appear to be research based, they are empirically grounded and proved effective for the published authors. Readers need to be cautious when applying these strategies, as situational or contextual factors may vary, affecting their effectiveness. Indiscriminant application of these strategies without critical evaluation and scrutiny is likely to result in undesirable or even disastrous results.
Discussion Over the last 30 years, an emerging body of literature on ESL nursing students has emerged. Nevertheless, the focus on Asian ESL nursing students is limited. An evaluation of state-ofthe-art scholarship on this subgroup of ESL students, with unique needs and characteristics, is needed if their learning outcomes and educational experiences are to improve.
CONCEPTUAL FRAMEWORKS Conceptual frameworks at the cultural or macro level are needed to understand, interpret, and predict the behaviors of Asian ESL nursing students. The conceptual frameworks of collectivism vs. individualism and low-context vs. high-context cultures offer a robust framework at the cultural level. Other potentially powerful explanatory frameworks, such as the Face-Negotiation Theory by Ting-Toomey (1988), may also be applied to supplement the existing conceptualizations.
Because Asian students operate within a very different cultural paradigm that may affect their behaviors and process of language acquisition, an Asian-specific language acquisition model may be developed. The Cummins Model of Second Language Acquisition is generic and offers general explanations for this process, but it does not take into account the important modifying factor of culture. It could be modified to include culture as a dynamic variable in the acquisition of a second language.
LANGUAGE AND COMMUNICATION To a large extent, patterns and styles of communication are determined by culture. In other words, the above section on conceptual frameworks can help us understand and interpret Asian ESL nursing students' communication patterns and styles. Moreover, there is indication that Asian languages, such as Korean, have a language structure that is different from the English and a different way to answer questions in a negative format (Xu & Davidhizar, 2005). There is a wealth of knowledge on intercultural communication developed in other disciplines or fields of study such as cross-cultural psychology and cultural anthropology. Nursing scholars need to study this literature and tease out those parts that can be applied to the understanding of Asian ESL students in general, and Asian ESL nursing students in particular.
INSTRUCTIONAL STRATEGIES A considerable amount of research in the last 30 years has focused on addressing the needs of ESL nursing students and specific instructional strategies to enhance their academic success, especially regarding preparation and passing of the licensure exam. Many instructional strategies suggested in the literature are based on individual experiences and only amount to anecdotal evidence, with severe limitations on generalization. Anecdotal evidence is the weakest in the hierarchy of categories of evidence (Melnyk & FineoutOverholt, 2005). To improve instructional practice with Asian ESL nursing students, stronger evidence needs to he generated through rigorous studies.
IMPLICATIONS FOR FUTURE RESEARCH In order to advance knowledge on Asian ESL nursing students, the following suggestions are deemed relevant. First, research on Asian ESL students needs to integrate scholarship from other disciplines to enhance the rigor of research and scholarship. Second, more empirical research, with more rigorous research designs, needs to be conducted to provide stronger evidence to improve teaching practices and generate more generalizable findings. Third, an evidence-based approach should serve as the overarching framework and context for the inquiry on Asian ESL nursing students. The ultimate purpose of research on this group of nursing students is to improve their learning outcomes and educational experiences.
Conclusion It is predicted that the number of Asian students coming to the United States will remain high for the foreseeable future because of the megatrend of globalization. However, due to cultural differences, language barriers, and a host of other challenges, some Asian ESL nursing students have been unable to realize their potential and career goals. It is a moral imperative and an intellectual challenge to move the research agenda on Asian ESL nursing students forward in order to enhance their learning outcomes and quality of educational experiences.
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Tina Hunter Scheele, MS, RN, is an associate professor at Greenville Technical College, Greenville, South Carolina. Rosanne Pruitt, PhD, RN, FNP, is a professor and director, Clemson University School of Nursing, and associate dean, College of Health, Education and Human Development, Clemson, South Carolina. Arlene Johnson, PhD, RN, CPNP, is an associate professor, Clemson University School of Nursing. Yu Xu, PhD, RN, CTN, CNE, FAAN, is a professor, School of Nursing, University of Nevada Las Vegas. For more information, contact Ms. Scheele at Tina.Scheele@gvltec.edu.
