Many studies have suggested that nursing students with an English-as-an-Additional-Language (EAL) background face significant communication challenges due to the linguistic demands posed by nursing education (Crawford & Candlin, 2013a, 2013b; Glew et al., 2015; San Miguel & Rogan, 2015). Strong communication skills are necessary to ensure patient safety in the clinical setting and to successfully relay information to other health care professionals. Success in the clinical setting also involves proficiency in higher level English, as understanding medical terminology and nursing communication requires more than just aptitude in basic English communication skills (Crawford & Candlin, 2013a).
In addition to providing academic support, skill-based interventions have the potential to create an atmosphere of inclusivity and social acceptance among EAL students, mentors, and faculty. Because EAL students often suffer from social isolation and discrimination (Junious, Malecha, Tart, & Young, 2010), connecting with other EAL students with similar challenges allows them to make new social connections and build confidence (Boughton, Halliday, & Brown, 2010; Crawford & Candlin, 2013b; Mitchell, Del Fabbro, & Shaw, 2017). One way to achieve this social agenda is through the establishment of an EAL support group for nursing students. By creating a safe and supportive environment for students to develop linguistic competency, postsecondary institutions can provide skill-based interventions while also addressing the psychosocial needs of EAL students (Choi, 2016). Choi (2016) provided an EAL support group template for nursing students, which successfully integrates both academic and social support strategies. The structure of this group consisted of large group gatherings where members of the support program were able to share their clinical experiences and practice communication; individualized mentoring with peer mentors who were either non-EAL senior-level nursing students or EAL senior-level nursing students who were prior participants in the support program; mentoring with the faculty liaison to the support program; and ad hoc curriculum-specific workshops that addressed pronunciation of specific nursing terms and clinical communication. EAL participants were able to contribute to periodic newsletters on this program by writing articles on their own nursing experiences and could contribute these experiences on the website specifically dedicated to the support group (Choi, 2016).
Supportive nursing faculty and mentor qualities are important considerations for fostering EAL student success. Mentors must create a supportive environment by being culturally accepting and encouraging of diversity (Olson, 2012). Evidence suggests that providing students with role models from similar cultural backgrounds (i.e., ethnic role models) is conducive to student success (Malecha, Tart, & Junious, 2012; Olson, 2012). In fact, several sources have argued that lack of ethnic role models in postsecondary institutions presents a barrier to success, requiring stakeholder attention and remediation (Olson, 2012).
Several EAL nursing student support programs have examined the positive benefits of academic support (Boughton et al., 2010; Crawford & Candlin, 2013a, 2013b; Weaver & Jackson, 2011). However, there has been a dearth of programs and recent studies examining the nonacademic issues faced by this group of students. The EAL Nursing Student Support Group developed at Mount Royal University has attempted to address these challenges; both academic and nonacademic in nature. Using a hermeneutic approach, this study examines the experiences and impact of this support group. The main purpose of this study was to determine the following question: Does a support group for EAL nursing students improve academic success as perceived by the participants? This study sought to:
The key philosophical approach underpinning this research was hermeneutic phenomenology. A Gadamerian approach was used to guide the research process and data analysis (Binding & Tapp, 2008; Gadamer, 1989). For the researchers to understand the lived experience of EAL nursing students as they participated in this unique support program, data analysis was conducted with a number of considerations, including the prior experience of the author as a former EAL nursing student, maintaining a reflexive lens throughout the inquiry process, and having a bidirectional and iterative consultation process with the research team. This process overlaps with the work of Gadamer in the areas of fore understanding, authenticity, and the hermeneutic circle (Binding & Tapp, 2008; Gadamer, 1989; Regan, 2012).
To support the analytical process, two student researchers were hired. Their tasks included reviewing the raw data for common themes, retabulating the data along the identified themes, surveying the literature pertinent to the themes identified, and participating in face-to-face meetings with the principal investigator to discuss the merits and validity of the identified themes. These meetings were imbued with a sense of authenticity as the team strove to promote a critical and open flow of discussion among the team and in the text of the interviews. Trustworthiness of themes and interpretation of the interview text depended on a consensus view of all parties involved. One of the student researchers was also involved in manuscript preparation.
EAL participants in this study were specifically asked about their experiences in the support group, which ran the whole academic year. Study participants were interviewed and asked to reflect and comment on all aspects of this program.
Participation in this study was voluntary. Subjects were selected if they met the following criteria: (a) 18 years and older; (b) registered in the Mount Royal University Bachelor of Nursing Program; (c) native (or country of origin) language other than English; (d) no specific course prerequisites were required; and (e) part-time or full-time student. The Table displays participant demographics.
