Journal of Nursing Education

Major Article 

Academic Success for Culturally and Linguistically Diverse Nursing Students: An Integrative Review

Lisa Scandale Lewis, EdD, MSN, RN, CNE; Lacrecia Mebans Bell, MSN, RN



Culturally and linguistically diverse (CALD) students are at increased risk for attrition from prelicensure nursing programs. The literature clearly describes the struggles of CALD nursing students, and interventions that have increased student satisfaction and feelings of belonging. There is less evidence for interventions that correlate with academic outcomes. This integrative review sought to identify studies with an intervention and evaluation of an academic outcome for CALD nursing students.


An integrative review was done according to the methodology described by Whittemore and Knafl. Two reviewers evaluated literature from 2000 to 2019 and identified 11 articles for analysis.


Evidence based strategies to support CALD nursing student academic success include formal educational interventions, linguistic modification of test items, peer support, and multiple intervention programs.


This review identified evidence-based strategies to support CALD nursing student success and made recommendations for nursing research and education. [J Nurs Educ. 2020;59(10):551–556.]



Culturally and linguistically diverse (CALD) students are at increased risk for attrition from prelicensure nursing programs. The literature clearly describes the struggles of CALD nursing students, and interventions that have increased student satisfaction and feelings of belonging. There is less evidence for interventions that correlate with academic outcomes. This integrative review sought to identify studies with an intervention and evaluation of an academic outcome for CALD nursing students.


An integrative review was done according to the methodology described by Whittemore and Knafl. Two reviewers evaluated literature from 2000 to 2019 and identified 11 articles for analysis.


Evidence based strategies to support CALD nursing student academic success include formal educational interventions, linguistic modification of test items, peer support, and multiple intervention programs.


This review identified evidence-based strategies to support CALD nursing student success and made recommendations for nursing research and education. [J Nurs Educ. 2020;59(10):551–556.]

The United States is a country of rich cultural and ethnic diversity; however, the nursing workforce does not reflect this diversity (American Association of Colleges of Nursing, 2019). Health equity and improved patient outcomes are recognized benefits of increasing nursing workforce diversity (Perez et al., 2018). To increase workforce diversity, it is necessary to educate more culturally and linguistically diverse (CALD) nursing students. For this article, CALD students in the United States are defined as those who do not speak English as their primary language or who grew to adulthood and received primary and secondary education in a country or culture outside of the United States.

In a global society, immigrants and children of immigrants become students in their adopted countries. Some people travel internationally for their schooling. Academic nurse educators in countries all over the world face the challenge of supporting students from CALD backgrounds. Learners from CALD backgrounds are not regularly or consistently tracked in most U.S. institutions of higher education. The National League for Nursing (2018) reported that 29.3% of students in prelicensure nursing programs were from racial or ethnic minorities, but CALD students were not identified as a specific group. U.S. News and World Report (Friedman, 2017) reported on 92 colleges with English language learning support programs, noting that an average of 2.4% of their student bodies participated in these programs. The percentage of CALD nursing students may vary by program type and location. In the United States, there are several paths to RN licensure: diploma, associate degree, baccalaureate, and master's direct entry. Community colleges tend to have high enrollment of CALD students (Raufman et al., 2019). Nursing programs in states with diverse populations, such as California and New York, may serve from 25% to 50% CALD students (Raufman et al., 2019).

CALD students may have been academically successful until entering nursing school, when they must learn the culture and language of the clinical environment, as well as the English language skills needed for NCLEX®-style test questions. These language skills are more challenging than conversational English and may take CALD learners much longer to master (Salamonson et al., 2019). The literature clearly documents higher attrition rates and poorer academic outcomes for CALD nursing students (Abele et al., 2013; Denham et al., 2018).

