Factors influencing the performance of English as an Additional Language nursing students:...

F e a t u r e

Factors influencing the performanceof English as an Additional Language

nursing students: instructors’perspectives

Tam Truong Donnelly, Elaine McKiel and Jihye Hwang

University of Calgary, Calgary, AB, Canada

Accepted for publication 15 December 2008

DONNELLY TT, McKIEL E and HWANG J. Nursing Inquiry 2009; 16: 201–211

Factors influencing the performance of English as an Additional Language nursing students: instructors’ perspectives

The increasing number of immigrants in Canada has led to more nursing students for whom English is an additional language

(EAL). Limited language skills, cultural differences, and a lack of support can pose special challenges for these students and

the instructors who teach them. Using a qualitative research methodology, in-depth interviews with fourteen EAL nursing

students and two focus group interviews with nine instructors were conducted. In this paper, the instructors’ perspectives are

presented. Data acquired from the instructors suggest that the challenges experienced by EAL students and instructors reside

in a lack of awareness and support at the institutional and structural levels rather than solely on capacities of individual EAL

students or instructors. From this study, identification of supportive activities for nurse educators and education sector decision

makers emerged.

Key words: education of EAL nursing students, English as an additional language (EAL), ESL nursing students, nursing educa-

tion, nursing instructors’ perspectives.

In 2001, immigrants comprised 17% of Canada’s total popu-

lation; by 2006, the immigrant population had increased to

19.8% (Statistics Canada 2006). According to Statistics

Canada (2006), the increase in immigrant population was

responsible for two-thirds of Canada’s population growth

between the years 2001 and 2006. Today, virtually one in

every five Canadians is foreign born. This growing diversity

brings with it a range of different healthcare beliefs and

practices for which culturally competent healthcare services

are needed (Hyrcak and Jakubec 2006; Vissandiee, Des

Meules, and Schotsman 2006; Lu et al. 2008). One way of

meeting the needs is to promote cultural diversity within the

nursing profession and one approach to achieving this is for

faculties of nursing to recruit, educate, support and retain

foreign-born students from diverse ethnic groups.

While it is recognized that students from different ethnic

groups can contribute to the ultimate goal of providing

culturally competent, holistic nursing care, their inclusion in

Canadian education programs presents special challenges for

both students and educators due to language, cultural barri-

ers and a lack of educational support for English as an Addi-

tional Language (EAL) students1 (Jalili-Grenier and Chase

1997). Such challenges are manifested by high drop-out rates

of EAL students from nursing programs (Jalili-Grenier and

Chase 1997; Bosher and Smalkoski 2002; Guhde 2003; Choi

2005).

Correspondence: Tam Truong Donnelly, Faculty of Nursing, University of Calgary,

2500 University Drive NW PF 2203, Calgary, AB, T2N IN4 Canada.

E-mail: <[email protected]>

1 At the university where this study was performed, the term EAL has replaced

English as a Second Language (ESL) because of perceived negative connotations

such as hierarchy and inferiority that are attached to the word ‘second’. Addition-

ally, English is the third or fourth language for some of the students.

� 2009 Blackwell Publishing Ltd

Nursing Inquiry 2009; 16(3): 201–211

To gain a greater understanding of the challenges and

how to respond to them, a study involving EAL nursing

students and their nurse educators was undertaken.

Specifically, factors that either supported or hindered the

students’ learning and successful completion of the program

were explored. The study addressed the following research

questions:

• What are EAL students’ needs, concerns and strengths?

• How do they cope with language barriers and cultural

differences?

• What are the key factors that help them to be successful in

the nursing program?

• What are the key factors that inhibit their capacity to be

successful in the nursing program?

In this paper, the instructors’ perspectives relative to

these questions are presented.

LITERATURE REVIEW

Previous studies regarding effective recruitment and

retention of EAL students in nursing programs explored

academic challenges and barriers faced by these students.

The studies revealed that EAL nursing students’ academic

performance is affected by many inter-related factors includ-

ing language, cultural values reflected in teacher–student

relationships and assertiveness, perceived social support,

financial strain and family responsibilities (Shakya and

Horsfall 2000; Bosher and Smalkoski 2002; Sanner, Wilson,

and Samson 2002; Cunningham, Stacciarini, and Towle

2004; Xu and Davidhizar 2005; Song 2006). While language

difficulties, culture shock, low level of social support,

decreased self-confidence and self-esteem, and isolation were

identified as common experiences among international

students studying in new host countries (Menard-Warwick

2004; Dao, Lee, and Chang 2007; Sovic 2008), ESL nursing

students reported additional challenges with communicating

clearly and effectively with clients and staff, asking for help

from clinical instructors and peers, and colloquialisms

(Shakya and Horsfall 2000; Bosher and Smalkoski 2002;

Sanner, Wilson, and Samson 2002; Guhde 2003; Cunning-

ham, Stacciarini, and Towle 2004). Although many studies

revealed barriers and challenges relative to EAL nursing

students (Abriam-Yago, Yoder, and Kataoka-Yahiro 1999;

Shakya and Horsfall 2000; Sanner, Wilson, and Samson

2002), there is scant research that explores the strengths of

EAL students, the challenges for instructors who teach EAL

students and the institutional resources needed to meet the

unique learning needs of EAL students.

