Writing and Communication Challenges for ESL Students Majoring in the Health Professions

Adam Sprague, Bellin College, adam.sprague @ bellincollege.edu

“They’re just not speaking right,” “They just can’t write,” and “Please fix them before the assignment is due,” are common pleas for help from faculty members in the health professions that I receive regularly as the only professor at my current campus who teaches English or Communication courses. Clearly, this rhetoric is concerning for any student but is particularly problematic when targeted at non-native English speaking (NNES) students. Note, the major challenge cited by faculty is not the content itself but that NNES students have difficulty demonstrating profession-specific academic literacies like writing and speaking at a level that matches their monolingual peers.

What makes these requests unattainable is the fact that academic literacy in its broadest sense is not just a linear, cognitive activity. Sure, it does involve the production of text, but it, more importantly, also includes the interpretation of texts within specific social contexts. Leki (2007) defined the term as “interpretation and production of academic and disciplined-based texts” (p. 3). It involves learning the “genres of language used in the learning of academic subject matter in formal schooling contexts” (Richards & Schmidt, 2013, p. 2). This means that the level of academic literacy required changes based on the program of study. For a student to succeed, then, students in the health professions must master not only generalized academic literacy (Carter, Ferzli, & Wiebe, 2007) but also the specialized language of nursing, radiology, or sonography, for example (Carter & Rukholm, 2008; Woodward-Kron, 2008).

This is no quick-fix task, rather this a large-scale issue that college administrators must have a direct means of addressing–simply passing off a NNES student to a peer tutor or English professor because a faculty member does not believe it to be their job to teach language simply does not work and immediately others the student into feelings of inferiority. Skeptics of my claim may point to successful graduation rates among their NNES students. However, a college takes a great risk by not addressing these issues as students without adequate academic literacies will undoubtedly experience greater difficulties in becoming successful in their profession, which may reflect poorly upon the degree-granting institution. Crossman (2014) notes that NNES “take longer to graduate, [are more regularly] placed on academic probation, and . . . withdraw more often than their monolingual peers” (p. 3).

Therefore, academic institutions at all levels must ensure they have the proper writing and speaking admission requirements measures in place as well as a well-considered academic support network for NNES students. The purpose of this paper is not to champion any singular approach to addressing this problem (as all institutions have their own unique affordances and restraints) but to offer a multitude of possibilities that push past problematic solutions like a single course or peer tutor, which quite simply is never enough. Oral communication skills have gained increased importance with the ever-increasing multicultural nature of healthcare settings–a major challenge for NNES on the job (Candlin & Roger, 2013; Lum, Dowedoff, & Englander, 2016, Sedgeqick & Garner, 2017); however, oral communication skills remain overlooked as they are almost never required courses within health profession programs and the vast majority of Health Communication courses and textbooks have students writing, not speaking, and analyzing workplace hierarchies and how the industry is represented in the mass media instead of practicing and roleplaying how to communicate with patients and colleagues or write a patient chart. This also means that we are not teaching NNES students the genres of writing they will actually need to perform after graduation.

Purpose of Writing Education
This naturally brings us to a much larger question. What is the overall purpose of academic writing in higher education? The historical viewpoint is writing helps us determine who is literate and who is not (Karach & Roach, 1993, p. 238). This has changed, though, as our discipline has evolved into writing across the curriculum programs with the goal of helping students gain writing skills for post-graduation (Leki, 2007). In fact, in nearly every class, writing is the primary way in which students are evaluated (Hyland, 2006). To highlight this point, Graves, Chaudoi, Ru’auni, & Lasiuk (2009) found that nursing students regularly wrote as many as nine projects in any given course across thirteen different genres with the two most common being reflective writing and research-based essay/report writing. But does reflective writing and evidence-based practice syntheses prepare NNES students for the actual writing they will do on the job? The answer is, overwhelmingly, no.

