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.

Discussion
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.

Conclusion
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.


References

Alvarez, A., & Abriam-Yago, K. (1993). Mentoring undergraduate ethnic-minority students: A strategy for retention. Journal of Nursing Education, 32(5), 230–232. https://doi.org/10.3928/0148-4834-19930501-11

Bazerman, C., Adair, B., & Debora, F. (2009). Genre in a changing world. WAC Clearinghouse; Parlor Press.

Candlin, S., & Rogers, P. (2013). Communication and professional relationships in healthcare practice. Equinox Publishing.

Carter, L., & Rukholm, E. (2008). A study of critical thinking, teacher-student interaction, and discipline-specific writing in an online educational setting for registered nurses. Journal of Continuing Education in Nursing, 39(3), 133–138. https://doi.org/10.3928/00220124-20080301-03

Carter, M., Ferzli, M., & Wiebe, E. N. (2007). Writing to learn by learning to write in the disciplines. Journal of Business and Technical Communication, 21(3), 278–302. https://doi.org/10.1177/1050651907300466

Chung, T. M., & Nation, P. (2003). Technical vocabulary in specialised texts. Reading in a foreign language, 15(2), 103-116. Retrieved from http://nflrc.hawaii.edu/rfl/October2003/chung/chung.pdf

Crawford, T., & Candlin, S. (2013). Investigating the language needs of culturally and linguistically diverse nursing students to assist their completion of the bachelor of nursing programme to become safe and effective practitioners. Education Today, 33, 796–801. https://doi.org/10.1016/j.nedt.2012.03.005

Crossman, K. E. (2014). Intensive English for academic purposes: A curriculum designed and developed for local English language learners entering university (Unpublished doctoral dissertation. University of Calgary.

Diaz-Gilbert, M. (2004). Vocabulary knowledge of pharmacy students whose first or best language is not English. American Journal of Pharmaceutical Education, 68(4), 1-8. https://doi.org/10.5688/aj680491

Donnelly, T. T., McKiel, E., & Hwang, J. J. (2009). Challenges and motivators influencing the academic performance of English as an additional language (EAL) nursing students: The perspectives of the students. Canadian Journal of Nursing Research, 41(3), 130–150. Retrieved from the CINAHL Plus with Full Text database. (Access No. 105441193)

Duff, P., Wong, P., & Early, M. (2000). Learning language for work and life: The linguistic and socialization of immigrant Canadians seeking careers in health care. Canadian Modern Language Review, 57(1), 9–57. https://doi.org/10.3138/cmlr.57.1.9

Gimenez, J. (2008). Beyond the academic essay: Discipline-specific writing in nursing and midwifery. Journal of English for Academic Purposes, 7(3), 151–164. https://doi.org/10.1016/j.jeap.2008.03.005

Graves, R., Chaudoir, S., Ru’aini, M., & Lasiuk, G. (2009). Writing assignments in the faculty of nursing at the University of Alberta. Unpublished research paper. Retrieved from https://www.artsrn.ualberta.ca/

Hyland, K. (2006). Disciplinary differences: Language variation in academic discourses. In K. Hyland & M. Bondi (Eds.), Academic discourses across disciplines (pp. 17–47). Peter Lang.

Karach, A., & Roach, D. (1993). Collaborative writing, consciousness raising and practical feminist ethics. In D. Barton, M. Hamilton, & R. Ivanic (Eds.), Worlds of Literacy (pp. 237-246). Multilingual Matters.

Kilbride, K. M., & D’Arcangelo, L. (2002). Meeting Immigrant Community College Students’ Needs on One Greater Toronto Area College Campus. Canadian Journal of Higher Education, 32(2), 1-26. Retrieved from the ERIC database. (Accession No. EJ661236)

Lavelle, E., Ball, S. C., & Maliszewski, G. (2013). Writing approaches of nursing students. Nurse Education Today, 33(1), 60–63. https://doi:10.1016/j.nedt.2011.10.021

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Lum, L., Dowedoff, P., & Englander, K. (2016). Internationally educated nurses’ reflection on nursing communication in Canada. International Nursing Review, 63(3), 344–351. https://doi.org/10.1111/inr.12300

Mann, K., Gordon, J., & MacLeod, A. (2009). Reflection and reflective practice in health professions education: A systematic review. Advances in Health Sciences Education, 14(4), 595–621. https://doi.org/10.1007/s10459-007-9090-2

Müller, A., Arbon, P., & Gregoric, C. (2015). A school-based approach to developing the English proficiency of EAL university students. Journal of Academic Language and Learning, 9(2), A63–A78. Retrieved from https://pdfs.semanticscholar.org/

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Parmar, J. R., Tejada, F. R., Lang, L. A., Purnell, M., Acedera, L., & Ngonga, F. (2015). Assessment of communications-related admissions criteria in a three-year pharmacy program. American Journal of Pharmaceutical Education, 79(6), 1–9. https://doi.org/10.5688/ajpe79686

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Tapp, J. (2015). Framing the curriculum for participation: A Bernsteinian perspective on academic literacies. Teaching in Higher Education, 20(7), 711–722. https://doi.org/10.1080/13562517.2015.1069266

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The Reading and Writing Lab for International Students at Carroll University

Dolores Greenawalt, Carroll University, dogreenie @ hotmail.com

International students face a difficult transition as they move to the United States for school. In addition to the typical adjustments they make as first-year college students, they also adjust to speaking in American Standard English (ASE), which, at the very least, is their second language (even their third or fourth). Therefore, their college English class is imperative to helping them succeed and build confidence in their speaking and writing. Often, those less confident in their English skills need additional help understanding facets like sentence structure, use of articles, style and diction. For many international and non-native English speaking students, ASE is not taught in enough detail in an average three-credit English class. Attending an additional English Reading and Writing Lab can also increase their skills and encourage active learning that connects the classroom to their life outside the classroom.

