Nurse Education in Practice 14 (2014) 686e691
Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Discipline matters: Embedding academic literacies into an undergraduate nursing program Sharon P. Hillege a, 1, Janice Catterall b, *, Barbara L. Beale a, 2, Lyn Stewart a, 3 a b
School of Nursing and Midwifery, University of Western Sydney, Locked Bag 1797 Penrith, NSW 2751, Australia Student Learning Unit, University of Western Sydney, Locked Bag 1797, Penrith, NSW 2751, Australia
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 21 September 2014
In recent years the higher education sector in Australia has been increasingly concerned with ensuring that the English language proficiency levels of students are commensurate with the academic and professional tasks that they must perform. In many universities, this heightened attention to language proficiency has driven changes to teaching and learning practices. This paper reports on a project to embed academic literacies development into a core first year subject within a Bachelor of Nursing program in a large, culturally and linguistically diverse, metropolitan university. Prior to the commencement of their nursing program 747 students completed a Post Enrolment Language Assessment. Students who required additional support were advised to enroll in tutorials which included an additional literacy focus. These tutorials were part of the normal tutorial program for this nursing subject. Students with lower level language skills who attended the streamed tutorial with additional literacy support showed a greater improvement in their written communication than those with similar language proficiency who attended non-streamed tutorials. Evidence suggests that this improvement was transferred into writing tasks in other non-streamed subjects. The findings reported in this paper highlights that discipline specific embedded strategies are an effective approach to the development of academic literacies. © 2014 Elsevier Ltd. All rights reserved.
Keywords: Nursing education Academic literacies Undergraduate Strategies
Introduction The importance of good oral and written communication abilities in nursing cannot be underestimated Garling (2008) recognised that patient safety can be compromised through miscommunication in inter-professional communication, documentation and during clinical handover. Conversely, effective communication was found to reduce errors and improve patient safety (Garling, 2008). In the higher education sector the development of communication capabilities is increasingly viewed as the responsibility of academic programs, and attention has turned to the most effective ways of achieving these goals. The long term goal of this project was to embed academic literacies development across the curriculum for all students. The term academic literacies
* Corresponding author. Tel.: þ61 24736 0847; fax: þ61 24736 0853. E-mail addresses: [email protected] (S.P. Hillege), janicecatterall@gmail. com, [email protected] (J. Catterall), [email protected] (B.L. Beale), lyn. [email protected] (L. Stewart). 1 Tel.: þ61 24570 1926; fax: þ61 24570 1420. 2 Tel.: þ61 29685 9269; fax: þ61 29685 9599. 3 Tel.: þ61 29685 9411; fax: þ61 29685 9599. http://dx.doi.org/10.1016/j.nepr.2014.09.005 1471-5953/© 2014 Elsevier Ltd. All rights reserved.
is used as an umbrella term to cover a number of sub-categories commonly used in to describe language practices in higher education including academic writing, communication skills and English language proficiency. Whilst it is acknowledged that English language proficiency includes listening, reading writing and speaking, and these issues are being addressed in our school, the focus of this paper is on the development of essay writing skills. In order to gather evidence to support changes to teaching and learning practices, a program was designed that would focus on providing additional academic literacies support to students identified with lower levels of English language proficiency. The model entailed using a Post Enrolment Language Assessment (PELA), a brief writing task, and streaming, which involved separating students into tutorials for this specific subject. This streaming was based on the results achieved for the PELA writing task. This model was adapted from one used successfully in several disciplines at another university. In response to a need identified in one of these projects (San Miguel et al., 2013), this paper aims to supplement existing accounts of student satisfaction with evidence of academic achievement. The strategy described in this paper was an early initiative in a holistic program adopted by the School to improve the academic literacies of nursing students. This
S.P. Hillege et al. / Nurse Education in Practice 14 (2014) 686e691