Student involvement consisted of being available for individual interviews. Participants were not compensated for this study and were allowed to withdraw at any time. At the study's conclusion, students were invited to debrief. The option to participate in the debriefing was left up to the student. If any distress arose from these interviews, students were referred to appropriate support services, such as mental health resources, available on campus. Ethics approval was granted for this study by Mount Royal University.
Audiotapes of participant interviews were used to examine verbal content for emerging themes. Themes were then interpreted, and a clearer picture emerged detailing the lived experiences of these students.
Interviews themselves used a series of open-ended questions that specifically examined (a) whether students perceived that the EAL Nursing Student Support Group contributed to their academic success, and (b) which components of educational support the participants found to be most helpful. Participants were encouraged to elaborate on those factors that led to continued success as a nursing student.
Individual interviews revealed eight themes common to the lived experiences of each EAL nursing student. These themes include crisis, communication, skill-based interventions, social aspects, nursing faculty qualities, student success, improved nursing practice, and student engagement.
Many participants joined the EAL Nursing Student Support Group in a state of crisis, exacerbated by poor academic standing and psychological distress. Participants often turned to the support group following referral by other faculty members, rather than as a proactive measure to supplement their learning. This was reflected in initial student interviews, where students were often focused on improving their current academic standing and avoiding imminent failure. One student explained:
In order to meet the benchmark for the course, I need to make changes and improvements in the following areas in the next two weeks…[I need to] build up my communicati[on] skills. To attain this, I will participate in the nursing EAL suppor[t] group to learn the proper ways of articulating my ideas to the [patients], group members, and instructors, thus strengthening my communication skill[s].
However, once the students gained the support and guidance necessary to lift themselves out of academic crisis, other goals surfaced, such as a desire to engage in social networking opportunities and address other unmet needs. Participant #1 later explained:
The conversation between us is so helpful. Without it, I would have failed the clinical. You gave me a lot of valuable advice such as how to communicate with my instructor and the group members…. In the last week of my clinical, I tr[ied] to demonstrate to my clinical instructor that I can make it…. [Over] the holiday season…I think I will just spend much time watching TV, English program…. [I want to learn more about] the culture…. I'm still separated from this kind of world. I'm still communicating or using the words that I learned in China.
Another participant (#2) stated, “You [mentor] gave me mo tivation. I almost quit three times…. You're [a] stress reliever. Just talk[ing] [to you] puts a big smile on my face.”
When asked to explain what she would like to gain from the EAL support group next, participant #2 explained, “I hope to find a friend to talk [to]…[to] shar[e] experiences, tips, empathy.”
Research findings validated many communication challenges echoed in the literature. All participants expressed concerns regarding communication and identified the need to improve and further develop their academic language proficiency. One participant (#7) stated:
We don't know how…to express our feelings, especially how to communicate with the patient…. The first time I went to the clinical practice I was so worried [about] if I [would] say something wrong, and if I [would] respond to the patient in a not professional way.
With respect to communication, participants voiced concerns regarding pronunciation, articulation, cultural language competency, basic interpersonal communication skills, medical vocabulary, and writing competency.
Pronunciation was a widely cited concern among the EAL student population, as EAL students found it difficult to make themselves understood. Due to feelings of isolation and a general lack of social exposure to native speakers outside the classroom, many EAL students lacked the opportunity to learn from other people's speech and overall pronunciation. Participants also struggled to pronounce certain words and communicate effectively.
Articulation was a common concern among the EAL student population. Many students struggled to pace their speech effectively, use appropriate tone, and enunciate their speech in a clear and fluent manner. One student (participant #5) stated, “I've learned that as long as I talk slowly and remember to say the ending of words then it's easier for people to understand me.”
Many participants also acknowledged challenges related to cultural language competency. Several EAL students identified a need to expand their cultural knowledge and to become self-aware of cultural differences between their own culture and that of Canadian culture. To effectively communicate with patients and establish therapeutic relationships, participants came to understand that they would have to seek assistance and develop personal competency in this regard.
As medical terminology requires more than just aptitude in basic English communication skills (Crawford & Candlin, 2013b), communication involving medical terminology was another priority concern for EAL students. Participants identified a need to develop medical terminology and language frequently used in the clinical setting to ensure patient safety and effectively communicate with patients, instructors, and peers. One participant (#8) explained, “It give me a hard time at first because I don't know how to say those allergies, those medicines…. I don't know exactly how to pronounce all those diagnos[es].”
Finally, essay writing and general writing competency were also identified as communication challenges for many EAL students, presenting barriers to academic success for several participants. EAL students found it difficult to express their thoughts, understand assignment objectives, and meet satisfactory academic writing standards.