Just as the students for whom English is a second or addi-

tional language are confronted with challenges, so are

those who teach them. Faculties are constrained by time and

resources, institution and service sector policies, and their

own lack of formal preparation for teaching EAL students

(Yoder 1996; Jalili-Grenier and Chase 1997; Shakya and

Horsfall 2000; Pardue and Haas 2003). Studies by Jalili-

Grenier and Chase (1997) and Xu and Davidhizar (2005)

suggested that lack of understanding of EAL students and

their cultures by faculty may lead to negative interpretations

of students’ behaviors. Davidhizar and Shearer (2005) identi-

fied the need for faculty to be capable of assessing the

student, use personalized approaches to address the needs

of the student, plan interventions and evaluate their

outcomes in the most culturally appropriate way.

Jalili-Grenier and Chase (1997) reported other signifi-

cant differences between faculty perceptions of areas of diffi-

culty and those of the students. Completing required

readings and assignments, writing examinations and term

papers, listening and taking notes in lectures, participating

in seminars and tutorials, engaging in conversations were all

rated as more difficult for the EAL students by the instruc-

tors than by the students themselves. From Jalili-Grenier and

Chase’s perspective, these conflicting perceptions arose as

the result of lack of cultural awareness, understanding and

effective communication between the students and their

educators. Therefore, as part of this study, instructors’ per-

spectives on the academic experiences of EAL nursing stu-

dents were examined and compared with the perspectives of

the EAL students. These findings are reported in a separate

paper.

ACADEMIC REQUIREMENTS

This study was conducted at a western Canadian university

that promotes self-directed learning and critical thinking.

Within the Faculty of Nursing, on average, students are

required to write one to two major academic papers and two

to three written examinations per course, plus give one

group or individual oral presentation. Active participation

through questions and discussions is an expectation in class,

clinical and laboratories. All of these activities require flu-

ency in English. Therefore, to be admitted to the Faculty of

Nursing, all students must demonstrate English language

proficiency in one of the following ways:

• successful completion of at least 3 years of formal, full-

time study at an English secondary or post-secondary insti-

tution in an English-speaking country;

• graduation from a degree program offered by an accred-

ited university in a country which the university recognizes

as English language proficiency exempt; or

202 � 2009 Blackwell Publishing Ltd

TT Donnelly, E McKiel and J Hwang

https://www.researchgate.net/publication/7482952_When_Your_Nursing_Student_Is_Culturally_Diverse?el=1_x_8&enrichId=rgreq-db8017c3-5f0d-4deb-aa3e-1453c60ebc1b&enrichSource=Y292ZXJQYWdlOzI2NzUwNDYzO0FTOjEwNDE4ODQ0MDc0MzkzOUAxNDAxODUxODY4NTc4

https://www.researchgate.net/publication/7482952_When_Your_Nursing_Student_Is_Culturally_Diverse?el=1_x_8&enrichId=rgreq-db8017c3-5f0d-4deb-aa3e-1453c60ebc1b&enrichSource=Y292ZXJQYWdlOzI2NzUwNDYzO0FTOjEwNDE4ODQ0MDc0MzkzOUAxNDAxODUxODY4NTc4

• a mark of 75% or better on the Alberta English Language

Arts 30–1 diploma examination or equivalent course from

other Canadian provinces;

• achieving a prescribed minimum grade on the internet-

based Test of English as a Foreign Language (TOEFL iBT)

or Michigan English Language Assessment Battery

(MELAB) examination or Canadian Academic English

Language (CAEL) or International English Language Test

System (IELTS) – Academic Module or English for Aca-

demic Purposes (EAP) Program (Tier 3).

RESEARCH METHODS

Participants and data collection

In this exploratory qualitative study conducted at a Can-

adian university, we used a maximum variation purposive

sampling to recruit instructor participants. A maximum vari-

ation purposive sampling is ‘the process of deliberately

selecting a heterogeneous sample and observing commonali-

ties in their experiences’ (Morse 1994, 229). A variety of

strategies were used to recruit faculty members, which

included posting invitational notices about the study

throughout the Faculty of Nursing, and sending an informa-

tion letter about the study to all instructors in the 4-year and

accelerated 2-year undergraduate programs via their mail-

boxes in the Faculty of Nursing or via e-mail. All full-time

and part-time Faculty of Nursing instructors who identified

as having EAL students in either theory or clinical courses or

who had taught EAL students in the past were invited to par-

ticipate. A total of nine full-time and part-time instructors

who met the study inclusion criteria voluntarily participated

in the study. This paper reports data obtained from the

instructor participants. Data obtained from the students will

be reported in a subsequent paper. Ethical approval was

obtained from the ethics review board at the university

where the study was conducted. All participants signed the

consent form. All participants’ names used in this paper are

pseudonyms.