Nurse educators have sought to address the issues that contribute to academic failure and attrition for CALD students and have developed strategies for improvement. The literature describing the circumstances and experiences of CALD nursing students (Mikkonen et al., 2016) and suggesting strategies based on expert advice or student satisfaction (Choi, 2018) is vast. Olson conducted an oft-cited critical review of the literature in 2012. In that review, Olson (2012) identified language, culture, academic and personal obstacles and facilitators to CALD nursing student success. Olson's (2012) review included 25 articles, many of which reported on outcome measures such as participant perception or satisfaction. In the wide landscape of literature about CALD nursing students, there is a dearth of evidence to support strategies associated with academic success such as grades, program progression, and program completion. Therefore, the authors conducted an integrative review to identify and collect the evidence specifically focused on supporting CALD nursing student academic success. This review was designed to provide information for nurse educators in the United States and other areas where nursing education is provided in English.


The integrative review was conducted according to the methodology described by Whittemore and Knafl (2005) and consisted of five steps: identifying the problem, searching the literature, evaluating the data for inclusion in the synthesis, analyzing the data, and presenting the data. To identify the problem, the authors posed the research question: What are evidence-based strategies that support academic success for prelicensure nursing students who are culturally and linguistically diverse?

The authors searched databases CINAHL®, ERIC, PubMed®, and Scopus® and hand searched the reference lists of pertinent articles. Search terms used included English language learner, retention, successful, nursing students, nursing education, foreign born, achievement, linguistically diverse, problem solving, and ESL. The authors used the web application Rayyan (Ouzzani et al., 2016) to analyze the 615 identified abstracts or titles. Figure 1 describes the process of identifying articles for inclusion. Articles eligible for inclusion were English language articles published between 2000 and 2019, which described studies (research or quality improvement) that implemented specific support strategies for prelicensure nursing student success and then evaluated them. For the purpose of this review, CALD students were defined as those who attended secondary school in a different country or who grew up in a household where the primary language was different from where they were attending nursing school. Literature was excluded if it did not focus on the population of interest, if the study did not include an intervention and evaluation, or if the outcomes measured were not academic. While screening articles for inclusion, the authors read about studies from Great Britain and the European Union. The articles included in this review describe studies conducted in Australia, as well as all regions of the United States.

Literature search strategy.

Figure 1.

Literature search strategy.

To evaluate articles for the integrative review, the authors considered quality of the evidence. Including only studies that evaluated academic outcomes such as test performance, grades, academic progression, or program completion ensured that the evidence was at the second or higher levels of Kirkpatrick's Evaluation Model (Reio et al., 2017). The authors also considered the JBI Levels of Evidence (Joanna Briggs Institute, 2014). No articles were excluded based on level of evidence, but the levels were identified as part of the evaluation. After an iterative process of independent reviewing and collaborative discussion, the authors ultimately selected 11 articles for analysis.

Data analysis was informed by Whittemore's and Knafl's (2005) description of a four-step process: data reduction, data display, data comparison, and conclusion drawing and verification. The articles are presented in Table A (available in the online version of this article), with population, sample size, purpose, methods, findings, and level of evidence.

Summary of Articles Included in Literature ReviewSummary of Articles Included in Literature ReviewSummary of Articles Included in Literature ReviewSummary of Articles Included in Literature ReviewSummary of Articles Included in Literature ReviewSummary of Articles Included in Literature Review

Table A:

Summary of Articles Included in Literature Review


The 11 articles analyzed for this review, like much nursing education research (Oermann & Conklin, 2017), did not meet the criteria for high level of evidence. Most of the studies described in these articles were conducted at a single site, often with a small sample. Only two of the studies (Moore & Clark, 2016; Salamonson et al., 2010) involved a comparison group that did not receive the intervention.

Interventions used in the studies included formal educational sessions, in the form of a course or component of a course (Bosher & Smalkoski, 2002; Campbell, 2008; Hillege et al., 2014; Salamonson et al., 2010; Miguel et al., 2006). Another intervention involved a strategy that focused on faculty development: modifying or simplifying the language in test items (Bosher & Bowles, 2008; Moore & Clark, 2016). One study connected academic outcomes to a peer-mentoring program (Igbo & Sule, 2019). The remaining studies implemented programs that included multiple interventions, such as educational activities or workshops, as well as faculty development and peer support (Anders et al, 2007; Brown, 2008; Doggrell & Schaffer, 2016).