constantly evolving program remains a core feature within the School. Context of the strategy The nursing program is situated in a large metropolitan Australian university which caters for a diverse multicultural community representing more than 170 cultural/ethnic groups. It attracts a student population that is diverse culturally and linguistically, as well as, in socio-economic background and age. In 2010, 2122 students were enrolled in the Bachelor of Nursing. Of these, 17% (361 students) were international and 27.7% (588 students) came from lower socio-economic postcodes. In 2009, Smith and Taylor reported that (44.4%) of students in this program did not speak English as their main language at home. Salamonson et al. (2012) found that 38% of local students in the nursing program at this university were born overseas and tended to be mature-aged, and engaged in high hours of paid work. Currently around 16% of students enter through the traditional schooling pathway, while others are admitted through vocational education and training pathways, mature age provisions, foundation courses or from overseas. Nursing lecturers at this university cater for a student population that is heterogeneous in terms of the English language proficiency, prior experiences and preparedness for academic study. In seeking to cater for this diverse group of students, the teaching team in this study was also responding to standards set by the professional nursing and registering authorities and increasingly by the higher education sector. An increasingly regulated environment The National Competency Standards for the Registered Nurse require the nurse to effectively communicate with individuals and professional groups in order to facilitate provision of care (The Australian Nursing and Midwifery Council (ANMC), 2006). Registration with Australian Health Practitioners Registering Authority (AHPRA) (2011) requires English language skills at a level where all registered health practitioners can provide safe and competent practice. This level is considered to be an International English Language Testing System (IELTS) level 7 in each of the four components (listening, reading, writing and speaking) or attaining at least a B score across all four components of the Occupational English Test (OET). Evidence of completion of five years of fulltime equivalent education taught and assessed in English in a recognised country also fulfils the requirement (AHPRA, 2011). Therefore if there is a disparity between the English language proficiency of students at entry level and the level required at registration, then nursing programs have a responsibility to develop the communication skills of students throughout the BN program. On a broader scale, the tertiary sector has reacted to fears that low English language proficiency levels might be impacting on academic standards (Birrell, 2006). This concern, raised in the context of the English proficiency of incoming international students, came at a time when a number of studies were highlighting the difficulties that international students were experiencing with the complexities of analytical and critical writing (Heatley et al., 2011). In a similar vein, Borglin (2011), writing with a European nursing perspective, reported that students often leave Higher Education Institutes without meeting acceptable levels in academic writing or critical thinking, attributing this to a number of factors, including the prevalence of ‘non-traditional students’, the theoryepractice divide and the relative paucity of teacher training among nursing lecturers. Experience in Australia suggests that concerns about levels of English language proficiency should not be confined to international students only (Murray, 2013). One
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outcome of this debate in Australia has been the release of the ‘Good Practice Principles for English Language Proficiency for International students’ which highlight the responsibility of universities for ensuring the development of English Language proficiency (Department of Employment, Education and Workplace Relations (DEEWR), 2009). Universities are required to put in place measures that ensure language needs of students are identified early and that there is adequate support (Murray, 2010). Of particular relevance to the nursing pilot project reported on in this paper is Principle 6 which requires that the development of English language proficiency is integrated with curriculum design, assessment practices and course delivery through a variety of methods (DEEWR, 2009, p. 4). There is a good fit between this principle and the context of many newer universities in that local students, both native English speakers and those who speak English as an additional language, are as likely as international students to require additional support to successfully engage with their studies. Rationale for the selection of an embedded approach In developing this program, the project team was primarily informed by an academic literacies approach which views the development of ability in reading and writing as a social practice linked to disciplinary knowledge and discourses (Lea and Street, 1998). The model is useful to nursing education because it recognises the complexity of switching between literacy practices as students move from theoretical to practical literacy settings and between various assessment and professional genres. In the development of teaching resources and classroom strategies the teaching team also drew on the pedagogical traditions of the “Writing Across the Curriculum” movement, in