Data were collected through two focus groups with the

instructors, each focus group lasting 1.5–2 hours. The instruc-

tors were asked to describe their experiences teaching EAL

nursing students at the university, how they managed ⁄ sup-

ported the students’ language and cultural differences, what

they believed to be strengths and barriers for the students to

achieve success in the nursing program, what supports they

drew upon to foster their teaching with these students, and

what they perceived as the best strategies to assist them to

teach EAL students. The focus group interviews were

conducted by an experienced facilitator. To preserve confi-

dentiality and anonimity of the instructor participants, we

employed a focus group facilitator who was not an employee

of the university where this study was conducted. The focus

group interviews were audio-taped and transcribed verbatim.

Field notes were completed immediately after each focus

group by the facilitator.

Data coding, analysis and interpretation

Data coding, analysis and interpretation were conducted

manually by the two principal investigators and, additionally,

by two trained research assistants who used ATLAS TI, a qualita-

tive data analysis software. Audit trails were established to

ensure the rigor of the data analysis methods. The research

team met regularly to review the processes used to conduct

the interviews, personal reflections, analytic descriptions and

interpretations.

The manual data analysis involved line-by-line reading,

recording comments in the transcript margins to identify,

refine, add to, and categorize emerging ideas, concepts

and themes. Quotes and experiential examples were noted.

To generate a higher level of data conceptualization and

broader theoretical formulations, emerging themes and con-

cepts were achieved by comparing within and across data set

transcripts, across research participants and across the set of

data analysis generated by using ATLAS TI. An outcome of the

analysis was a set of inter-related concepts and themes that

describe the experiences of EAL students and their instruc-

tors, including the social processes and influencing factors

and structures. We also found that data generated by manual

analysis were congruent with data generated by ATLAS TI.

Trustworthiness

As there is always an element of uncertainty and ambiguity

in researchers’ interpretations, validation of the researchers’

reconstruction of meanings was performed. Carspecken

(1996) recommended several ways that researchers can sup-

port articulation of meanings. First, the more familiar

researchers are with the culture of their participants, the

closer their articulated meanings would be to that of the par-

ticipants. The researchers of this project were either mem-

bers of a different ethno-cultural background or have had

many experiences working with EAL students. Peer debrief-

ing between members of the research team gave additional

insights into the social, cultural, economical processes which

the students are coping. Second, the use of dialogical data

generation during focus group and sharing the results of

our preliminary data analysis among the research team

members through meetings that include presentations and

� 2009 Blackwell Publishing Ltd 203

Instructors’ perspectives of EAL nursing students

consultation of what is conceptualized had helped to ensure

the rigor of our findings.

FINDINGS

The analysis of the data from the instructors revealed the

need for the development of more supportive strategies and

more educational resources for EAL nursing students. The

instructors were aware of academic issues of EAL students

and were eager to assist them in completing their nursing

program successfully. However, lack of time and knowledge

along with lack of institutional policies, resources and sup-

port limited their ability to support EAL students effectively.

They identified several challenges they faced when teaching

EAL students, the teaching strategies they implemented to

assist the students, strengths and challenges which they

believed their students faced, and offered recommendations

for constructive changes within the Faculty of Nursing that

would assist them to teach EAL students.

Challenges for instructors

THEME 1: LACK OF RESOURCES

Instructors identified a lack of any available, institutional

support system for them to support EAL students effectively.

Helping EAL students was perceived to be the individual

instructor’s responsibility rather than a shared responsibility

with the Faculty of Nursing or the University as a whole. Hence,

academic support provided by instructors to EAL students was

often performed outside of clinical hours (refer to ‘Develop

a formal support system for instructors’, see p. 208). As one

instructor said:

I have to call her, and ask her to have one to one time withme, working on her English, not just the general English,but about the medical terms, about the health care system,So it would take extra hours from me, but I think it’s a must,we have to do that.

Similarly, another instructor commented:

Some students I’ve met with on a regular basis for coffeebecause they perceive that the interaction on a social basiswould help them. I would role play a patient scenario whereshe would ask the questions as if I was the patient, so I gaveher a little story about what was wrong, and then I would say,‘ok, now, ask what you think are relative questions to that’.And then you would role play this back and forth, and wepracticed it, well, we picked different role plays all the time,and a lot of it was useful except if the scenario changedslightly. The students who we did this with, over time thefeedback I got verbally is, it was very helpful. [But] the timeI spent doing it was horrendous.

Although instructors’ one-on-one help was hugely appre-

ciated by EAL students and contributed to their academic

improvement, such individualized supportive strategy was

not optimal for three reasons. First, addressing the needs of

EAL students was time consuming, often leaving instructors

exhausted. Second, such effort is not sustainable in the long-

run. These two barriers were reflected in a statement by a

clinical course co-ordinator who said:

When we look at kind of the standards of clinical teachingon top of all the other responsibilities, you burden them[clinical instructors] with all these other issues [of EALstudents]. And they [clinical instructors] don’t come backto work for us.

Third, not all EAL students had the benefit of the extra time

so all students were not perceived to be treated equally.

Instructors commented further on the lack of awareness

and support for them to deal with the challenges of teaching

EAL students. They felt that their needs were unheard and

unmet:

There is no support. I went to a couple of things in theLearning Commons at the university here, and they askedwhat other topics in education were needed. For the lastthree times, I have put ‘working with EAL students.’ I havenever seen anything yet coming from the Learning Com-mons in terms of a focus for that need.

