In 2004, the Sullivan Commission report stirred the profession of nursing by calling attention to the large gap between the 25% racial/ethnic minority population of the United States and the 9% minority nursing workforce. Six years later, the equally influential Future of Nursing: Leading Change, Advancing Health (Institute of Medicine, 2011) report called for a renewed focus to enhance the diversity of the nursing workforce to meet the nation's current and future health care needs. Recent data show that progress is being made, with a racial/ethnic minority nursing workforce currently at 19% (Budden, Zhong, Moulton, & Cimiotti, 2013). However, this number remains disproportionate when compared with the most recent U.S. Census reports that show racial/ethnic minorities in the United States at 37%, with projections that more than half of the population will belong to a minority group by 2044 (Colby & Ortman, 2015). In addition to increasing the number of racial/ethnic minorities in nursing, it is equally important to increase the number of linguistic minorities. Although data are not available regarding the linguistic diversity of the nursing workforce, in 2011 nearly 21% of the U.S. population spoke a language other than English in their homes (Ryan, 2013). The growing cultural diversity of the United States, both racial/ethnic and linguistic, requires that the profession of nursing expand its ranks of diverse nurses.
To address the need for increased diversity in the nursing workforce, educational institutions have engaged in recruitment of students from underrepresented populations. Over the past 5 years, these efforts have been successful, and the population of racial/ethnic minority nursing students has increased to approximately 30% (American Association of Colleges of Nursing, 2016). Although increasing enrollment in nursing education programs is laudable, recent work by Debrew, Lewallen, and Chun (2014), Mulready-Shick (2013), and Sedgwick, Oosterbroek, and Ponomar (2014) continues to support evidence from the past three decades (Abu-Saad & Kayser-Jones, 1981; Keane, 1993; & Sanner, Wilson, & Samson, 2002) that minority nursing students face myriad issues that negatively affect their successful progression through nursing programs and into practice. In addition, according to Morton-Miller (2013), “educators often acknowledge the need to be culturally competent with patients but struggle when it comes to teaching diverse students” (p. 92). Although there have been studies of both students' and educators' perspectives on the challenges related to the education of minority nursing students, no study has looked at the perspectives of the two groups in the same program to ascertain where these perspectives overlap and where they diverge. The current study fills this gap by reporting on a parallel mixed-methods study that compared culturally and linguistically diverse (CALD) minority nursing students' perspectives with those of nursing faculty regarding the teaching and learning challenges faced by CALD nursing students and their nurse educators. The current study focuses on students who are both linguistically and culturally diverse, as the challenges facing multilingual students are perhaps the most complex.
The perspectives of CALD nursing students on the challenges they face in nursing education programs have been well documented. CALD nursing students have described various cultural differences that have affected their ability to fully engage in learning experiences. For instance, acceptable topics of conversation or styles of nonverbal communication such as eye contact may be unfamiliar. In addition, expected student behavior in the classroom and in interactions with teachers can be different from what they are used to (Debrew et al., 2014; Gilligan & Outram, 2012). Along with the cultural differences, CALD nursing students have reported that language difficulties with reading, writing, and speaking were impediments to success (Bosher & Smalkoski, 2002). In addition, it has been shown that when CALD students perceived that others were not understanding them well, they retreated from engagement and hesitated when speaking for fear of being embarrassed. These verbal retreats had serious repercussions for CALD students, as teachers sometimes made assumptions about the students' knowledge and abilities based on the success of communication with others (Koch, Everett, Phillips, & Davidson, 2014).
Finally, CALD nursing students have also reported experiencing discrimination that affected classroom engagement and clinical interactions (Debrew, Lewallen, & Chun, 2014; Sedgwick et al., 2014). For instance, prejudice may influence the interactions of non-CALD students with CALD classmates, inhibiting the development of peer relationships that are vital to success in nursing education (Koch et al., 2014). These studies have shown that the obstacles that CALD students must overcome are pervasive throughout their journey through nursing education.