I facilitate the Reading and Writing Lab offered at Carroll University, a small private university in Waukesha, Wisconsin. This lab provides a space for students to work on assignments together or to practice specific writing and reading skills with me, an expert equipped to tutor on issues that many student volunteer services cannot. They often come in pairs or small groups and tackle issues together, which ensures their effectively integrating into the campus and expanding their resources. They can begin at a level they choose and work independently through their homework or complete mini-lessons on the formalities of academic writing.

Designing and facilitating such a lab ultimately accommodates non-native English speakers who are often the linguistic minority. According to the Institute of International Education (IIE) (2018), the percentage of international students in American higher education has risen from 3.8% in 2006/07 to 5.3% in 2017/18. In SY 16/17, the IIE’s Open Doors report found that one-third of all international students matriculate from China. Among the colleges and universities educating these students, 83.3% report their largest concern for this population as their English preparedness. Additionally, 76% worried about engaging them in the classroom, and 71.9% worried about integrating them on campus (Baer, 2017). The results are a reminder of the difficulties that all international students may face regardless of country of origin.

To put these percentages in perspective, at Carroll, that number averages only one to two international students in any given class. Thus, rather than enrolling them in an ASE English class where they may be the only international student, we enroll them in a class where ASE is not the native tongue. I have found that my own inclusive class of non-native English speaking students who need extra help with ASE to feel more confident because they are surrounded by similar people. This inclusive class was also encouraged to participate in a Reading and Writing Lab facilitated by an active professor (me). In this environment, they are more open to learning the basic tenets of English because they do not feel isolated, which can occur in other, more inclusive classrooms.

We found that creating a class specifically for non-native English speakers–both first- or second-generation American students and international students–encouraged relationship building and confidence among them in both the classroom and on campus. This type of connection encourages active learning, deeper learning, and extensive discussions that may otherwise not have occurred in an English class where everyone’s skills are more varied. The rate of increased confidence can rise faster when a group of students can work on their struggles with other classmates without fear of isolation.

The weaknesses in ASE among the class and their want for further understanding was the common denominator that brought them together during lab time, which centers around activities that allow them to put the information they are learning into action. Writing in different styles can help them acquire a larger vocabulary and practice different uses of language. Experimenting with writing styles also helps them explore and determine how to convey information to readers, and it provides the opportunity to decipher which techniques best illustrate their point. Creating scenes where they are film critics, source analysts, or angry constituents can provide situational assignments that will both test them and invoke a deeper thinking process extending as the entire class works together. Allowing a mixture of techniques that crosses the boundaries of different writing styles creates writers willing to go outside of established conventions to create more depth in their work.

Sometimes, the students feel that limited lab time is insufficient for them to work on all of their skills, so having a lab connected to a class is a good way for them to transition the information from the classroom to other avenues. The lab is also a bridge to other campus services, and it helps lessen their trepidation when seeking extra help. The connections a Reading and Writing Lab provides helps expand their usage of these services by providing opportunities to connect with other coordinators and volunteers.

At Carroll, on average, those who visit the Learning Commons throughout the semester raise their grade by an entire letter. Additionally, through data collection such as card swipes, Carroll has seen a rise in international student visits to the Learning Commons after they visit the Reading and Writing Lab. They also feel more comfortable with asking for different services that will increase their understanding of class material.

Different versions of Reading and Writing Labs are popular across the country. A quick glance at Wisconsin shows that most colleges and universities have a version of writing lab or center. However, a lab designated to help first-year students who are non-native English speakers, run by a faculty member, can increase the amount and type of help students can receive.

With the increasing presence of non-native English speakers in the United States, it’s imperative that universities make clear connections with international and non-native English speaking students. By pairing inclusive classrooms and a Reading and Writing Lab as a method for students to improve familiarity with ASE, students will increase their confidence and understanding of English, become familiar with campus resources, and form connections and relationships with faculty and other campus staff. This higher increase in participation will create a more positive and effective experience for both international and non-native English speaking students.


References
Baer, J. (2017). Fall 2017 international student enrollment hot topics survey. Washington, DC: Institute of International Education.

Institute of International Education (2017). Open Doors report on international educational exchange. Retrieved from: http://www.iie.org/opendoors

Institute of International Education (2018). 2018 fast facts. Retrieved from: https://www.iie.org/Research-and-Insights/Open-Doors/Data/International-Students/Fact-Sheets-and-Infographics

A Celebration of Language: What It Means for ELLs to Have a Bilingual Identity and How Teachers Can Celebrate Their Bilingualism in the Classroom

Holly Fait, Silverbrook Intermediate School, West Bend, hfait @ wbsd-schools.org

Abstract. Fait reviews research on what it means to have a bilingual identity and how factors such as family, the community, and individual motivation shape how students come to value their bilingualism. She also includes several practical ways to build a positive attitude toward bilingualism into classroom instruction by addressing individual motivation, family, and community values. By involving students, families, and members of the school community, the bilingual students have become excited to share their talents as bilingual learners.

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¿Comprende?

Jennifer Hewerdine, Professor of English at Arizona Western College and blogger at Writing Kairos, discusses methods of tutoring English language learners in their own language, which may lead to an understanding of how valuing learners’ discourse communities and language experiences can increase student learning or, at the very least, engage learners in the process. [PDF full version: ¿Comprende?]

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