Formal Educational Interventions

Effective communication is a critical skill for nurses (American Nurses Association, 2015). Although second-language learners may become conversationally fluent in a short period, it can take much longer to achieve fluency in technical, medical, and academic terminology (Salamonson et al., 2019). CALD nursing students may struggle with written, verbal, nonverbal, and para-verbal communication. The culture and values of the educational environment, as well as the health care environment, may be new and different to CALD students. The studies that implemented formal educational sessions were focused on communication. Several studies identified and addressed CALD students' need for communication support in the clinical setting.

Bosher and Smalkoski (2002) developed a formal course for associate degree nursing students from CALD backgrounds to teach communication skills in the health care setting. Although the course is required for CALD students who score low on an English language placement test, many participants took the course as an elective after being recommended to do so based on their clinical performance. The course was created in response to a thorough needs assessment, which included interviewing faculty and students, administering a survey to students, and conducting observations of performance examinations and clinical experiences. The needs assessment demonstrated that the participants struggled with clinical communication. The content of the course taught participants how to be assertive in communication and how to effectively gather information and be therapeutic when interacting with clients. Participants also examined the role of culture in health care and considered how their own culture influenced their communication. The authors collected survey data from participants about the usefulness of the course, but they also provided information that faculty reported improvements in clinical performance of participants and that one participant came off of academic probation and went on to graduate after taking the course.

Campbell (2008) described another formal course for associate degree nursing students from CALD backgrounds. The course, designed as a collaboration between the nursing department and the language immersion program, consisted of weekly 2-hour workshops focused on both written and spoken communication. The impetus for the creation of the course was a college strategic goal to increase student retention and graduation rates in a nursing program that included 75% of students born outside of the United States. Similar to the course described by Bosher and Smalkoski (2002), this course included role-playing experiences, as well as evaluations of the students' written and oral communication. Thirty-two students with limited English proficiency were eligible to participate in the course; 20 of these students did participate, whereas the remaining students who chose not to participate served as a control group. At the end of the semester, 65% of the participants in the course were still in the program and progressed to the next course, whereas only 58% of the control group persisted. This finding was statistically significant. In addition, the members of the control group who progressed had an average grade of C-, compared with the passing members of the course attendance group, who had an average grade of C.

Other studies used a strategy of embedding literacy skill teaching in nursing courses. Hillege et al. (2014) described a study in which academic writing skills content was embedded in a required first-year course focused on orientation to the nursing profession, in a baccalaureate nursing program. The embedded literacy skills content was provided in face-to-face classes and as web resources for online classes. Students with lower English language proficiency were encouraged but not mandated to enroll in the face-to-face classes. English language proficiency was assessed on all 747 students admitted to the program and enrolled in the professional nursing course. One hundred forty-seven students were assessed at a low level of English language proficiency, and 107 of those students attended the face-to-face course with the embedded literacy skills. At the end of the semester, the researchers collected qualitative data about the course through student surveys and analyzed student grades on an essay assignment that represented 40% of the course grade. They found that there was no statistically significant difference between the grades of students with high English language proficiency and the grades of students with low English language proficiency who had taken the face-to-face class. Conversely, students with low English language proficiency who had only access to the literacy skills content as web resources had lower grades on the essay. This difference was statistically significant.

Salamonson et al. (2010) conducted a randomized control trial using an embedded academic literacy workshop in an introductory bioscience course for students in a baccalaureate nursing program. The embedded content was focused on academic writing skills, with scores on a written case study assignment as the outcome of interest. An English language proficiency assessment was used to identify 106 students to participate in the study. Fifty-nine students were randomized to receive the academic literacy workshop, although only 28 attended. The 47 students assigned to the control group were given information about academic literacy support programs offered by the university. At the end of the study, the researchers evaluated scores on the written assignment, comparing the students who participated in the embedded workshop with those who comprised the control group and those who had been randomized to the intervention but did not attend. Students who had participated in the workshop had higher scores on the assignment than either of the other groups, and this difference was statistically significant.