Nurse Educator Perspectives
Like students, nurse educators identified language as an issue. They reported that it posed a barrier when teaching CALD students and found teaching CALD students to be challenging because their spoken English was hard to understand (Donnelly, McKiel, & Hwang, 2009, Sanner et al., 2002). Studies of nurse educators also identified bias as an issue. It has been noted that the attitudes of some nursing faculty members may interfere with the ability to teach diverse students and faculty bias regarding culture and language may obstruct learning and impose barriers that inhibit CALD students' success (Amaro, Abriam-Yago, & Yoder, 2006; Starkey, 2015). Some nurse educators struggling with the multitude demands of teaching verbalized their feelings of inadequacy when faced with a classroom that contained CALD nursing students, and others were overwhelmed by the time required to explain the meaning and context of what was being taught to CALD nursing students (Caputi, Engelmann, & Stasinopoulos, 2006; Donnelly et al., 2009). In general, many nurse educators regard teaching CALD students as doing something extra, requiring a change to their teaching.
This research study used a mixed-methods design in which nurse educators completed an online survey and nursing students self-selected to participate in focus groups. The participants were from an upper division baccalaureate nursing program in a large university, in which CALD nursing students make up about 20% of the nursing student population. The data were collected during the same time period from both groups, and the study was approved by the university institutional review board for the protection of human participants.
Student Focus Groups
Three focus group interviews were conducted with a total of 13 CALD nursing students whose home, first, or native language was not English. The CALD nursing student participants reported their countries of origin to be Cameroon (n = 4), Ethiopia (n = 1), Ghana (n = 2), Indonesia (n = 1), Nepal (n = 1), Nigeria n = (1), the United States (n = 1, ethnically Chinese), and Vietnam (n = 2). The interviews were semistructured, with open-ended questions that elicited information about the students' experiences in the nursing program. Because the interviewer was an ESL teacher familiar with the experiences of CALD students and outside the nursing program, a comfortable dialogue developed between the interviewer and students. Following Maxwell's (1996) suggestion to combine methods of data analysis, both categorizing and memoing strategies were used. Virtually all utterances were coded, using open and theory-based codes, and a code book was created. Memoing was used to both capture and facilitate the development of analytic thinking about the data. From this process, important categories were identified, and the relative importance of various issues was inferred.
Nurse Educator Survey
Twenty-nine full-time and 53 part-time nurse educators were invited to take part in the survey. Eleven full-time (response rate = 39%) and eleven part-time (response rate = 20%) nurse educators completed it. The participating nurse educators had an average of 12 years of teaching experience and taught an average of five CALD nursing students per semester. The researcher-developed survey (Fuller, 2012) contained questions related to demographics, nurse educator beliefs and observations regarding teaching CALD nursing students, and instructional strategies. The instructional strategies questions included the three subcategories of supportive strategies (creating a caring, positive learning environment), teaching practices (teaching both inside and outside the classroom), and language strategies (recognizing and addressing language needs). These instructional strategies were based on recommended teaching practices for CALD students in the nursing education literature (Fuller, 2013; Hansen & Beaver, 2012). Descriptive statistics were used to analyze the categorical responses, and thematic analysis was used for the open-ended responses and comments.
After analyzing the data from the two groups separately, the perspectives from nurse educators and CALD nursing students were systematically compared in an iterative process, yielding the major themes of Academics, Language, and Relationships.
In analyzing the theme of Academics, three prominent issues were found—workload, teaching practices, and testing—that revealed some similarities and some differences between the understandings of the CALD students and those of the nurse educators.
First, both the nurse educators and the CALD students (Table 1) identified workload as a major challenge. Although the nurse educators did not see academic ability as a major challenge to CALD students (Tables 2–3) and believed that they could be successful in nursing, many were concerned about the time it took for CALD students to read and prepare for class, and more than half felt that the amount of reading expected in the course was a problem. For example, on the open-ended question, “What is the most pressing issue in the education of CALD nursing students?” they made comments such as, “not enough time to truly absorb lecture and learning,” and “it takes the CALD students a lot longer to read the materials.” The student data echoed that of the faculty; they found that the reading load was heavy and that it took them longer to complete their work than it took their native English-speaking classmates. The student data also pointed to the first semester as especially difficult because the students were involved in learning both U.S. culture and nursing at the same time. The students commented on wanting the nursing faculty to appreciate the difficulty of confronting these tasks at the same time.
