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The following article takes to describe the strategies adopted to evaluate the use of English as a Second Language (ESL) in teaching adult nursing students. It indicates the theoretical model developed using Robert Stakes 'countenance model' to evaluate upper division (N300+) Nursing course for adults students using both English as a First Language (EFL) and English as a Second Language (ESL). As a nurse educator it is necessary to understand the challenges faced by adult nursing students both ESL and non-ESL so that the educational experiences of both groups of students can prepare them adequately for their work as professionals. English-as-a-second language students are usually taught in the same classes as their counterparts, non-ESL students. International ESL students are non-traditional students who have unique characteristics that need to be recognized by nursing faculty to ensure that the students’ educational experiences are maximized as much as possible. Commitment to world health has led to a growing presence of international nursing students. The focus on ESL students has been aimed at those in large public schools, yet those in smaller private universities also need to benefit from the strategies described in research studies. The setting of the study will be a baccalaureate school of nursing in a Arizona State university.

Keywords used

Evaluation,  English as a Second Language, English as a First Language (EFL), Countenance model, Nursing, WebCT

Reasons for using the countenance model in evaluation

The use of the “countenance model of evaluation” edges out itself from the rest because of its ability to suggest matrices for descriptive and judgmental data required to support the study of a new program as time lapses. It takes note of both the antecedents as well as the intended and unintended consequences of the program (Stake 1967). The model was first developed in the 1960's and has been an important component used in evaluation. It is takes to outline and explain the complexity of any innovation in education or even change it completely by analyzing both the observed and intended outcomes in different levels of operation. The congruential outcome between the observational and the intentional  factors sets a basis for judgment of either the failure or the success of the innovation.   The following figure summarizes  stake's “countenance model of evaluation” data matrix;


FIG 1. Stake's matrix for processing descriptive data (adapted), (Stake 1967)

Literature review


Trend data has indicated a shortage of nurses that is projected to continue and become more acute in the future. The studies have recommended that strategies for attracting minorities into the nursing profession be put in place. The thinking behind this is that it will help to meet the looming shortage of nurses and also that the most effective way to meet the needs of a population that is increasingly diverse is to diversify the nursing profession (Lucas, 2007; Malu and Figlear, 1998; Choi, 2005). There has been a blanket waiver for the immigration of foreign nurses to manage the nursing shortage leading to increases in immigrants who join nursing programs. Additionally, there has been an increase in the number of international students who declare nursing as a major. This increase can be attributed to among others migration from resource-poor and war-torn countries to resource-rich countries. Unfortunately however, the number of nursing ESL students who graduate from nursing programs is significantly lower than that of the non-ESL students.

A report by Malu and Figlear (1998) indicated that there was an increasing number of English as a Second Language (ESL) students who enrolled in nursing programs. ESL students are defined as those students for whom English is not the primary language in their homes. This means that the students may not be fluent in Standard English leading to difficulties in the students’ clinical work and course work.  Investigators have found that the attrition rate of ESL students is generally higher than those of their non-ESL peers (Memmer and Worth, 1991).  A study comparing the academic characteristics of ESL and non-ESL students shows that ESL students are at greater risk of failing to complete their studies in their first semester (Femea, Brathwaite and Abdur-Rahman, 1995). Often the times of academic problems are related to problems of language. The United States has seen a great influx of international students in the recent years. Most of these students have English as a Second Language. Many investigators have found that English as a Second Language nursing students have special language needs which need to be addressed (Choi, 2005; Guhde, 2003). Nursing is a profession that is highly dependent on written communication in terms of recording patient data and translating doctor’s orders. It is also dependent on accurate verbal communication because many orders are passed on by verbalizing. A comparison between ESL and non-ESL students found that ESL students had more difficulty in clinical courses compared to their non-ESL counterparts (Guhde, 2003). The reason for this is perhaps because a high level of interactive communication skills is needed to pass the clinical courses. Another significant difficulty experienced by ESL students is passing the NCLEX-RN exam which requires high language skills.  

Most international students fall in this category of ESL students. In addition they also have other challenges that may affect their learning process.  Research into the experiences of students who are studying abroad have found that these students struggle with language skills both clinically and academically (Kilstoff and Baker, 2000). The students also have difficulties with nursing perspectives and nursing practices in their new countries. International students have added to the cultural diversity in the education system but also present challenges. These students have different backgrounds thus their approach to tutors is different compared to the non-ESL students (Guhde, 2003).