particular, the importance of genre-based, student-centred activities that allow students to understand and reflect on the language features of disciplinary discourses (Russell et al., 2009). In keeping with this tradition, the project team sought to create space in the curriculum for disciplinary specific writing practice and feedback. An important advantage of a disciplinary specific approach is that students learn the conventions of writing that will be relevant in their nursing studies (Andre and Graves, 2013). The term ‘embedded’ refers to disciplinary specific approaches where student capabilities in required academic literacies are developed within the content and assessment framework of the program and within the timetabled classes of the program. While there are undoubtedly places in higher education today for more generic approaches to writing instruction, adjunct, study skills approaches are increasingly seen as less effective and less attractive to contemporary students than more embedded approaches (Wingate, 2006). Similarly, Haggis (2006) has argued that it is no longer possible to ‘remediate’ for the diversity of prior experiences and types of preparedness in the student body, because it cannot be assumed that students are sufficiently prepared for completion assessment tasks. Murray (2010) proposes that abilities related to both academic literacies and professional communication should be embedded into curricula as a part of the normal responsibility of the subject lecturer. Yet, not all subject lecturers are confident language teachers. This embedded team teaching model was attractive to nursing lecturers and language experts because of the opportunity to build professional capacity by exchanging expertise through the collaborative development of resources and through teaching partnerships. Another advantage of an embedded model is that explicit development of academic literacies can occur within timetabled classes. It is often students who are judged to be most at risk of academic failure by their lecturers who are least likely to attend additional ‘bolt on’ classes (Wingate, 2006). This is most likely due
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to a multiplicity of factors including a lack of confidence, lack of self-awareness and competing demands outside the academic workload for paid work and family (Hockings et al., 2007). Salamonsen et al. (2010) reported low attendance at a noncompulsory workshop, even when content was specifically related to nursing learning outcomes and where students with low English language proficiency levels had been specifically targeted. Description of the embedded program The primary goal of the teaching team was to embed academic literacies development within the learning and teaching framework of the subject. The teaching team was aware that tertiary academic literacies would be new to all commencing students and that diverse student populations would command a range of cognitive, linguistic, cultural and experiential resources. However, in this program, constraints on staffing, particularly the availability of the academic literacies experts to team teach meant that face to face teaching had to be directed to students with lower language proficiency levels. These students included native and non-native speakers of English. Students in this category were advised to attend tutorial classes that were team taught by nursing lecturers and academic literacy experts. However for student equity language-focused learning resources were made available to all students in both paper-based and online modes. The nursing subject selected for the explicit development of academic literacies was a core first year professional orientation subject in which the major assessment task was an essay. The essay assessment task is reasonably common in the nursing degree and presents students who are less prepared for academic study with particular challenges. In her important contribution to academic literacies pedagogy, Lillis (2001, p 39), has argued that essayist literacy “privileges the discursive routines of particular social groups” and that often the pedagogic practices that surround the task are implicit, rather than explicitly taught. The teaching team devised a number of changes to existing pedagogic practices including more active student involvement in the teaching and learning process, plentiful opportunities for dialogue related to academic literacies practices, and more opportunities for writing and feedback. Particular attention was paid to writing as a process in the context of nursing. Students engaged in guided critical reading of nursing literature and tasks, related to the development of overarching thesis statements, structuring arguments and draughting and editing, were carefully scaffolded. In addition, the teaching team involved students more actively in discussions about learning practices that would help them to develop the capabilities necessary for professional nursing practice. Huber and Hutchings (2005, p. 116) have coined the term ‘pedagogical intelligence’ to describe the adoption in the classroom of learning stances that are more intentional and reflective.