Table. Summary of Culturally Competent Instructional Strategies FACTORS TEACHING STRATEGIES SOURCES Tutoring * One-hour individual or Guhde (2003) group tutoring sessions on course material in Medical/Surgical and Health Assessment courses Cultural and * Use of the Integrated Guttman (2004) linguistic competence Skills Reinforcement Model assessment strategies to improve basic skills in writing, reading, listening, and speaking; promotes active learning through inquiry in group work, specific reading, writing, speaking assignments, and peer evaluation * Speaking skills with evaluation of oral presentation (number of mispronounced or misused words, content, form, clarity, listener response) * Listening skills by collection of a summary of important concepts covered in first class * Writing skills by administration of a pretest writing exercise on a given topic Language proficiency * Utilization of SPEAK: Klisch (2000) assessment and Speaking Proficient English transcultural Assessment Kit to evaluate knowledge spoken proficiency * Assertiveness training * Extend testing time if appropriate * Name memo and composite photo to help faculty correctly pronounce ESL student's name * Require transcultural nursing course * Evaluate retention strategies through use of satisfaction survey Learning theory, * Create mutual Malu & Figlear reading, writing, understanding between (2001) research faculty and ESL student by use of a student questionnaire and learning styles inventory * Promote use of study groups and meet on a regular basis * Faculty should design class activities that require group work * Use reading and clinical setting journals * Create concept maps * Integrate technology Second language * Develop academic language Malu & Figlear acquisition, learning fluency by preparing list or (1998) theory categories of problem words, use flash cards to build a concept map, and connect related concepts and abstractions * Encourage nurse educator and student collaborations through orientation, tour school to familiarize students with classroom and lab facilities, resources, and support services * Meet periodically with transcultural adviser to discuss progress and problems * Encourage active involvement in learning through participation in discussions, conferences, and new learning experiences and challenges * Continue to develop English language proficiency Academic factors that * Placement tests in Memmer & Worth influence retention language and reading (1991) and attrition of comprehension minority and minority ESL students * Remediation for low scores on placement tests * Medical/nursing terminology course * Nursing Career Day (helpful in encouraging students to persist) * Preadmission meeting (builds camaraderie and provides assistance in completing admission process) * Orientation program (program review, registration assistance, how to seek assistance) * Workshop on study skills and writing in nursing * Involvement of students' families at a nursing Open House * Financial aid coordinated by the nursing program * Coordinator who monitors progress and provides "bridge" between students and faculty/staff/resources * Mentor program for nursing students with ESU minority faculty * Flexible class load option * Ratio of nursing students to teacher in clinical (patient care) labs less than 9:1 * Additional clinical (patient care) and skills learning assistance * Academic advising and peer tutorial assistance * Access to counseling services * ESL/minority student participation in campus organizations * Visiting ESU minority nursing leaders as guest speakers * Instill ESU minority students' sense of belonging and increase student pride * Workshops to sensitize nursing faculty * System for early faculty intervention * Participation in groups to decrease racial and ethnic intolerance * Improvement of test-taking strategies * A strong total faculty commitment * Early connection with pre-nursing students to the program Technical aspects of * International English Shakaya & language; speaking Language Testing System Horsfall and listening (ILTES) as part of admission (2002) requirements * Support writing centers for students to gain assistance with written communication * Support public speaking in class and among tutorial groups * Peer and family support to encourage interaction frequently among people of shared language and cultural background * Draw diagrams to help understand anatomy and increase eye contact * Promote reading/writing in English outside classroom Collectivism vs. * Asian students and faculty Xu & individualism; must learn about each other Davidhizar (cognitive domain) (2005) high-context vs. * Students and faculty must low-context be willing to reach beyond zone * Students and faculty must learn how to engage in intercultural communication (psychomotor domain) comfort