Generally, international students arrive in the US with multiple cultural influences and meet an almost equal multiplicity of varying cultures in the US. Many of the things that people do and say are socially constructed, positioned and located (Lucaks, 2007). International students thus find themselves in a new position and location of learning in an alien environment. This may be a comfortable environment for readers who come from educated middle-class backgrounds, but this is often quite different for the international students. A study of Taiwanese students in graduate and baccalaureate programs in Australian universities found that in spite of the obstacles experienced by these students they found it enjoyable to study in Australia (Wang et al, 2008). Additionally, they developed strategies that helped them to overcome obstacles in learning. This study reinforces other studies which have found that ESL nursing students have unique challenges. The study also highlights the responsibilities of nursing faculty in developing a curriculum which addresses the academic, clinical, sociocultural, pedagogical, clinical and language needs of the international students. Bosher and Smalkoski (2002) point out that often ESL have challenges when it comes to communicating assertively with other nurses and clients during clinical placements. For instance, these students are reluctant about asking for clarification from a patient and will instead nod or pretend to understand while continuing with a procedure (Bosher and Smalkoski, 2002). This problem becomes even worse in the elderly patients who may not hear well and/or have little patience when listening to someone with an accent (Guhde, 2003). Other problems that could occur also stem from non-verbal communication especially when students avoid making eye contact with their patients. This is closely related to non-assertiveness and can be partly explained by different cultural norms (Duff and Wong, Bosher and Smalkoski).  Other issues that contribute to cultural discomfort include issues of privacy, discussion of gender roles and bodily functions all of which contribute to a lack of assertiveness on the student’s part and thus adversely affecting their clinical experience.

Language acquisition and nursing

Julian, Keane and Davidson (1999) identify language competence and social competence as factors influencing the progress and eventual success of international students in nursing programs.  The Cummins Model is useful in understanding how people learn language; it explains that language acquisition occurs in two ways: basic interpersonal communication (BICS) and cognitive academic language proficiency (CALP). CALP enables students to evaluate, analyze and interpret concepts. Proficiency may at the BICS level does not guarantee proficiency at the CALP level which is necessary for communication as a professional in the healthcare environment. This is more difficult in the medical field as it requires proficiency in general English as well as medical terminology which in many ways is a language in itself (Guhde, 2003). A study of the experiences of nine ESL international students who were doing a nursing undergraduate degree found that their experiences could be classified into two broad categories (Shakya and Horsefall, 2008).  The categories were supports and challenges. The challenges had several themes, language being one of them. Language included several technical aspects such as listening and speaking and interactions when placed in tutorial groups (Shakya and Horsefall, 2008). Other themes that were described include lack of orientation and ethnocentrism. The supports identified included support from family and friends, university related support and the student’s own personal strategies and strengths (Shakya and Horsefall, 2008). The study participants in the study by Shakya and Horsefall (2008) faced a variety of challenges but they struggled to overcome the challenges using diverse methods.

Nursing faculty

Nursing texts that focus on issues of cultural diversity have addressed the importance of understanding and studying the beliefs, values and practices of clients from diverse cultures in an effort to create a workforce that is culturally competent. Evidence shows that the needs of a diverse population are met most effectively by a diverse nursing profession. This has led to increases of immigrant students and minority students in nursing programs. However, the structural changes in nursing education required to keep pace with the increasingly diverse population have not been made (Lucas, 2007). The nursing education workforce remains unrepresentative of the general population. Minority and immigrant students are reported to perceive it as sometimes hostile and nonsupportive (Lucas, 2007). Generally there is underrepresentation of the indigenous minority groups in the nursing faculty of most schools. International students are also underrepresented.

Lucas (2007) argues that the difficulties experienced by ESL students (both international and from the indigenous minority groups) stem not just from low language proficiency and cultural dissonance but also from unrealistic expectations by faculty members. Faculty who may not be familiar with how language is acquired often do not comprehend that international students and immigrants may never sound like native English speakers (Lucas, 2007). Faculty may not be aware of the idiosynncracies to be found in the English language and how difficult it can be to learn these. Additionally, faculty often tends to consider the differences in global and local concerns and thus differences between them and the students they teach. A Canadian study (Jalili-Grenier, 1997) found that there were significant differences in the perceptions of nursing students and nursing faculty with regards to challenges experienced and how helpful specific learning techniques have been. A more recent study conducted by Kilstoff and Baker (2005) had similar findings: that there were significant differences in the perceptions of international nursing students and nursing faculty regarding the challenges of the students’ educational experience. This points to a disconnect between the nursing faculty and students which creates the risk of interventions being put in place which may not adequately meet the needs of the students.