students to write a 100e120 word sample of their writing about a topic familiar to everyday life, using formal language. 2) These language assessments were graded by Teaching of English to Speakers of Other Languages (TESOL) qualified staff which included Nursing Academics. The assessments were graded numerically according to predetermined literacy criteria as a level one (proficient), level two (borderline) or level three (requiring additional support). There were 747 students screened; 147 students (19.7% of cohort) were identified as requiring additional support with academic writing. It was the view of the language experts that these students would find it difficult to engage successfully with academic writing tasks within the nursing curriculum. 3) These students were advised to attend the tutorial classes in which explicit academic literacies development would be a focus (streamed tutorial). These tutorials occurred at the same time as conventional tutorials and were taught by staff from the Student Learning Unit together with nursing academics with interest or qualifications in language development. 4) Core academic literacies activities were embedded into subject specific content, over seven two hour tutorial sessions. In addition the standards and criteria for the essay task were specifically orientated towards further assessment of academic literacy. In order to ensure equity, students graded as having a satisfactory level of literacy (conventional tutorials) had access to the same literacy support information on the subject website. Notably due to the success of this strategy, all tutors were required to integrate core academic literacies strategies into their tutorials in the following year. This process has been further refined and continues to be implemented in a relevant subject in the first year. In order to improve consistency in grading of assessment tasks across the streamed and non-streamed tutorial classes, workshops for the teaching and grading team were conducted prior to the marking of the essay task. The markers were unaware of the students' literacy levels when assessing the students’ work. Statistical analysis was conducted on the essay results of all the students comparing the mean score between those in tutorials with an additional literacy focus graded as three in the PELA (n107) and those graded as a level one or two (n 600)who were attending conventional tutorials. A further analysis compared students graded as level three, who did not attend the tutorials with an additional literacy focus (n ¼ 40) with those who did. At the end of semester essay results of all core units of study were compared. The final step was the administration of a survey to evaluate the effectiveness of the developed resources delivered in this core unit of study. This 5 Item Likert Scale Survey which included open ended questions, was conducted in the streamed tutorials with the additional literacy focus. Participants
Aim
The participants were seven hundred and forty seven commencing student nurses enrolled in a Bachelor of Nursing program in 2010.
The overall aim of this study was to evaluate the embedded literacy strategy in a core subject in the Bachelor of Nursing (BN) program.
Ethics
Research design A mixed method approach was used to collect the data. It is appropriate to use a mixed methodology when data is collected from both qualitative and quantitative sources (Borbasi and Jackson, 2012). T- Tests were conducted on the essay results. The program followed the pattern. 1) a Post Enrolment Language Assessment (PELA) completed by all the students pre commencement. The Post Enrolment Language Assessment (PELA) required
Ethical approval was sought and granted from the University Ethics Committee. Informed consent was gained from the students prior to completing the screening test and the evaluation. Participation in the project was voluntary and anonymous. Students who did not give consent were excluded from the study. Results/findings The results focused on the performance of the students who attended tutorials with an additional literacy focus. All students in the
S.P. Hillege et al. / Nurse Education in Practice 14 (2014) 686e691
subject completed a 1200 word essay task which was worth forty percent. The essay was submitted after all academic literacies interventions had been completed in the tutorials. The mean of the essay mark in tutorials with an additional literacy focus was calculated. Fig. 1, illustrates that even though students graded as a level one (in the PELA) achieved marginally better in the essay results, there was no statistical difference between those that were graded as a level three who attended the streamed tutorials with an additional literacy focus, to students who attained a level two (p ¼ .723) or a level one (p ¼ .253) in their language assessment task. The mean of the student essays in conventional tutorials (for those students with a level one in the initial language assessment) was 22.09 and 21.55 for those with level two language skills, while those graded as a level three and attended the tutorials with an additional literacy focus had a mean of 21.25. This finding indicated that students beginning with a much lower language skill base were able to improve these skills if they were in tutorials with an additional literacy focus. An additional comparison was conducted using the mean essay mark between students who were graded as level 3 in the PELA who attended tutorials with an additional literacy focus and those who did not. Fig. 2. Results showed one hundred and seven students (N ¼ 107) (level three) attended tutorials with an additional literacy focus and forty (level three) attended conventional tutorials. The mean essay mark for students in the tutorials with an additional literacy focus, who had been graded as level three was 21.25, as opposed to, 17.5 for those graded three who had either chosen not to attend tutorials with an additional literacy focus or who were screened after the streaming process had taken place. Students in tutorials with an additional literacy focus had a statistically significant higher mark (p ¼ .007) for their essay than those graded as a level three who attended conventional tutorials. Evidence suggested that the students who had attended tutorials with the additional literacy focus were able to transfer this improvement in writing skills to other subjects. Results from essays in other subjects of study, submitted after the core subject essay, revealed that students in the tutorials with an additional literacy focus (in the core subject) had overtaken students in the conventional tutorials in their other subjects of study that required the essay genre. Again this reiterated the value of this intervention. Fig. 3. These encouraging results were further supported by a survey which was administered in the tutorials with an additional literacy focus. Data from the 5 item Likert scale revealed that students self -reported significant transference of writing skills to other areas (e.g. assignments in other subjects, professional writing). In addition, general confidence was perceived to be enhanced with 60% of respondents, indicating that the language focused input succeeded in making them more comfortable with both the expectations and processes of academic writing.