Participants perceived skill-based interventions to be most conducive to their growth and development. When asked to describe what EAL support measures were most meaningful to their personal development, EAL students cited interventions that helped them develop specific skills relevant to the nursing curriculum and success in the clinical setting. Participants were most receptive to interventions addressing linguistic competency, academic writing in the nursing program, and effective studying strategies.
As pronunciation, articulation, cultural language competency, basic interpersonal communication skills, and command of medical vocabulary were identified as priority concerns among the EAL student population, interventions targeting these linguistic competencies were well received. Some testimonials include:
- I learned how to pronounce some words correctly which are used frequently in daily life and nursing practice…. I can ex press myself to other people clearly and other people don't need to say “pardon” or “what do you mean” anymore. (Participant #4)
- This is the first time I am learning about [jaw and tongue exercises]. It helps to relax my tongue. When I am talking too fast my tongue tends to become stiff and this exercise helps to relax my tongue helping me talk more clearly. (Participant #15)
Participants found writing workshops and one-to-one men torship to be invaluable resources for the development of aca demic writing proficiency. EAL students were appreciative of writing assistance, as success in the nursing program often de pends on writing ability. Compared with other generic support services available on campus, participants believed that writing interventions embedded in nursing curricula better suited EAL learning needs and made a more meaningful contribution to their growth and development. One participant stated:
This EAL nursing [Student] Support Group has [impacted] my academic learning by improving the way I write an essay. I learnt a lot from this help and improved the way I think of things when it comes to writing and understanding questions asked.
EAL students also rated time management seminars positively. Both in small group and large group settings, participants were receptive of new study strategies and advice from other students. As the nursing program is demanding and fast-paced, EAL students appreciated learning effective time management skills and familiarizing themselves with the broader Canadian postsecondary education system. When asked what interventions were most helpful, one participant (#2) identified “meetings with instructors one on one and getting help in specific learning areas…[including] strategies for studying, time management, [and] recording what is specific for objectives” as most helpful.
In addition to academic support, participants also turned to the EAL support group for social support and a sense of belonging. As many EAL students experienced isolation, crisis, and discrimination in their studies, joining the support group allowed participants to gain the support and encouragement necessary to carry on with the nursing program. One student stated:
I felt I was not the only one who is struggling. That made me feel better about myself.… I got motivated and I did pretty good in my nursing paper and nursing midterm. I am looking forward to join[ing] the next class.
Another participant explained:
I know some students came from the same place and have the same situation, so we know that we can come together…. I have the feeling I am a member of this EAL group…. It [pro vides] motivation,...social support, a community.
Social aspects of the EAL support group also facilitated social networking opportunities, cultural immersion, and a safe place for disclosure. As many participants lacked peer support in the classroom and struggled to establish support networks with native speakers, the EAL Nursing Student Support Group provided students with a venue to form new social contacts and build resilience from within the EAL community. One participant (#8) explained, “We have the same problems. I like to talk to ESL student[s] because…we can maybe sit together and talk together and think about [what] we can do…how can we survive?”
The EAL support group also provided students with the opportunity to immerse themselves in Canadian culture and become more familiar with Canadian customs and traditions. As many participants came from countries with different education systems and expectations, EAL nursing students welcomed this opportunity. When asked what he would be most interested in learning, one participant (#7) said, “Everything related to the culture. I want to learn, I'm eager to learn the culture and customs so I can more easily connect with the local students.” Another participant explained:
I love learning from other students, I love learning about dif ferent cultures and backgrounds and recognizing that we are all students…no matter where we come from…and having that connection, that interaction, that we don't necessarily get in the classroom because [we] are so busy studying or focus[ing] on other things.
For some participants, the EAL support group facilitated mental well-being. One student explained:
With the support of [the] EAL nursing student group, I sur vive and breath[e] in the environment, which is full of stress, pressure, and so on. I feel [good] while I am in the group. People there create a peaceful “un-bias[ed]”…atmosphere.
Many participants felt that the EAL support group provided a safe place for disclosure and for the sharing of mutual experiences. For some students, disclosure served as a means of coping and building resilience, whereas other students used disclosure to develop confidence in communication and voicing opinions. One student explained:
[The EAL group allowed me to] meet with people with simi lar experiences [which] allowed me to be more comfortable in voicing my opinion and know[ing] that I am not alone, giv[ing] me more confiden[ce] throughout my journey in the program.
Another student (participant #2) explained, “I received advice [through] sharing. I received validation about my challenges. Validation made me see some of my qualit[ies] that I didn't see myself.”
Another student stated:
EAL group [members are] just like…family members be cause they support you.… Sometimes we just need a saf[e] en vironment and I get a sense of safe[ty] from here, that's why I really enjoy attending this EAL group.