Instructors reported that reaching out to each other was the

only consistent strategy for them to deal with their frustrations

and concerns. For example, they ‘go to each other as col-

leagues. So if there has been an issue, we do a lot of debriefing’

and ask questions, ‘I have this problem, and have you had any-

thing like that, and what have you done?’ They identified the

need to build strong, readily available, systematic institutional

support networks specific to teaching EAL students.

THEME 2: PATIENT SAFETY

Patient safety was the most frequent concern expressed by

the clinical instructors regarding EAL students’ nursing prac-

tice. The students’ language barriers and different cultural

understanding together with a non-supportive learning

environment resulted in challenges to providing safe, com-

petent nursing care. The instructors described EAL students

as having difficulties with correct charting, understanding

orders for medications and procedures, and communicating

and interacting with clients and colleagues. The difficulties

deeply concerned the instructors as improper charting,

incorrect administration or omission of medications and

inability to understand clients could seriously endanger the

clients’ safety, health and well-being:

The whole language and safety thing … A wrong medica-tion, if they don’t understand what they’re giving, and theyhave trouble, is it a language issue, or is it a knowledge andsafety issue, and this is one of the challenges we run into,



actually, the odd student we feel we need to fail. And then ifit goes to appeal or whatever, it’s how much of this is lan-guage, and if it’s language, should we not be giving extraleeway to the student. If it’s safety, shouldn’t we have pulledthe plug earlier? So it becomes a real issue.

Relative to EAL students’ ability to provide safe nursing

care, instructors preferred students to ask for help when

needed. However, several instructors identified reluctance

by EAL students to ask questions and to seek feedback from

their preceptor nurses, peers and clients:

If they were assigned a patient, and they were told to go anddo some things, they didn’t question it. Even though theydidn’t seem to understand, it was ‘yes, yes.’ And off they went,but they didn’t always do what the instructions were … It waslike they would insult me or challenge me by asking the ques-tion, but then I didn’t know that they didn’t understand.Then it becomes a situation where at times they’re unsafebecause in an emergency situation, if something happens, orthey’re there with someone else, and they were told: ‘Go getthe oxygen tank, the patient’s hypoxic or something like this,and they say yes, yes.’ And they go out of the room and theydon’t understand, and they don’t come back with an oxygentank. I mean this could be quite serious for the patient.

Several participants associated different cultural orienta-

tion and values with the students’ reluctance to ask questions.

In addition to safety issues that arose from their reticence to

question, they wondered whether the students would be able

to advocate for patients if ethical dilemmas arose:

Because of their culture, I represent power to them. Theydon’t question me. I always wonder when they graduate,would they practice ethically? If they only defer to positionsto people in power, will they question the physicians?

THEME 3: BALANCING EAL AND NON-EAL STUDENTS

Because clinical instructors needed more time and effort to

support EAL students and to address their unique learning

needs, having more than two EAL students in a clinical

group compounded the challenges. They often felt that

their time with other non-EAL students was compromised.

They were frustrated that they could not balance the needs

of both EAL and non-EAL students. Non-ESL students told

them that they felt ‘cheated’ and complained that their

learning experiences were sacrificed for the sake of helping

EAL students. This created a dilemma for instructors as they

felt burdened by a professional responsibility to ensure safe

nursing care by EAL students while creating a fair, positive

learning experience for non-EAL students in the group:

I’ve had groups of students [who perceived] their educationhas been compromised because of those needs of thegroup. We’re encouraging collaboration, though it is a verycompetitive environment, where the student is looked at interms of individual performance. If you have more than two

English as an additional language in a clinical group ofeight, you’re hooked.

Although instructors and course co-ordinators tried to

distribute EAL students fairly throughout clinical groups,

there was no systematic way of doing it because course

co-ordinators were not informed as to which persons were

EAL students. One co-ordinator reported:

When I try as a coordinator to organize the groupings, thereused to be a little bit of leeway where you could kind ofdetermine mostly informally who might have struggled withEnglish as a second language, and try to put them intogroups so they’re spread out. That information is hard toget. It’s hit and miss, and now when I just did this last courseof 150, there were so many non-Caucasian names. I basicallyhave five names in every group that I have no idea whattheir English skills are, and it’s only mere luck if the profes-sor didn’t get three. So this collaboration only goes this far.I know in clinical, they felt very, very cheated.

Another co-ordinator said:

So you’ve got a clinical instructor with four ESL students,and four other students, and this poor person, and sure you[the instructor] go to your course coordinator and you tryand get the assistance you need, but is it enough? And, weburn them out, and so some of those [instructors] will justsay. ‘It’s too much’, and so we’re looking at a situation nowwhere we’re having a hard time getting clinical instructors.

Strengths of EAL students from the instructors’

perspectives

Instructors summarized the strengths of the EAL students as

determination, strong work ethic, perseverance and resil-

iency. They described them saying:

They work sometimes three and four times harder than stu-dents who are English as first language, whether it’s just inreading something that we might read once or twice –they’re reading it three, four, and five times for content andcomprehension … There aren’t enough hours in the dayfor them to do their work.