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Fig. 2. Comparison of the mean essay mark between students graded as a 3 in conventional tutorials and graded as a 3 in tutorials with an additional literacy focus Ttest ¼ 2.79,df ¼ 63, p ¼ .007.
60 50 40 30 20 10 0
regular streamed NHW Ban Essay Essay
BF Essay
UGH Essay
Fig. 3. Comparison of the essay results in percentage between subjects for regular and streamed students.
Student comments described how the academic literacies strategy was received by the students. One indicative comment stated: ‘The information was so useful that we could apply what we learnt in essays in all the subjects. Also to mention the general confidence as it was our first time in university and we didn't know exactly what to do. However, after these sessions everything was just clear and university writing was made easy.’ Most comments referred to an increase in respondents' appreciation of writing as an ongoing development as illustrated by the following comment:‘Writing is not easy for me, it will need a lot more practise to be more confident next time.’ Another student indicated:‘I used to write the way I talked, but now I can write differently in a scholarly, academic manner. I understand that if I don't write simply and clearly, reading can be difficult for other people to understand.’
Discussion
Fig. 1. A comparison of the mean essay mark between those graded as 3 attending tutorials with an additional literacy focus and those graded as 2 and 1 in conventional tutorials Graded 1 compared to graded 3 in an additional literacy focus tutorial Ttest ¼ 1.147, df ¼ 177, p ¼ .253 Graded 2 compared to graded 3 in an additional literacy focus tutorial T-Test ¼ 3.54 df ¼ 205.9 p ¼ .723.
The results of this strategy were positive. The TESOL trained lecturers who marked the initial screening task reported considerable differences in the English language competency of students ranging from the highly proficient to those graded as level three whose writing exhibited multiple challenges in coherence, structure and clarity. The embedded academic literacies program allowed students, who were initially less prepared for the writing demands of university, to develop their written language and their confidence with written language in the tutorial context of the core subject. These findings mirrored those reported by San Miguel et al. (2013) who found that forming streamed tutorials for ESL students in a nursing subject, contributed to deeper understanding of the
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content and to comfort and confidence. In order to achieve this level of confidence or mastery, a student needs to continuously work towards learning the basic rules and norms of the English language (Archee et al., 2013). Understanding these basic rules and norms, improves the clarity of the message conveyed between the writer and the reader (Archee et al., 2013). In nursing there are many instances when written communication is required. Report writing, for example, is extremely important, where clarity and accuracy of the information conveyed is essential and is a legal requirement. Additionally as highlighted by Komarraju and Nadler (2013) the development of academic literacies has the capacity to improve overall performance as students develop higher order learning skills, increasing their self-confidence and self-efficacy to become motivated self-regulated learners. This process is important in disciplines such as Nursing as students are expected to develop both critical thinking and complex psychomotor skills necessary for practice as a nurse or midwife. Therefore students who develop higher levels of self - confidence and selfefficacy through a higher degree of literacy performance will become confident learners who will become competent practitioners (Komarraju and Nadler, 2013). This has a flow on effect in the development of motivation and self empowerment. The evidence of academic achievement was particularly noteworthy. The results were extremely promising because they showed that, although the average marks for the streamed group appear modest, there were several critical outcomes that are worthy of recognition. Firstly, many students in the streamed group were able to pass their essay, a circumstance that would have appeared unlikely as identified by markers who had previously assessed the students' level of written proficiency. In addition, despite the significant difference in the initial written proficiency of each of the graded groups, the streamed tutorial groups almost bridged that gap to level results at similar to the overall cohort. Finally comparisons across the written assignments for three other subjects studied by this student cohort in the first session of their course, suggested that there is evidence to suggest that students were able to transfer these newly acquired academic skills developed through explicit teaching to other subjects. It appears that an explicit focus on language was beneficial to the diverse range of students who attended tutorials with an additional literacy focus. This again reiterated that this strategy was effective in developing written communication in students who exhibited