Miguel et al. (2006) published the final study that described a formal course to teach communication skills to CALD students. This study was conducted with first-year students in a baccalaureate nursing program who were from non-English–speaking backgrounds and who received a failing grade in their first clinical placement. The course was not mandatory, but all 15 eligible students chose to participate, likely because the course was accompanied by the option of completing their clinical experiences on a schedule that permitted them to progress with their cohort. The course consisted of 20 hours spent in the nursing laboratory, with an emphasis on role-playing clinical communication situations. Twelve of the 15 student participants went on to successfully complete their next clinical and progress in the program.

A specific type of communication is the written communication used for academic examinations. Writing high-quality test items is a challenge for nurse educators (Oermann & Gaberson, 2016). The following studies (Bosher & Bowles, 2008; Moore & Clark, 2016) examined linguistic modification of test items to avoid bias that may disadvantage CALD students.

Linguistic Modification of Test Items

Two articles described studies that involved linguistic modification, or simplification of test items. Bosher and Bowles (2008) made the important point that linguistic bias in test items creates construct-irrelevant variance, which is a threat to the reliability and validity of the test and interferes with actually testing students on their knowledge of content. They describe linguistic bias as complexity and inconsistency in terminology and grammar, typically in the English language words, not in the medical terminology. When test items contain such linguistic bias, the test becomes not just an examination of the content but also an examination of the students' English language proficiency.

In their 2008 article, Bosher and Bowles described a study to determine the effects of linguistic modification on CALD nursing students' comprehension of nursing test items in a pathophysiology course. The students were in their first year of a baccalaureate nursing program, and all five participants reported struggling with multiple choice tests. The researchers were language experts who collaborated with nursing faculty on this study. The study involved a series of interviews with each participant, during which 171 test items were reviewed for linguistic or cultural difficulty. Ultimately, 39% of the items reviewed were identified as problematic, and the researchers then modified the language of those items to decrease linguistic complexity. Content experts were involved in this linguistic modification process to ensure that the constructs being tested were not altered, and that the items were still valid tests of the content. CALD students evaluated the original items, compared them with the revised items, and then rated them for difficulty. The researchers also analyzed the items for Flesch-Kincaid Scale reading grade level, finding that the revised items were written at an eighth-grade level, in comparison to the original items, which were written at a tenth-grade level. The participants were able to read the revised items significantly more quickly, while comprehending them accurately.

In their 2016 article, Moore and Clark described a study that included 644 nursing students from prelicensure programs in Texas, Nevada, and Minnesota, 135 of which were students from CALD backgrounds. Participants were randomly assigned to an experimental group (67 CALD students and 252 non-CALD students) and took a 50-item linguistically modified test. The control group students (68 CALD students and 257 non-CALD students) took a 50-item test of test bank items from a textbook publisher, which had not been linguistically modified. All students who took the linguistically modified test had higher scores than those who took the standard test. CALD students had higher scores on the linguistically modified test than those who took the standard test. These results did not reach statistical significance. However, the researchers noted that CALD students taking the linguistically modified test were able to complete the test in significantly less time.

CALD nursing students may struggle not only with the formal requirements of nursing school, but also with social interactions in a different culture. The next article (Igbo & Sule, 2019) described how a peer-mentoring program was effective for improving academic outcomes in CALD students.