Major Themes Generated From Culturally and Linguistically Diverse Student Focus Groups
Nurse Educator Beliefs About CALD Nursing Students
Nurse Educator Observations of CALD Nursing Students
Second, in comparing the perspectives of faculty and students regarding teaching practices, larger discrepancies existed. Specifically, a majority of nurse educators said they helped CALD nursing students to prioritize information (Table 4), but the students reported that only a few teachers did this. Although the data on teaching practices were often not directly comparable because the students did not use the same language as the faculty survey, similar constructs were revealed when the two data sets were aligned. For instance, a majority of the faculty reported using stories, scenarios, and case studies to provide context for teaching, whereas the students, by contrast, complained that few teachers presented information using visual aids, such as concept maps, or helped them integrate or apply concepts. In addition, the students named a number of cultural patterns used in class that they wished were taught explicitly. For instance, in clinical settings, these included topics of conversation and forms of touching considered appropriate by Americans, and in lessons about pediatric and maternal child care, they included culturally bound concepts, such as developmental milestones. Taken together, these data indicate important differences between the faculty's perspective that they were making efforts to meet the needs of the CALD students and the students' perspective that their needs were not adequately being met.
Nurse Educator Teaching Strategies and Practices
Third, there were important differences in the faculty and CALD nursing student data on the difficulties of test taking. For the students, one issue was that they were not familiar with the format of the tests and needed time to decipher what the question was asking (Table 1). However, few of the nurse educators allowed extra time for CALD students to take examinations (Table 4) (although some did provide extra time for thinking and processing in classroom, laboratory, and clinical settings). A second test-related issue was cultural bias. Students felt that it was unfair for them to get a test item wrong when, for example, they knew the nutritional issue being tested but not the food item. One student explained, “I didn't know what sauerkraut was. Sauerkraut is supposedly a very salty food…[and for] hypertension, you don't want to give high-salt foods. And if I saw high a salt food on the question, I'd be able to answer.” Only about one third of the nurse educators reported that examinations were evaluated for such bias (Table 4). From the students' perspective, biased questions meant that their grades did not reflect what they knew and the faculty, therefore, did not realize how intelligent they were.
Although both the nurse educators and the CALD students recognized language difficulties, such as the need to learn vocabulary, the two groups differed in terms of how much emphasis they placed on language as a problem. The educators believed it to be the primary challenge, but the students emphasized it less. The nurse educators' emphasis on language as a problem was evident in the quantitative survey results (Tables 2–3), as well as their answers to open-ended questions, with comments such as “missing key concepts along the way due to language barrier.” From the student data, it seemed that the nurse educators and the CALD students had different expectations for the students' writing, with the educators using native English-speaking students as the standard and expecting nonnative English speakers to measure up to that standard. The students felt that some faculty placed too much emphasis on form (e.g., grammar, American Psychological Association style, typing) in their grading of papers. Although many students were intent on improving their writing and more than half of them made use of on-campus writing tutors (Table 1), several felt that this was an unreasonable expectation.
The nurse educators and CALD students had different understandings of what inhibited oral communication. The educators saw the success of oral interactions as resting on the CALD students' oral/aural English skills. For example, one explained, “verbal communication is a challenge, CALD students usually speak very softly, so not only do others listening have to decipher their accent, they also must strain to hear.” The students, on the other hand, described communication difficulties that stemmed not so much from their English ability, but from the attitudes of the people they were speaking to. When they felt disrespected, they explained, they lost confidence and did not communicate as well as they otherwise could have.
Much of the faculty data on language pointed toward a deficit understanding of the CALD students' abilities. Their responses reflected the beliefs that all nursing students should write and speak like American-educated students, and that CALD students have difficulty communicating because they do not. The student data, in contrast, revealed more complex understandings of the ways that successful communication relies on the efforts of all parties involved.
Rather than language, the students felt that relationships with faculty and classmates were the biggest challenge they faced (Table 1). In interactions with faculty and mainstream students, CALD students believed they were viewed as inferior. For them, their reports of teachers' comments about their knowledge of vocabulary (e.g., “You don't know what loafers are?” or “You don't know cottage cheese?”) were less about language proficiency than they were about positioning them as cultural and program outsiders. Such responses made the students feel unwelcome and stupid. Some students not only felt like they were being treated as outsiders, but they felt they were being treated unfairly as well. Despite the fact that during the focus groups, participants were visibly uncomfortable talking directly about discrimination, one student did finally ask the interviewer, “So I wanted to ask you a question: Is this school only for White people?” From the context, it was clear that the student used “White” to reference issues of language and place of origin as well as race, and that several students felt that racial/ethnic, linguistic, and xenophobic discrimination was occurring.