Nursing Faculty Qualities
Participants were appreciative of supportive instructors who were empathetic of their challenges as EAL students. Instructors who took the time to appreciate students as individuals and find commonalities between themselves and their students were well received. One student (participant #8) explained, “[my instructor] is also a shy person. She talked to me and she said I understand exactly how you feel.… She was very helpful like that because she can understand.” Participants were also fond of instructors who were “caring, supportive, and knowledgeable of options” (participant #2) and were disappointed with instructors who assigned blame, reduced self-esteem, and failed to give direction for further improvement. One participant explained:
I don't have self-esteem because first I think I have put so much energy and I'm going to change my image in my teach er's mind…but she seemed to give me that kind of message I'm totally inadequate, why I was put in this program?
Several students also cited the importance of cultural role models, stressing the need for culturally diverse faculty members. As many students felt a disconnect between themselves and their instructors, having a cultural role model provided the motivation and encouragement necessary for perseverance through the nursing program. One student explained:
I can learn from her, her experience especially…I feel close. I think she can understand me really good, really well even though I [don't express myself well], she can understand me maybe because we have similar culture.
Another student stated:
After I heard [the instructor's] story I say okay, no complain ing. So, after that I kind of got some encouragement because… [the instructor]…suffered so much and she never complains and she shares her story with others and it encourages me.
The theme of student success is an overarching theme that captures many areas, including improved nursing practice, personal growth and development, critical thinking skills, self-reflexivity, and student engagement. For the sake of clarity, each of these components is presented separately.
Improved Nursing Practice. The EAL Nursing Student Support Group group facilitated improved nursing practice evidenced by improved academic performance and clinical performance. Student feedback also revealed that participants perceived the EAL support group to be instrumental to their success. When asked to describe the influence of the nursing support group on his academic learning, one student (participant #7) stated, “This EAL Nursing Student Support Group focuses on what we really need as a nursing student who speaks English as a second language…. That is really important for me to become more successful in doing my clinical practice.” Another participant (#10) explained, “The nursing support group gave me support to…achieve my educational goals and [obtain] a technical degree.”
Personal Growth and Development. Despite their initial struggles, participants demonstrated growth and development under the guidance and support of the EAL Nursing Student Support Group. Students learned from their mistakes, applied learning strategies, and came to a turning point in their academic careers, where a little bit of confidence and motivation allowed them to succeed in both the clinical and academic settings. One student (participant #15) explained, “The EAL support group gives me motivation so when I am studying I feel like I am not the only one and I can do it. I…want to put more hard work into what I'm doing.” Students also demonstrated remarkable growth from their initial registration with the group, eventually attaining the skills necessary to succeed on their own and transition into independent practice. One student explained:
I enjoyed seeing students week after week. I think one of the most meaningful things for me was seeing what I call “stu dents blossom….” I literally watched students develop more confidence…. I loved seeing that progression, and that's what I would say was very beautiful—to help students feel more con fident.
Critical Thinking Skills and Self-Reflexivity. Student success was also attributed to the development of self-reflexivity and critical thinking skills. As both of these qualities are essential competencies for successful nursing practice (College and Association of Registered Nurses of Alberta, 2013), skill-based interventions targeting self-reflexivity and critical thinking helped to foster success in the nursing program.
Students used self-reflection to identify growth areas and formulate goals for success. One participant (#1) used self-reflection to identify a need to “be organized, know what you need to improve and…take initiative” (participant #1), and further explained that although “you can't change others…you can change yourself to greet any challenge in your life.”
Critical thinking allowed students to appreciate the importance of “logical reasoning, and application of standards (Brunt, 2005)” (as cited in College and Association of Registered Nurses of Alberta, 2013, p. 24.). Participants in the EAL Nursing Student Support Group used critical thinking skills to ensure patient safety, design appropriate care plans, and respond to the demands of the clinical setting. In doing so, students were able meet entry-to-practice competencies and fulfill clinical requirements, without judgment or the pressure of academic evaluation.
Student Engagement. Success in the EAL Nursing Student Support Group inspired a legacy within the group, where many students were motivated to give back to the EAL student community and help future generations of EAL students succeed in their nursing degree. One participant explained:
I hope we can build the infrastructure to keep the group go ing…. I think everyone really enjoys it and everyone benefits from it…. I hope we can leave as much of a legacy as we can while we are here so that other people can continue [our work].
After participating in the EAL Nursing Student Support Group as mentees, many participants from this cohort of students decided to pursue further opportunities for academic engagement by taking on new leadership opportunities within the support group and acting as student mentors for new generations of EAL students.