Peer Support

Igbo and Sule (2019) contributed the single article that described peer mentoring as an intervention to support academic success in CALD nursing students. The researchers created a program of peer mentoring for international students at their historically Black college or university (HBCU) baccalaureate nursing program. Mentors received training and ongoing support from the researchers, who served as program advisors. Mentors and mentees spent a minimum of 10 hours per semester together in discussion focused on academic skills as well as socialization. Over the course of the program, the majority of mentees became mentors. The researchers analyzed scores on the comprehensive exit examination and found that the nursing students who had served as peer mentors had significantly higher scores and passed the comprehensive exit examination at a significantly higher rate than students who were not part of the program. This outcome was true for two cohorts in a row, the first with 24 peer mentors and the second with 28. Given that 82% to 95% percent of the mentors had been mentees, the researchers concluded that the dual mentor–mentee experience was valuable.

In addition to targeted interventions such as a mentoring program, some researchers have combined more than one intervention to create a program of support for CALD nursing students. The following articles (Anders et al., 2007; Brown, 2008; Doggrell & Schaffer, 2016) described more holistic interventions that supported CALD nursing students in myriad ways.

Multiple Interventions

Three of the articles included in this review described studies in which the intervention was a program of multiple interventions. Although these articles had less detail on each component of their intervention programs, many of the components are similar to interventions used in other studies in this review.

Anders et al. (2007) wrote about a recruitment and retention program directed at Hispanic students in their baccalaureate nursing program. The program included an educational outreach manager to recruit Hispanic students from prenursing courses and local high schools. Students were given financial support in the form of stipends and scholarships, as well as case management services. Academic support provided through the program included mandatory study groups, required tutoring for students who score less than 75% on any examination, and one-to-one academic coaching with the program managers. In addition, the program funded a cultural consultant who provided both faculty development and student support activities. When the researchers wrote this article, 43 students were participating in the program and eight had successfully graduated and passed NCLEX on the first attempt.

Brown's (2008) article described a pilot project for CALD students at an HBCU baccalaureate nursing program. With input from the CALD students and faculty, a program was developed that included language, academic, faculty, and social support. Twelve CALD students participated in the program. The specific strategies used included vocabulary journals, study groups, oral class presentations, varied teaching and evaluation methods, frequent feedback, mentors, and social activities. Faculty development was part of the program and included cultural awareness workshops. The researchers evaluated the program by looking at outcomes including academic progression and first-time pass rate on the NCLEX. Both CALD student graduation rate and NCLEX pass rate significantly increased following the implementation of the program.

The third article that described a program of multiple interventions was by Doggrell and Schaffer (2016). That article focused on a study that implemented a support program for CALD students in an accelerated baccalaureate science of nursing (ABSN) program, during their pharmacology course. The researchers offered the intervention program to all students but compared the outcomes of the accelerated program students with those of the traditional program students. They also compared the outcomes of the 2 years prior to program implementation to those during the 2 years after the program initiation. Each year, the average number of students taking the pharmacology course was approximately 250. The intervention consisted of online resources materials that were available through the learning management system, and face-to-face workshops about study skills and available resources. Following this intervention program, the rate of ABSN CALD students failing or withdrawing from the pharmacology course significantly decreased. Although the number of CALD students in the ABSN program increased, there were no failures in the pharmacology course in the 2 years following the intervention.


The studies reviewed for this article all examined types of support for CALD students previously described in the literature. Olson's (2012) literature review described barriers and bridges to success for CALD students and listed language support programs that included role-play, linguistic modification of test items, and peer support. This review builds on Olson's (2012) work by synthesizing reports of studies that looked at academic outcomes of those support activities.

Several factors were limitations to this literature review. To find articles that met the inclusion and exclusion criteria, the authors searched literature published as long ago as 2000 and included articles published in 2002. The context of nursing education may have changed so significantly in the past two decades that the interventions described would not be effective in the modern setting. The authors were also limited by time and access to literature; with more time and the use of more search engines, it is likely that additional literature would have been identified for inclusion in the review.