For students, the relationships they had been able to make with some faculty were important resources (Table 1). One student commented, “…even if they just listen. Sometimes they are not even doing anything about the problem but the fact that I'm telling you my problem and you are giving me an ear.” Some students found that such relationships helped them understand and navigate the program requirements and provided guidance, career advice, and encouragement. Recalling the importance of faculty as resources, a student recounted how one nurse educator offered her encouragement in her stressful first-semester clinical experience: “She literally held my hand [laughter], just to calm my nerves.”
In contrast to the students' feeling that it was difficult to connect with faculty, Table 4 demonstrates that faculty believed they were open and available. The majority of the faculty reported that they routinely made an effort to connect with CALD students on a personal level, believed that they showed their support through having an “open door” office policy and encouraging CALD students to visit. In addition, a large majority reported that they made the learning environment inclusive and accepting for CALD nursing students. Thus, the nurse educators and CALD nursing students had different perspectives on the availability of the nurse educators as resources to which the students felt they could turn.
The CALD students believed that their U.S. classmates viewed them as different and did not form relationships with them for that reason. They reported classmates getting up and leaving when they sat down at the beginning of class, refusing to join groups with them, and displaying disrespectful behaviors when they spoke. These behaviors were not only unpleasant, but they became hindrances to their successful academic performance. For instance, when classmates did not listen respectfully when she spoke, one student decided not to ask any more questions in class, which took away an important strategy for her to refine her understandings of the material. The lack of relationships with non-CALD classmates made it difficult to join study groups. Although the CALD students spoke of the importance of these groups to their academic success, the majority reported having no native English-speaking American friends, and only one had ever studied with a native English-speaking, U.S.-educated classmate. Despite the fact that the CALD students reported constant difficulties in this regard, the nurse educators reported that they did not often observe native English-speaking students avoiding making groups with CALD nursing students (Tables 2–3). This helps to explain the finding in the student data that most teachers did not address classroom segregation. In sum, nursing faculty did not perceive the isolation that CALD students experienced.
Discussion and Implications
Hansen and Beaver (2012) maintained that nurse educators should adapt to the learning needs of CALD nursing students and implement appropriate practices that can improve the teaching and learning environment for all. This can be accomplished by adopting a culturally responsive pedagogy, what Yoder (2001, p. 320) called “bridging.” By addressing the differences between CALD student and nursing educator perspectives and actions revealed in the current study, nursing programs can work toward such a pedagogy.
From the results presented in this article, it is clear that nurse educators should develop ways to build relationships with CALD students. Building such relationships would directly address CALD students' feelings of being positioned as outsiders and provide guidance and encouragement. Improving these relationships could help with academic issues as well, because relationships open up a line of communication for nurse educators and CALD students to discuss such issues as workload and the particular difficulties involved in the first semester. These difficulties were not only reported by the students in this study but also discussed in the literature (Gu & Schweisfurth, 2006; Skyrme & White, 2011). Nurse educators and CALD students could discuss teaching practices and test design so that students could become better acquainted with why and how U.S. nurse educators teach and test the way they do, and teachers could think more about how better to meet the needs of their CALD students. Like the teachers of previous studies, the nurse educators in this study reported that they had not received any formal education regarding teaching CALD students, and they voiced concern regarding what they viewed as a lack of institutional support. As one nurse educator explained, “If we have multiple CALD students in the class, each student could have different issues…. We have no formal resources in our department to assist students or faculty with CALD issues.” Therefore, relationships with their CALD students are an important resource for nurse educators who want to develop the cultural knowledge necessary to improve their teaching.
In addition to building relationships, nurse educators need to take CALD student experiences into consideration when thinking about how to meet the commitment of professional nursing education organizations, such as the American Association of Colleges of Nursing (2014) and the National League for Nursing (2014), to value cultural diversity in nursing care and education. Valuing diversity means shunning deficit theories that position CALD students as ignorant and mainstream students as the standard to be emulated. This means that it is reasonable for faculty to teach relevant aspects of U.S. culture explicitly, including words such as sauerkraut, as the students in this study desired. It also means that it is problematic to use native English as the standard expected for all students (Canagarajah, 1999) and to assume that when an oral interaction falls apart, it is due to the nonnative speaker's lack of English proficiency. A particularly important finding of this study was that verbal retreats came about because CALD students felt disrespected, not because their English was not good enough. This finding points to the need for more complex understandings of communication challenges.