Yanoff and Burg (1988) reported that the most important writing tasks for healthcare professionals include writing a patient’s history, physical examination reports, progress reports, and discharge summaries. We can easily see that the rhetorical situation surrounding these writing tasks is vastly different than that of reflective and research papers, which means a NNES student would need to think very differently to succeed with these writings than they did during their college education. This clear and obvious realization led Yanoff & Burg (1988) to call for a drastic change to curricula in medical schools to teach such writing. However, nothing has changed. Reflective writing and research papers remain the norm for students majoring in the health professions (Lavelle, Ball & Maliszewski, 2013; Mann, Gordon, & MacLeod, 2009, Van de Poel & Gasiore, 2012).

Writing Challenges Facing NNES Students, According to the Students
So, what do NNES students regularly struggle to overcome? Kilbride and D’Arcangelo (2002) surveyed 146 students and found that language support was not sufficient for their linguistic needs. What is more, other NNES students have found that schools do not even provide students “access to the support necessary for their academic success” (Crossman, 2014, p. 40). Moreover, education requires students to master contextual conventions particular to the discipline, which is essentially impossible without adequate language education and support (Myles, 2002, p. 2). NNES nursing aide students in Canada found it nearly impossible to understand linguistically dense texts and slide presentations from their professors and found it just as difficult to keep up with the rapid colloquial speech and discipline-specific terminology used (Duff, Wong, & Early, 2002).

This is a major issue of concern as the medical field is dense with technical and specialized rhetoric that adds an increased layer of complexity to listening, reading, and writing. Scholars have found that healthcare majors are exposed to technical jargon 37.6 percent of the time versus just 16.3 percent of the time for other majors (Chung & Nation, 2003, p. 253). Diaz-Gilbert (2004) compounds the problem as he found that this difficulty is only part of the problem as NNES students lack the fundamental knowledge of health-related vocabulary on which the majority of students’ conversations are based–and such terms are not explicitly taught in class. Weaver and Jackson (2011) also found that NNES students reported that the major problem for them was understanding the course content and keeping up with lectures. NNES students also reported that the types of writing assignments they are assigned did nothing to improve their oral communication, and there was no transparent connection to practice (Lum, Dowedoff, & Englander, 2016). This disconnect between classroom and practice becomes even more frustrating as numerous studies have shown that writing assignments take NNES students four times longer to complete than monolingual students (Muller, Arbon, & Gregic, 2015). This lack of satisfactory linguistic support has been directly linked to higher frustration levels for NNES students, which then leads to students having more difficulty completing their degree requirements on time or at all (Alvarez & Abriam-Yago, 1993, Donnelly, McKiel, & Hwang, 2009; Murray, 2011, 2012).

Admission Requirements as Solution?
There are some possible solutions to consider prior to student admission. One possible solution may be to reassess who we admit to our schools. By reevaluating how struggling NNES students performed on the Test of English as a Foreign Language (TOEFL), for example, may be a good starting place (or even starting to require students to take it). If NNES students are reporting that there is not enough support on campus, and your campus does not have the means to offer better support, administrators may want to consider raising their minimum TOEFL requirements to lower student and faculty frustration and improve the odds of student success. The use of profession-specific language tests and/or other strategies is needed but currently this is not a common program admissions practice.

Another option might be to require the documentation of prior education in English at secondary schools or recognized institutions of higher education. Some schools require 3 or 4 years of postsecondary education. Others consider prior living situations as well. NNES student applicants can provide proof of language ability by demonstrating a prior education in an English-speaking country for 3-6 years.

Many schools will require NNES to submit an essay to accompany their application. Such writing submissions vary in nature. Some schools require an essay between 1,000 and 2,000 words, while others have students perform timed writings (usually around 30 minutes) that they submit to the college or university. At the very least, a low stakes admission requirement could be to simply have students complete a language self-assessment survey that is submitted along with the student’s application.