Implications for Research

Although the literature includes many recommendations to enhance the success of CALD nursing students (Olson, 2012), researchers have not always rigorously evaluated these recommendations. Specific learning or study strategies, such as providing audiotapes of lectures or workshops on test-taking skills, should be studied in terms of their effect on academic outcomes. Programs of support that include multiple interventions have shown effectiveness (Anders et al., 2007; Brown, 2008; Doggrell & Schaffer, 2016); it may be valuable to study the influence of individual interventions to determine whether any of them would be beneficial independent of the multi-intervention effective programs.

The level of evidence was low for most of the studies in this review. It would be valuable for schools of nursing with large enrollment and large populations of CALD students to study academic support interventions in a systematic way, with control or comparison groups. To increase generalizability, researchers should replicate the studies that provided higher levels of evidence in different settings.

Implications for Nursing Education

The findings of this review build on the work of prior reviews (e.g., Olson, 2012) by presenting the studies that evaluated interventions in terms of academic outcomes. The literature provides much evidence on interventions to support CALD nursing students' socialization and feelings of belonging. This review adds the element of academic success.

Schools of nursing should consider implementing formal English language support for their CALD students, including opportunities for role-play focused on clinical scenarios, such as those described in the work of Bosher and Smalkoski (2002), Campbell (2008), Hillege et al. (2014), Salamonson et al. (2010), and Miguel et al. (2006). Faculty at schools of nursing would benefit from additional training on cultural awareness and avoiding cultural bias especially in tests and evaluation, as supported by the studies described by Bosher and Bowles (2008) and Moore and Clark (2016). Peer mentor programs, such as the one implemented by Igbo and Sule (2019), are another intervention that can be accomplished with minimal resources and still provide evidence-based support for CALD nursing students. In addition, the successful multi-intervention programs of support (Anders et al., 2007; Brown, 2008; Doggrell & Schaffer, 2016) offered suggestions for support strategies.

Implications for Nursing Practice

The nursing profession does not represent the diverse populations served. Although there is increasing diversity in the nursing student population, CALD nursing students experience greater rates of attrition and NCLEX failure. To increase the diversity of the nursing profession, it is imperative for schools of nursing to learn to support CALD students' academic success. CALD nursing students who achieve academic success become the diverse nursing workforce of the future. The studies described in this review offer evidence-based strategies to do so.


This review examined the literature for studies demonstrating academic outcomes of interventions to support prelicensure CALD nursing students. Articles included in the review demonstrated success with interventions such as formal English language support, faculty development, and peer mentoring. Recommendations were made for future nursing education research on this topic and for current strategies that schools of nursing may implement to support their CALD students.


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Summary of Articles Included in Literature Review