Yoder (1996) describes responses of faculty to nursing ESL students. These include a mainstreaming pattern, generic pattern, the culturally non-tolerant pattern, the struggling pattern and the bridging pattern. High cultural awareness is characteristic of the bridging pattern in which faculty use teaching approaches that are culturally adaptive. This has been found to be the most positive students (Klisch, 2000). Information on how frequently this is used is not available. Yoder (1996) asserts that all nursing programs should have one person who has advanced graduate preparation in transcultural nursing care theory with the ability to promote faculty development.  

Use of the generic approach focuses on achievement of Anglo-conformity goals (Yonder, 1997).  Improved communication is one of the ways through which retention amongst ethnically diverse students can be improved (Yonder, 1996). One study describes specific strategies that were used to teach Asian-American nursing students which involved the use of common cultural themes such as placing the group before the individual, action instead of words, saving face and respecting authority (KataokaYahiro and Abriam-Yago, 1997).

The use of ESL in the Arizona State University ( ASU): The evaluation

Since the inception of the ESL program in United States Universities, many institutions have been on the fore front in adopting it and the Arizona State University has not been left out too. However, a comprehensive evaluation of this flexible and diverse venture has not been that successful. The following findings indicate the evaluation procedure in progress while the intervention procedure is still shaping itself. Upgrades in the softwares used as well as the widespread awareness of technology among the students have been on the forefront in boosting the development of the innovation.

Data collection

Intensive measures were taken to ensure that both qualitative and quantitative data were successfully combined. The following indicates various methods used to collect the data.

      Focus Group Discussions (FDG's) – this was done on both the teachers and the students.

  • The use of questionnaires

  • Interviews

  • Server statistics

  • Participated observation

  • The Internet (Emails)

  • Specific subject oriented research papers.

  • Reports from group studies

  • School report

Summary of interim research findings and their implications

The findings hereby presented illustrate the evaluation approach and fully represents the discussion of the congruential outcomes found to culminate themselves between the observed and the intended during the time of transaction and the proposed mode of action to be taken

Full information of the research findings can be retrieved from the university library.  Also the following diagram can be used to elaborate further on how to understand the outcomes of an of evaluation using the countenance model.

Descriptive data

Observed antecedents

Intended entecedents



Empirical contingency

logical contingency                                                                                                                                                        

Observed transactions

Intended transactions




logical contingency        

                                                                                                         Empirical contingency


Observed outcomes

Intended outcomes


The Intended transactions: More than 15% actively support its use. A 15% usage target was initially set at the managerial level and onto surprise their was more than 15% uptake. According to analysis of the server statistics, this target was easily attainable therefore indicating success in the uptake of ESL at that level. However, findings from the pilot year indicated a significant change in the adoption of ESL in nursing.

Observable transactions: 30% usage.

Citing server statistics, more than 30%  of the modules covered used WebCT at some point on the 2nd year of implementation. However, a comparison report between different schools indicated variation between different schools ranging between over 60% and below 20% usage. This is brought about by different administrative capacities and rules. Nursing came third upon  its comparison with other departments on the use of ESL. The other two were mathematics and computing schools.  

Proposed form of action. Background research and qualitative knowledge needs to be brought in and supplement the available quantitative knowledge in a bid to re conciliate the differences in the findings. Statistics obtained from the server are applied as a basis to the snapshots of the activities in the institution. I t is supposed to be used by the committee to chart the fall and rise of using ESL in nursing. The server statistics are used as a baseline snapshot of activity and welcomed by University committees who can then chart the rise or fall or use the data gathered as their basis for requesting more investment on ESL or to justify their resource expenditure.

Unintended outcome

The countenance model of evaluation accounts also for the unintended outcomes resulting from the intervention. In this case, the most unexpected outcome is the implementation of the ESL due to the different cultures of students and tutors.