Some of these students from other countries … They have ahuge resilience. I look at these Asian women that have comewith two kids, and the husband is back in China, and they’resending them here to get an education, so here’s a womenwho’s in nursing, with two young children, husband’s backthere, no support system, but she’s going to make it work.So, one of the strengths is resilience. They have that back-bone.

Instructors also commented on the students’ respectful

behavior towards teachers and positive attitudes towards

learning:

Andyouknowtheexamplethat Igaveof theeasternEuropeancountry physician, I looked at her and I said, ‘Why are you



studying nursing?’ I said, ‘you know, why didn’t you get yourEnglish, and then you know, write your CMA exams?’ And shesaid, ‘because I was so excited to learn something different’.I was so impressed, I thought wow, this lady is quite something.So there is a sense that they really do want to learn. It’s not justgive me the degree and get off my back. There is a sense thatthey really value education. There is a certain respect forpeople thatwedon’talways see inCanadianculture.

Challenges for EAL students from the instructors’

perspectives

THEME 1: LACK OF INSTITUTIONAL SUPPORT FOR

EAL STUDENTS

Lack of suitable support and resources for EAL students

emerged as a major theme:

We are looking to track a certain percentage of ESL stu-dents because it funds the university better, but where is thesupport to manage and support the ESL students? There isnone. I think that’s the part that the university needs to lookat; we have health services for students and we have all theseother things, but we certainly are not supporting them interms of resources for ESL.

Instructors noted that English language proficiency courses

are available for international students, but said they are not

affordable and do not suit the particular needs of EAL nurs-

ing students, such as understanding medical terms and com-

municating with patients and colleagues in the healthcare

setting:

They have conversational English classes. They talk a lotabout cultural issues and how to support that, but it requiresthe student to have to take extra courses and have to pay forthose extra courses, and students just, unless it’s demanded[or] part of the program, they won’t do it.

One of the strategies that instructors thought might help

students was for them to work in a healthcare environment.

However, many EAL students’ visas only allow them to work

at the university which prohibits them from applying to

health centers.

Lack of support in the hospital setting was identified as

another challenge. One instructor commented:

We’re seeing a health care system where staff are busy …When they get a student that does not speak English verywell, that is more challenging to spend some time in com-munication, in making sure they’re understanding eachother. There isn’t the luxury of taking that time to figureout where is the student coming from, does the studentunderstand what I’m saying, and then can I trust the studentto come to me when they don’t understand … How [can] apreceptor that’s got a heavy work load also give the studentthe kind of help that the student needs. That’s a real strug-gle, where do we fit in that, and how do we support the pre-

ceptor? How do we support the student to be successful? …It’s a conflict.

Several instructors acknowledged that without support, the

personal experiences of EAL nursing students could poten-

tially discourage them to the point that they would withdraw

from the program with hurtful feelings or feelings of animos-

ity. One instructor described an incident when her EAL stu-

dent felt rejected and dejected. The student told her:

[My patient] didn’t like me because I’m a man, he didn’tlike me because I’m foreign, and he didn’t like me becausehe couldn’t understand me. I am just so tired. I am trying sohard. If this is how it feels to be a nurse in Canada, maybeI can’t do it.

THEME 2: LACK OF ENGLISH PROFICIENCY

From the instructors’ perspectives, lack of English proficiency

was a major deterrent to EAL students’ successful perfor-

mance. As clinical instructors identified earlier, language

was a barrier to grammatically correct charting, asking

questions and communicating thoughts and knowledge

clearly. Instructors who taught theory classes also identified

several challenges for EAL students, including difficulty

understanding lectures, completing paper assignments and

writing examinations:

You look around and you see they come everyday to class.They’re there, and they don’t write a thing down, and whenyou actually talk to them, you discover that they don’tunderstand much of what you’ve said in class. So everythingthey get is from the readings. Now, that jeopardizes thembecause I don’t teach just from the readings. I bring in newinformation that will help them understand the reading orhighlight something in the readings.

As stated earlier, instructors believe that EAL students

work very hard to write academic papers and complete

patient research. However, their hard work and effort is

often not apparent because nursing is largely about interac-

tive communication in the clinical setting and effective clini-

cal communication was identified as a major challenge for

EAL students. One instructor described the emotional

barriers that are created for a student who lacks fluent

English skills:

Lots of time, they’ve done a tremendous amount of patientresearch about the diagnosis, their drugs, and the varioustreatments, but it’s the interpersonal interaction with thepatient where they’re completely terrified. So, it’s about talk-ing. ‘How do you approach a patient?’ ‘How do youapproach your primary nurse?’ They’re very afraid ofapproaching the primary nurse, I think partly because theyknow they [the nurses] are busy. They don’t want to appearto be ill prepared, and yet they know they don’t know some-thing, and so there is incredible tension about that.



In an effort to overcome the language and cultural

barriers, educators who taught theory courses implemented

several strategies to support EAL students and to create posi-

tive learning experiences. They allowed more time for EAL

students to complete assignments, review examinations and

go over incorrectly answered questions. They encouraged

students to ask questions and participate in group discus-

sions in the classroom. They checked examinations for

biased terms or use of slang, and they provided synonyms on

examination papers (e.g. inserting ‘stealing’ in brackets to

explain the word ‘fraud’).