Author(s)/YearPurposeSample SizePopulationMethodMain FindingsLevel of evidence for effectiveness (Joanna Briggs Institute, 2014)
Anders, Edmonds, Monreal, & Galvan (2007)Test a program of supportive interventions to improve retention and NCLEX passage rate43Hispanic nursing studentsIntervention was a group of services including financial support, academic coach, educational outreach manager, nurse mentors, and cultural consultant. Evaluation was retention rate and NCLEX pass rate.8 students who completed with on time graduation and passed NCLEX on first try; unclear what the baseline was but this is apparently an improvement in terms of progression and graduation rate as well as NCLEX pass rate.4
Bosher & Bowles (2008)To determine whether linguistic modification or simplification of test questions reduces construct irrelevant variance in assessments, and makes easier for ESL students to understand5First year BSN ESL students who had struggled with examsPrimarily qualitative; interviews and one- to-one reviewing of patho exams with participant and researcher to identify questions that were confusing. Researchers then revised questions using principles of linguistic modification, validated them with language and content experts, then had participants review and rate for difficulty on 1–4 scale.Test items that were revised were more readable based on participant evaluation as well as Fleisch-Kincaid Scale (reading grade level) while still testing content at same level of rigor per content experts.4
Bosher & Smalkoski (2002)Development and testing of a course to improve clinical communication28ESL students in associate degree nursing programInterviewed 5 students, questionnaire for 28 students (total ESL population, observations of lab exams and clinicals, faculty interviews. 18 students took course (intervention).ESL student issues including assertiveness, paralinguistic communication, understanding client's nonverbal communication, “small talk,” confidence, asking for help, recognizing cultural values, following instructions and seeking clarification. After course (intervention) 1 failing student passed, and 1 came off probation and went on to graduate.4
Brown (2008)To test a support program for ESL nursing students at an HBCU35ESL students at a HBCU, in both AD and ABSN programsIntervention was general support program with study groups, vocabulary journals, oral presentations in class, faculty development, and student support groups and study strategy sessions.Percent of graduation (total and on-time) and NCLEX first time pass rate were all improved.4
Campbell (2008)To test a communication skills course to improve grades49ESL students in first semester of nursing programIntervention was a 20-hour course for oral and written communication skills.More students who took the class passed their first semester compared to those who did not take the intervention class; grades were improved, too.3
Doggrell & Schaffer (2016)To see if a support program intervention would help students to do better in a pharmacology course51–135ABSN and BSN students, domestic and internationalSurveys of if/how much students used intervention (which consisted mainly of web resources); compared withdrawal and failure rates pre- and postintervention.Second-degree ABSN nursing students who do not have university background do worse in general, but the intervention helped them The number of international students withdrawing or failing after the intervention was decreased but that number was quite low to begin with.3
Hillege, Catterall, Beale & Stewart (2014)To find if nursing students with low English literacy level would have improved written communication after an embedded literacy intervention in their professional nursing course107Nursing students with low English literacy levelAll students screened for literacy level with PELA, intervention was offered embedded into “tutorials”; summative evaluation essay scores compared across groups.Students with low literacy had much better essay grades if they attended the classes with the embedded literacy component, they even did better on their grades in other courses too.2
Igbo & Sule (2019)Implemented a peer mentoring program for international students at a HBCU5252 student mentors (82% to 95% of whom had previously been mentees in the program)Compared comprehensive exit exam scores to general population of students; intervention was program of peer support.Mentors had much higher passing rate.3
Moore & Clark (2016)Evaluation of impact of linguistic modification of nursing exam test items on academic performance of ESL and non-ESL students644Senior nursing students at three different schools in different states, some ESL and some not.Compared scores on 50 test bank questions that were linguistically modified with the same questions NOT linguistically modified; compared ESL to non-ESL student scores.Non-ESL students had higher skills than ESL students in both groups; all students had higher score on linguistically modified questions, but the difference was not statistically significant. All students rated the linguistically modified questions as easier and on average all students took 10% less time to complete the linguistically modified questions.2
Salamonson, Koch, Weaver, Everett, & Jackson (2010)To evaluate the effect of an embedded academic writing support for ESL students106Nursing students with low to medium English language proficiency (<19 on ELAS score); 59 attended workshop, 47 were control groupIntervention was embedded workshop for writing skills for nursing papers (case study assignment). Outcome was grades on written assignments.Students who received intervention had statistically significant higher grade on assignment then control group.3
San Miguel, Rogan, Kilstoff, & Brown (2006)To evaluate an intervention communication class for ESL students to learn clinical communication15Nursing students from “non-English speaking backgrounds ”Criteria for assessing interpersonal communication ability described by the author and students evaluated by that criteria in their first clinical. Those who failed that criteria were put in an intervention class (content informed by student perceptions, instructor perceptions and their clinical evaluations) and then they did another clinical where they were evaluated again on the same criteria12/15 students satisfactorily passed the follow up clinical; student and teacher satisfaction was high4

Dr. Lewis is Assistant Clinical Professor, and Ms. Bell is Clinical Nurse Educator, Duke University School of Nursing, Durham, North Carolina.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Lisa Scandale Lewis, EdD, MSN, RN, CNE, Assistant Clinical Professor, Duke University School of Nursing, 307 Trent Drive, Pearson Building, Room 3061, DUMC Box 3322, Durham, NC 27710; email:

Received: December 16, 2019
Accepted: June 08, 2020


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