How can nurse educators begin to build relationships with CALD students? They can begin by being more assertive in how they approach CALD students, for example, by not assuming that the students will make free use of office hours. Relationships can be improved indirectly, through a deliberate effort by nurse educators to recognize differences without stigmatizing people. Recognizing differences includes evaluating tests and teaching materials for cultural bias, recognizing and adapting to the fact that CALD students may require more time to process English texts, valuing diverse accents, recognizing the courage it takes to nurse in a second language, and offering moral support when a CALD student is at first hesitant. Nurse educators can also promote relationships between CALD and other students to engender a constructive learning environment.
How can nurse educators teach CALD students the English they need without positioning them as inferior? One thing they can do is explicitly teach the language of nursing that nursing students are expected to use and give them ample feedback and opportunities to practice between graded assignments. It is unreasonable to assume that students will have the English they need to complete nursing assignments when they enter the program given that the writing demands of disciplines differ (Hyland, 2000) and can be acquired only in context (Gee, 2008; Street, 1995). Therefore, nursing students, and CALD nursing students in particular, need to be taught the language of nursing in nursing programs, as they acquire the values and social practices of the nursing community. Finally, nurse educators can make greater use of teaching strategies known to be helpful to CALD students as highlighted in Table 4.
Because both surveys and focus groups had a low response rate and were self-selecting in terms of participants, the data presented in the current study may be skewed. The order of the survey questions may have influenced how the nurse educators answered the open-ended questions at the end, as answering the multiple choice and rating questions with established answers could have conditioned the respondents to provide what they thought were acceptable responses. Therefore, alternative perspectives may not have been divulged. In terms of the student data, no observation data were available to corroborate the focus group statements, so the actions of others described by the students cannot be evaluated. However, the influence of the actions on the students themselves (their emotions and memories) are valid and can be analyzed. Finally, the comparative analysis may have been affected by the different nature of the survey and focus group data collection methods. Although the authors do not suggest that these findings are generalizable to other institutions, from comparison with prior studies it seems clear that there are patterns in the challenges faced by CALD nursing students.
The recent report Assessing Progress on the Institute of Medicine Report: The Future of Nursing (Altman, Butler, & Shern, 2016) made note that the nursing workforce is still not representative of the U.S. population and called for the profession of nursing to make diversity in nursing a priority. For this to happen, nurse educators need to support and promote the academic achievement of CALD nursing students. Perhaps now is the time to “reframe this issue by acknowledging some of the inadequacies within nursing education that may be contributing to minority [CALD] student attrition” (Giddens, 2008, p. 79). Acknowledging the inadequacies of nursing programs to meet the needs of CALD students requires self-reflection and dialogue. As Terhune (2006) explained:
Critical self-reflection and dialogue allows for the more subtle and insidious forms of discrimination and separatism to be uncovered and dismantled. It will allow for the removal of the chill often felt in the air in academic institutions by non-Whites. It will allow for the organization to individually and collectively see itself truthfully and develop a strategy for consciously changing. It allows for not just recruitment, but the ultimate goal of retention.
The profession of nursing has made progress in recruitment of diverse nursing students, and the population of minority nursing students is increasing; however, these efforts must now be supported with actions that enable CALD nursing students to progress and move into the profession as nurses. A process combining critical self-reflection and dialogue with CALD students can lead to effective, nondeficit-based strategies for promoting the success of these nursing students.