THEME 3: CULTURAL DIFFERENCES

The education methods that students had experienced in

their home countries differed from Canadian methods. EAL

students were not generally familiar with inquiry-based learn-

ing (IBL) and the concept of interactive learning. They are

often dependent on instructors for directions:

They’re used to a hierarchical learning … I’m speaking spe-cifically to the Asian and also the Eastern Europeans; theyhave a very hierarchical perspective on teaching. They don’task question the professor … we’re saying we work together,and we’re going to learn together. They don’t understandthat; that’s so foreign to them.

In addition, some come from cultures where beliefs

about personal space and eye contact can interfere with pro-

viding holistic care in the Canadian context.

Plagiarism was another issue that confronted instructors

and perplexed the students. For many of the EAL students,

using other people’s work without referencing it was consid-

ered normal and acceptable:

We do peer-reviews of papers, and so his paper was reviewedby a fellow student who picked up plagiarism, a lot of thequotes. But then I learned; they don’t have these rulesabout writing you know, taking people’s word, and havingto put them in quotes and reference. That isn’t an issue atall in a lot of countries, you’re quite open, welcome to use it… But I honestly don’t think that it was at all a plagiarismissue from his perspective, and it was again that learning ofwhat we expect from scholarly papers here.

Thus, it is important for instructors to explain these

concepts to students, clarify expectations with writing using

the format set out by the American Psychological Association

(APA), and allow sufficient time for EAL students to under-

stand and practice it in writing academic papers.

From the instructors’ perspectives, EAL students strug-

gled most with contextual, relational nursing practice, prac-

tice that required critical thinking skills and reflections.

Instructors identified that EAL students often completed

thorough biomedical assessments but struggled with assess-

ing the psycho-social aspects of health and incorporating

that into their care plans. As one instructor noted, ‘The sub-

jective piece is totally missing most of the time unless you are

coaching that out in discussion’, and another instructor

pointed out, ‘It’s not that they don’t think critically. It’s that

we’re not language-ing in the way they understand it’. The

instructor emphasized the importance of using strategies to

extract the contextual piece from the EAL students and

assist them in understanding:

what, how, when, and where they derive [the] context fromin terms of beliefs and what they value in themselves, andhow those [values and beliefs] might play a context.

Differences in cultural values and beliefs between

instructors and students were barriers to holistic nursing

care. For example, an instructor described an incident

where her cultural values conflicted with those of the

student’s:

It’s that cultural piece that will actually stop them fromdoing something that we highly value in clinical practice.I have students who won’t tell, or give information to thepatient, because in their Chinese culture, it’s the son orthe daughter who makes the decision for the older adult… It raises major flags for me and concern that if I washer patient, how was she going to help me understandwhat was going on in my life, if she’s not willing culturallyto step out of her culture, and to look at the culture she’sin.

Cultural confusion arising from colloquialisms also created

problems. As one instructor described:

In a culturally diverse hospital setting, mix of cultures ofthe student, the patient, and the primary nurse createhuge variance in communication such as misinterpreta-tion. For example, an elderly Caucasian Canadian wouldprobably describe a term ‘voiding’ as ‘passing your water’.But that wouldn’t make sense for an EAL studentwho comes from a culture where they don’t have suchexpressions.

Strategies that instructors found effective were placing

EAL students in a more culturally diverse unit and assigning

them with clients and nurses who came from the same cul-

tural background. They found that the students gained more

confidence, appreciated the value of speaking an additional

language, extended their comfort boundaries and expanded

their clinical opportunities:

An English second language [student] was coming for arepeat of psych mental health, and so I just tried to findthe site that would offer more diversity in terms of thepatient population. Also, there was a unit where there wasmore diversity in terms of the nurses as well. We didn’tknow prior to putting her there how it would work out, butthe clinical instructor there was very an engaging type of



person as well … I learned through the clinical instructorthat this student who could get very good marks, again, herintelligence wasn’t the issue, but her speech, it was some-times difficult to understand her. A nurse who had comefrom China was working on the unit and buddied with[the student], and it just turned out marvellously well, andshe got off to a good start. There were absolutely no con-cerns with her so, that really taught me something aboutcreating the environment in a way to facilitate just herrelaxing a bit.

Other strategies which clinical instructors found helpful

were consulting with the hospital unit manager regarding

appropriate patient assignments (e.g. avoiding patients per-

ceived to be discriminatory or too difficult for the student),

meeting regularly and working on a specific assignment with

the student, debriefing and conversing with the student

before and after each clinical, advocating for an environ-

ment of open communication, and encouraging students to

ask questions:

It’s not about the skill; it’s more about their level of confi-dence and mastery. I spend a lot of time in the beginningjust talking to the student. I always say, ‘so tell me what’sclinical been like for you?’ … Trying to pull out of themwhat that might mean, and it takes a little while. Normallythese kinds of sessions happen over the course of a fewweeks.