Support structures for ESL international nursing students

As early as the 1990s the need for strategies that would retain ESL nursing students was identified. There has been a growing body of literature describing the importance of diversification of the nursing profession to meet the needs of a diversified population. Efforts of recruiting and retaining students from underrepresented groups (that is the ethnically diverse born in the US and immigrants) have been made. These efforts have however been hampered by high attrition rates of ESL students. Early articles focused on the need for aggressive methods of advising, counseling and academic support that considered academic issues and psychosocial factors which are a hindrance to the success of this group of students (Klisch, 2000). Other strategies that have been identified include the use of computer assisted instruction programs and improvements on communicative and linguistic competence in areas such as listening, speaking, reading, writing and learning styles.  

Klisch (2000) summarizes the development of educational strategies to improve retention  of ESL nursing students  into six main groups a) support for students (academic, social, language enhancement and financial) b) assessment and testing policies c) faculty development to assure grounding in cultural competence d) adapting teaching methods to recognize language challenges and cultural differences e) inclusion of cultural content in application opportunities f) Commitment of institutions to strategic management.

The need for language development is discussed in many articles, however there remains a gap because specific strategies have not been discussed in much detail. To implement more specific strategies Klisch (2000) asserts that it is necessary for assessment to be done prior to adopting strategies that will be helpful. The Giger and Davidhizar Model is one such model which consists of six factors that are interrelated. The interrelated factors include space, communication, time, environmental control, social organization and biological differences (Davidhizar, Dowd and Giger, 1998). The Countenance Model of Language proficiency has been presented as a tool that can assist in enhancing the language development of ESL nursing students. The model has eleven strategies that students can use to improve critical thinking skills and information processing skills (Abriam-Yago and Kataoka-Yahiro, 1999). Literature review of the strategies and supports described to assist ESL students have found that most of these strategies have been used in large public universities. These universities have a large number of international ESL students and have greater access to funding.  A question arises from this. How can schools that are smaller with limited funding best meet the needs of ESL students?

A study of a small school in which ESL retention strategies were used resulted in greater success and student satisfaction for the ESL students who were all of differing ethnicity. The students were Cambodian, Korean, East Indian, Maori, Filipino, Danish, Nigerian, Brazilian, Scandinavian, Ukrainian, Native American, Pacific Islander and Vietnamese (Klisch, 2000). The school made use of a sabbatical project and advancement awards used to enhance the cultural competency of students and faculty. Two nursing faculty took a course to enhance their cultural competence and one of them became a Certified Transcultural Nurse who assisted in the implementation of retention strategies. This led to the development of a Culturally Congruent Health Care course that became a requirement for all the undergraduate students. Some of the retention services included were ESL advisors for group and individual advising and English language enhancement which required testing using the SPEAK tool (Klisch, 2000). Those who failed the SPEAK test were allowed to take the test three times and they also benefited from tutoring. On passing the SPEAK test the nursing students received encouragement to participate in group English tutoring or individual tutoring. Those students who were interested formed language partnerships with other volunteers who are English as First Language nursing students (Klisch, 2000). The students also participated in an assertiveness training workshop offered during spring break.

Strategies that were implemented relating to the faculty included a faculty workshop that was aimed at improving nursing exam policies. This was so that faculty could be part of a process of reviewing nursing examinations that seemed to discriminate against students who came from diverse cultural backgrounds. Extended testing time is also another strategy that was included. This however varied with the student group with sophomores being allowed double the test taking time, juniors getting time and a half while the seniors got regular time (Klisch, 2000). Faculty development workshops were also included to enhance the faculty’s competence with regard to culture. Some of the topics included reduction of bias in testing and providing culturally congruent care.  

Social support has also been documented as a very important retention strategy thus in the school, ESL social events were held yearly. Other services included matching an incoming ESL nursing student with another ESL student who had been in the program for longer. In the matching process efforts were made so that the students who spoke the same first language were matched together. At the end of the program 74.2% of those who had started graduated and on completing a satisfaction survey, the students responded positively to the strategies that had been implemented (Klisch, 2000). Having an ESL advisor was the most positively perceived strategy among the students who filled out the satisfaction survey


Nursing literature has indicated that there are many varied ideas for retaining ESL (both international and indigenous ethnic minorities) nursing students. The description of the efforts of a small school indicates that ESL nursing students can be successful in large public universities as well as in smaller private universities. The retention strategies used have however to have the support of an institution as well as faculty commitment and an underlying philosophy that values cultural diversity. Further research may compare outcomes of different programs and exploration of retention rates over time so as to find out which are the best practices.



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