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Major Themes Generated From Culturally and Linguistically Diverse Student Focus Groups
|Forming relationships with faculty and classmates|
|Surviving and excelling in the first semester|
|Managing workload, especially reading requirements|
|Understanding test design and taking tests|
|Understanding colloquial American vocabulary|
|Integrating knowledge and applying it to cases|
|Mastering cultural communication knowledge for clinical settings|
|Relationships with faculty|
|Relationships with classmates (potentially)|
|On-the-job-training (e.g., internships, externships, volunteer work, jobs)|
Nurse Educator Beliefs About CALD Nursing Students
|Learning for all students is enhanced by the presence of CALD nursing students.||3.82|
|Having CALD nursing students in the classroom/laboratory/clinical setting is detrimental to the learning of the other students.||1.68|
|Even when they have language differences, CALD nursing students can still be successful in nursing coursework.||4.23|
|Teaching in the classroom/laboratory/clinical setting is hampered by the presence of CALD nursing students.||1.86|
|Most CALD students have difficulty in nursing programs due to their academic deficits that are not related to language challenges.||1.91|
|CALD nursing students invest sufficient time and effort into preparation for their learning experiences.||3.50|
|CALD nursing students are difficult to teach.||2.05|
|I frequently feel that I am not an effective educator when it comes to teaching CALD nursing students.||2.64|
Nurse Educator Observations of CALD Nursing Students
|Have you observed CALD nursing students flounder in a conversational setting due to the fact that the person the CALD student was speaking with was impatient with the student's English?||2.45|
|Have you observed CALD nursing students flounder in a conversational setting due to the fact that the CALD nursing student lacked appropriate vocabulary?||2.80|
|Have you observed CALD nursing students flounder in a conversational setting due to the fact that the person the CALD student was speaking with could not understand the student's English?||2.95|
|Have you observed CALD nursing students and other students experiencing difficulty working together in a group?||2.63|
|Have you observed English-speaking students avoid making groups with CALD nursing students?||2.84|
|Have you observed CALD nursing students who had significant difficulty with writing assignments? Related to:||2.95|
| Unfamiliarity with the expected writing style (63%)b|
| Inadequate academic vocabulary (59%)b|
| Formatting and word processing (45%)b|
| Inadequate nursing vocabulary (36%)b|
| Problems with developing logical connections (23%)b|
|Have you observed CALD nursing students who had significant difficulty with reading assignments? Related to:||2.67|
| Amount of reading expected in the course (55%)b|
| Lack of nursing vocabulary (55%)b|
| Lack of academic vocabulary (41%)b|
| Critical thinking required to understand the reading (41%)b|
| Level of required reading in the course being too high (18%)b|
Nurse Educator Teaching Strategies and Practices
|Nurse Educator Supportive Strategy||Not Usually or Sometimesa||Most or All of the Timea|
|I make an effort to connect with CALD nursing students.||18%||82%|
|I strive to be supportive of CALD nursing students by making the learning environment inclusive and accepting.||5%||90%|
|I have an “open door” office policy, and I encourage CALD nursing students to come to see me.||5%||90%|
|I recommend additional resources to CALD nursing students to support their understanding of the nursing content.||45%||50%|
|I assist CALD nursing students to access school resources.||23%||73%|
|Nurse Educator Language Strategy||Not Usually or Sometimes||Most or All of the Time|
|I avoid the use of idioms and other colloquial expressions in my teaching activities when I have CALD nursing students.||37%||54%|
|I structure learning so that CALD students have opportunities to practice speaking English in a health care context.||36%||50%|
|I make an effort to pair native English-speaking nursing students with CALD nursing students during learning activities.||32%||59%|
|CALD nursing students are encouraged to use translators or bilingual dictionaries in my classroom/laboratory/clinical setting.||54%||36%|
|Before teaching activities, I provide vocabulary lists specific to the course to CALD nursing students.||73%||18%|
|Examination questions are evaluated for linguistic bias before they are given to nursing students in my courses.||41%||36%|
|Nurse Educator Teaching Practice||Not Usually or Sometimes||Most or All of the Time|
|I use stories, case studies or scenarios to provide context for what I am teaching as an aid for CALD nursing students.||2%||59%|
|During learning activities I provide CALD nursing students with clear directions and expectations.||5%||82%|
|I assist CALD nursing students to prioritize key elements of learning activities.||2%||68%|
|When there are CALD nursing students listening to me, I make an effort to speak more slowly and clearly.||18%||77%|
|CALD nursing students are provided with informal assessments to evaluate their learning during my course.||40%||50%|
|I encourage CALD nursing students to learn about the nursing content in their native language.||86%||0%|
|I allow CALD nursing students extra time for thinking or processing when I interact with them in the learning setting.||36%||54%|
|I provide extra time for nursing students to complete examinations to accommodate for language differences.||68%||5%|
|I utilize some type of graphic organizer, diagram, picture, or visual aid when teaching CALD nursing students.||72%||27%|