Other Post-Admission Solutions
We have established the need for increased support for NNES students majoring in the health professions in this article and also evaluated some possible pre-admission solutions. However, there is much we can do post-admission as well. First, we must admit that a single writing course and a single communication course for NNES students is simply not satisfactory given the specialized needs of NNES. If NNES are admitted to a health professions major, we must at least give them a 2-course writing and speaking course sequence to help them develop the niche skills required to succeed. Another option would be to attach a 1-credit writing workshop to courses within the program to better assist these students. Yet another method of support would be to include a language support center like a Writing Center. To combine a Student Success Center or Career Center with a Writing Center would be unwise as they would not offer the discipline-specific rhetorical knowledge that a Writing Center could that was dedicated to the health sciences. In fact, many universities have moved to a writing-in-the-disciplines approach where Writing Centers are housed in each major building on campus (Humanities, Health Sciences, Fine Arts, etc.) to provide more focused assistance with assignments that the tutors are more intimately familiar with.

The information above paints a clear picture of why it is impossible to enact a “quick fix” when working with a NNES students majoring in the health professions because the ability to converse and express meaning that is only implicit, appropriate, and comprehensible to a particular social context is essential to professional discourse and to engage in safe practice (Jeffries et al., 2017; O’Neill, Buckendahl, Plake, & Taylor, 2007). All health professionals not only require the ability to use technical and everyday language but must also possess considerable cultural and pragmatic knowledge so that they can use appropriate rhetoric to communicate with a range of health professionals, patients, and their families (Sedgewick & Garner, 2017).

This article has also highlighted the fact that successful NNES students must master not simply a generalized academic writing skill but discipline-specific writing skills; that is, “writing that reflects the writing conventions of the discipline, refers to  the relevant literature, and ultimately enables a writer to assume membership in a particular discourse community” (Carter & Rukholm, 2008, p. 134), however the majority of health profession majors continue to emphasize the importance of written reflections and generic research papers. For NNES to succeed, it is clear that writing tasks must be developed in tandem with learning the advanced and technical English required by the profession (Crawford & Candlin, 2013; Jeffries et al., 2017). These academic writing assignments are perceived to have a tangible impact on students’ academic success and their competence to practice in their respective professions.

Moreover, the academic literacy demands within large health professions programs such as nursing, radiology, and sonography are specialized, requiring their students to possess a high level of general English literacy as well as discipline-specific language skills and knowledge. Because academic literacies are embedded in specific academic contexts, an increased understanding of the particular ways of constructing meaning, making judgments and determining what counts as valuable knowledge contributes to improved higher education programs (Tapp, 2015, p. 714). The process of developing academic literacy, through a variety of discipline-specific writing assignments, is a key socialization strategy to prepare health professions students to enter practice in employment settings.

I have also shown that there is an interconnected role between admission protocols, students’ English academic literacy development, and program learning experiences. Admission policies, especially those concerning English language ability, represent institutional and program gatekeeping strategies to ensure that prospective students have the required academic and linguistic ability to be successful (Parmar et al., 2015; Pill & McNamara, 2016). This article has suggested that current admission requirements may be too low or incongruent with the high levels of literacy demands expected within these specialized programs. Further research is needed to determine the relationship, if any, between higher completion rates (and eventual licensure) and the initial language entry requirements of their schools.

The research evidence presented within this article indicates that even when meeting the pre-admission language requirements, further significant, discipline-specific language support is essential for NNES students majoring in the health professions. Tapp (2015) concluded that undergraduate NNES students find the development of academic literacy to be difficult and that universities have a responsibility to provide access to contextualized academic literacy practices (p. 715). If this is the case, higher education institutions and educators need to adopt a more transparent, comprehensive approach, which includes making learning expectations more explicit as well as providing increased, discipline-specific learning support, especially for those with significant language challenges. As discipline-specific writing support carries the most efficacy for students (Bazerman, Adair, & Debora, 2005; Gimenez, 2008), I urge readers to pursue further investigations in an effort to understand to what degree institutional efforts are supporting NNES students’ writing development in the health professions.


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