RECOMMENDATIONS FOR BEST PRACTICES

BY THE INSTRUCTORS

Implement a more comprehensive screening

process

Some instructors advocated adding an interview to the

admission screening process because English proficiency

tests such as TOEFL, CAEL and IELTS do not discrimi-

nate sufficiently. Other instructors oppose this saying that

the university should not be gatekeepers to education

based solely on a student’s language ability. They

maintain that it is important to invite and educate EAL

students thereby preparing more culturally diverse nurses

and generating greater diversity among the nursing

population:

The screening to screen them out has value, but I alwayswant to know what it is we’ll lose because of that. Yes, thescreening out seems like the quick fix now, but I wouldhave to say, if across the world we’re going to see more ofthat transitioning between countries, and we’re going tohave a population that looks very diverse more so thanever now. Then, is that the way we should be thinking,how will those individuals offer to us, excellence innursing, but how can we do it to maintain, to promote[diversity]?

Design a language course for EAL students

Some instructors suggested developing a credit language

course that is specifically designed for EAL students:

I would like to suggest … can we incorporate some kind ofelective course so it’s part of the program, and so it’s not thattheir taking language as an extra course. Probably you’ll wantto incorporate English, focus on our healthcare system, onterminology, how you apply English in that sense, under-standing ways of communicating, and ways of understanding.

Develop a formal support system for instructors

Instructors expressed the need for a strong, extensive net-

work of support that included workshops and courses. They

wanted to learn about other cultures, issues relevant to teach-

ing EAL students, and how to deal with racism that exists

within the healthcare arena so that they can protect EAL stu-

dents. The system would need to build in time, financial sup-

port and work flexibility:

A course on cultural diversity and English, and speaking aspart of what we should be taking, just as much as the stu-dents who come with English as a second language … Kindof workshops and networking, and a wider university focusthat supports and understands that there are issues, andthese are the resources that we can offer you … Thereshould be some courses that helping us deal with some ofthese issues.

Expand the EAL support group in the faculty

Instructors suggested expanding the EAL support group

which is the only existing support resource for EAL students

in the Faculty of Nursing. One instructor commented that

being capable of referring her students to the group for aca-

demic assistance and emotional support made her feel less

burdened:

In the academic world, I think one of the things that theydid try to do was this special group, the ESL group. That wasfor the students, but at least I could say to them, ‘Go here.’Within our own faculty, you can actually join this group andget more support, and more help … So you didn’t feel likeyou had to provide all the support … It was helpful for meto know that I could send them somewhere within our ownfaculty that would offer some assistance.

Hire more culturally diverse instructors

Instructors expressed the need for more culturally aware

and culturally diverse instructors. They based this on their

observations that EAL students who were placed in a more



culturally diverse unit in terms of patients and nurses, were

more relaxed and performed better.

Collaborate with the local health region

Instructors emphasized the need for stronger linkages

between the Faculty of Nursing and the health region. From

their perspective, the lack of collaboration between the

education and healthcare systems intensified the challenges

for EAL students by not helping staff nurses and precep-

tors to recognize, understand and address their unique

needs.

Advocate for EAL students

Instructors reported that racism and prejudice occurred

within the healthcare system (e.g. a client refusing to have

an EAL student as a care provider) and the academic setting.

One instructor described it as:

One of the things that people often suggest to students is,go off and get a job, and just speak English … and I thoughtthat links to racism too. I think we actually don’t namewhat’s happening in our curriculum, and we don’t speakabout racism. We don’t name it as racism, and we then posi-tion [the student] as kind of responsible in a way, and notdoing as good a job as a [student] nurse should. I’m justnot sure if that’s ethical. We have such a mix of students, yetwe’re not willing to understand different cultures. We’renot willing to name racism in a political sense.

Strategies that instructors suggested to support students

included discovering students’ cultural values and beliefs

rather than expecting behaviors based on our own values

and beliefs, inviting students to be responsible for and to

become active participants in their own learning, and inter-

acting with the students in ways that include them emotion-

ally which involved building trusting, meaningful and

nurturing relationships.

DISCUSSION

The findings from this study both supported conclusions

from other studies and added to the understanding of chal-

lenges encountered by EAL nursing students and those who

teach them. Different cultural values, beliefs, attitudes and

education systems created ethical dilemmas, interfered with

critical decision-making in healthcare practice and ultimately

affected learning within the Canadian context. Instructor

participants emphasized that language difficulties did not

account solely for the challenges that arose; cultural differ-

ences were also significant barriers both academically and

clinically.

Lack of educational resources and support was a major

theme that emerged from the data. Instructors felt ill

prepared to meet the unique needs of EAL students. They

articulated the necessity for cultural education (i.e. work-

shops, courses and discussion groups) for themselves in

order to learn about and understand other cultures and

issues encountered in teaching culturally diverse students.

Congruent with a study by Bosher and Smalkoski (2002),

the instructors identified major challenges in clinical com-

munications and the need to address the issue more

broadly. Specifically, they recommended greater collabora-

tion between education and healthcare systems. In addition,

relative to healthcare systems, they noted that the need to

recruit and retain nurses who are culturally and linguistically

competent was not solely the responsibility of the education

system. It should also be a concern for regional health

authorities at the provincial and national level, if the public

is to receive optimal nursing care.

