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What do we know about educating Asian ESL nursing students? A literature review.

ABSTRACT Because of cultural differences and language barriers, some Asian nursing students who speak English as a second language (ESL) have not realized their full potential and career goals. Based on an exhaustive search through existing electronic databases in health sciences, this article synthesizes the published literature between 1980 and 2010 on this subgroup of nursing students in four domains: conceptual frameworks, language and communication, support and infrastructure, and instructional strategies. However, some of the classic works were published before 1980. Findings indicate that a body of literature on ESL nursing students has emerged in the last decades, with several limitations. Based on this review, implications for future educational practice and research are elaborated, with an emphasis on an evidence-based approach.

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.


Abriam-Yago, K.,Yoder, M., & Kataoka-Yahiro, M. (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.

Abu-Saad, H., Kayser-Jones, J., & Tien, J. (1982). Asian nursing students in the United States. Journal of Nursing Education, 21 (7), 11-15.

Choi, L. L. (2005). Literature review: Issues surrounding education of English-as-a-second language (ESL) nursing students.Journal of Transcultural Nursing, 16(3), 263-268.

Guhde, J. 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.

Guttman, M. S. (2004). Increasing the linguistic competencies of the nurse with limited English proficiency.Journal of Continuing Education in Nursing, 35(6), 264-269.

Hall, E.T. (1959). The silent language. Garden City, NY: Doubleday.

Hall, E.T. (1976). Beyond culture. Garden City, NY: Anchor Press/Doubleday.

Institute of International Education. (2010).Top 25 places of origin of international students, 2008/09-2009/10. Open Doors Report on International Educational Exchange. Retrieved from

Johnston, J. G. (2001). Influence of English language on ability to pass the NCLEX-RN. In E. Waltz & L. Jenkins (Eds.), Measurement of nursing outcomes (2nd ed., pp. 204-207). New York: Springer Publishing.

Kataoka-Yahiro, M. R., & Abriam-Yago, K. (1997). Culturally competent teaching strategies for Asian students for whom English is a second language.Journal of Cultural Diversity, 4(3), 83-87.

Klisch, M. L. (2000). Retention strategies for ESL nursing students.Journal of Multicultural Nursing & Health, 6(1), 21-28.

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Malu, K. F., & Figlear, M. R. (2001). Six active learning-based teaching tips: Promoting success for ESL nursing students. Nurse Educator, 26(5), 204-208.

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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
Table. Summary of Culturally Competent Instructional Strategies


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

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

                        * 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

                        * 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

                        * 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

                        * 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

                        * 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

                        * 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

                        * 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

                        * ESL/minority student
                        participation in campus

                        * Visiting ESU minority
                        nursing leaders as guest

                        * Instill ESU minority
                        students' sense of belonging
                        and increase student pride

                        * Workshops to sensitize
                        nursing faculty

                        * System for early faculty

                        * Participation in groups to
                        decrease racial and ethnic

                        * Improvement of test-taking

                        * A strong total faculty

                        * Early connection with
                        pre-nursing students to the

Technical aspects of    * International English        Shakaya &
language; speaking      Language Testing System        Horsfall
and listening           (ILTES) as part of admission   (2002)

                        * Support writing centers
                        for students to gain
                        assistance with written

                        * Support public speaking in
                        class and among tutorial

                        * Peer and family support to
                        encourage interaction
                        frequently among people of
                        shared language and cultural

                        * 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

                        * Students and faculty must
                        learn how to engage in
                        intercultural communication
                        (psychomotor domain) comfort
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Title Annotation:NURSING EDUCATION RESEARCH / ASIAN ESL STUDENTS; English as second language
Author:Scheele, Tina Hunter; Pruitt, Rosanne; Johnson, Arlene; Xu, Yu
Publication:Nursing Education Perspectives
Article Type:Report
Geographic Code:1USA
Date:Jul 1, 2011
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