San-Miguel et al. (2006) also addressed the importance

of cultural diversity in clinical placement sites saying that

hospitals with a culturally diverse workforce allowed students

to experience positive role models. Participants in this study

reported that EAL students performed better in a more cul-

turally diverse unit. This could be supported further by hir-

ing more culturally diverse, ethnic groups of educators that

reflect the student ethnic population in the program; a pre-

mise also put forth by Robinson (2000), Soroff et al. (2002)

and Sanner, Wilson, and Samson (2002).

As the faculty pointed out, good communication among

course co-ordinators, instructors and students is essential

in order to identify concerns accurately and to focus on

the right issues. Miscommunication and cultural confusion

between the student and the instructor play a significant role

in the students’ academic failure. Relative to these difficul-

ties, Rubenstein (2006) and Jalili-Grenier and Chase (1997)

emphasize the importance of recognizing the unique cul-

tures represented within a group of students and sub-

sequently the cross-cultural similarities and differences. As a

strategy, instructors could learn about their EAL students’

cultures, backgrounds, linguistic expertise, interests, family

responsibilities, expectations and extracurricular activities as

much as possible (Malu and Figlear 1998). This positions

them to promote respect and integrity of diverse cultures as

they guide and mentor students.

The formation of support groups comprised of instructors

and students build informal support systems and strengthen

decision-making and collective action. The teaching strat-

egies exercised by instructor participants in this study are

supported by findings from other studies as well. The

examples include providing synonyms for everyday words on



examinations, allowing more time for completing assign-

ments and examinations and encouraging EAL students to

ask questions and immerse themselves in English (Malu

and Figlear 1998; Cunningham, Stacciarini, and Towle

2004).

Understanding the average EAL student’s experience

requires the instructor’s willingness to be aware of and

attempt to reduce ethnocentrism, racism, stereotyping and

prejudice. Cultural sensitivity cannot be acquired by reading

a book or learning; it involves deliberate effort of opening

oneself to different worldviews and examining one’s own

worldview (Abriam-Yago, Yoder, and Kataoka-Yahiro 1999;

Harvey and Mac 2006). As a nurse educator, it is a profes-

sional responsibility to offer students chances to reflect upon

their own values and beliefs about cultural diversity and to

recognize any biases or discriminatory behaviors that can

negatively influence students’ learning and success.

Robinson (2000) found that facilitation of guest lectures

and meaningful classroom discussions about cultural diver-

sity and racism profoundly increased her students’ sensitivity

towards racism and prejudice existing in the healthcare

arena. Instructors in this study commented on attitudes of

non-EAL students towards their EAL colleagues highlighting

the need for faculty and non-EAL students to be aware of

and understand the academic challenges and cultural diver-

sity inherent in EAL students. The initiation of meaningful

discussions pertaining to cultural diversity would promote

understanding, cohesion and collaboration among the

student body.

Finally, the findings from the study suggest that the root

cause of the challenges experienced by EAL students and

instructors reside in a lack of awareness and support at the

institutional and structural levels rather than solely on

capacities of individual EAL students or instructors. The

University and the Faculty of Nursing must not only encour-

age EAL students but also provide appropriate, affordable

and accessible services to help them complete their studies

successfully. It is the professional responsibility of faculties

and educators to ensure that the necessary resources are

available and accessible.

CONCLUSION

The growing number of immigrants in Canada reflects the

need for the Canadian healthcare system to recruit and

retain culturally and linguistically competent nurses. Nurse

educators and decision-makers have opportunities for

enhancing the success of EAL nursing students by providing

well-co-ordinated services and on-going institutional support

to overcome their difficulties. In order to achieve all of this,

it is crucial to develop institutional policies and programs

that are responsive to the needs of the EAL students and the

instructors who teach them, that strengthen the educational

community by creating support groups among students and

faculties, and that provide interventional methods that build

upon the students’ strengths, assets and available resources.

The findings from this study were strengthened in a sep-

arate study by the same research group wherein EAL nursing

students described their challenges and barriers from their

own perspective. The students’ and instructors’ views, con-

cerns and recommendations were then compared. Although

the findings from the studies cannot be generalized due to

the small sample sizes and nature of qualitative research,

they could serve to raise awareness about the growing need

for multicultural oriented nursing education systems that

enable nursing educators and faculties to create supportive

learning environments conducive to learning, and to the

personal and professional growth of EAL students. Develop-

ing and using effective teaching strategies must be encour-

aged and shared among instructors. Future research is

projected to include implementation of the recommenda-

tions and evaluations of their outcomes.

ACKNOWLEDGEMENTS

We are grateful to all the students and the instructors who

participated in this research, and the University of Calgary,

Faculty of Nursing for the Nursing for funding to conduct

this study. We also give special thanks to the University of

Calgary USRP in Health & Wellness for providing student-

ship to Jihye Hwang, Yin Fong, Tiffany Fabro, and Delmar

Donnelly who were our project research assistants, Dr Janice

Kinch and Dr Jean Chow for their encouragements.

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