weaker capabilities in this area, at the beginning of their studies. It was noted earlier that the decision to embed academic literacies development in only half of the tutorial groups of the subject was a compromise based on available face to face teaching resources. The teaching team would concur with Haggis (2006) and Lillis (2001) in recognising that the linguistic demands of tertiary writing are new to all students and those strategies to develop academic literacies should be widely available through multiple modes. The evidence of academic achievement gathered in this study has contributed to the greater integration of academic literacies pedagogy into all tutorials in this subject. Early indications suggest that this is leading to improvements in essay scores across all proficiency levels. The integration of academic literacies that has occurred over time and reflects a paradigm shift from previous years when academic literacies development was a more marginalised activity. The embedded approach reported in this paper relied on collaboration between experts in nursing and academic literacies. One of the positive outcomes has been the sharing of expertise between disciplines which has resulted in capacity building amongst staff who are charged with the responsibility of producing graduates who are effective professional communicators. The development of communication skills is critical to safe nursing practice and this embedded model offers nursing education a
strategic way forward. The challenge for the teaching team in future years will be to provide inclusive, explicit academic literacies development to all students in core first year subjects using face to face as well as a blended multi-modal learning and teaching approach. We would suggest that further research be conducted in other faculties, with linguistically diverse student populations, using a similar or modified model, to suit individual teaching and learning requirements. Indication that students may be able to transfer academic literacies skills developed in one unit to writing tasks in other units is particularly promising and further investigation of this trend could significantly enhance the potential value of similar interventions. Conclusion We believe that the findings from this study will contribute to the understanding of how learning and teaching methods within disciplines can be transformed to take greater account of the increasing diversity of student populations. In this study students with weaker academic English language proficiency who attended streamed tutorials included both native and non-native speakers of English. It was evident to the teaching team that all students could also have benefited from more explicit academic literacies development. Nevertheless, given the limitations on resources, the compromise position which introduced additional literacies support into designated tutorials, still achieved positive results for students with lower English proficiency levels. It is envisaged that the small but significant gains made in student academic literacies abilities and grades will give renewed impetus to ongoing, whole-of-curriculum change. Acknowledgement A Barthel, L Craven, ELSSA Centre, UTS. (Post-enrolment language screening assessment used with permission). Associate Professor Yenna Salamonson and Dr Sansnee Jirojwong for statistical analysis. Frances Williamson, Erst Carmichael, Lauren Ross, Maria Inglis (Student Learning Unit), and Fiona McDermid (School of Nursing and Midwifery) assisted with teaching in tutorials with an additional literacy focus. TESOL support staff Frank Allatt, Ros Allatt, Colin Helmstedt, Heidi Creed and Marian Martin. References AHPRA, 2011. New English Language Skills Registration Standard from 19th September 2011 available from: http://www.ahpra.gov.au/documents/default. aspx?record¼WD11%2F5840. Archee, R., Gurney, M., Mohan, T., 2013. Communicating as Professionals, third ed. Cengage Learning Australia Pty Limited, South Melbourne. Andre, J., Graves, R., 2013. Writing requirements across nursing programs in Canada. J. Nurs. Educ. 52 (2), 91e97. Australian Nursing & Midwifery Council, 2006. National Competency Standards for the Registered Nurse. ANMC, Dickson, ACT. Available from: http://www. nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/CodesGuidelines.aspx#professionalboundaries. Birrell, B., 2006. Implications of low English language among overseas students at Australian universities. People Place 14, 53e64. Borbasi, S., Jackson, D., 2012. Qualitative research: the whole picture. In: Borbasi, S., Jackson, D., Langford, R. (Eds.), Navigating the Maze of Nursing Research. Mosby, Australia, pp. 153e178. Borglin, G., 2011. Promoting critical thinking and academic writing in nurse education. Nurse Educ. Today 32 (5), 611e613. http://dx.doi.org/10.1016/j.nedt.2011. 06.009. Department of Employment, Education and Workplace Relations, 2009. Good Practice Principles for English Language Proficiency for International Students in Australian Universities. www.deewr.gov.au/Highereducation/Publications/ Documents/Final_Report-Good_Practice_Principles.pdf. Garling, P., 2008. Final Report of the Special Commision of Inquiry into Acute Care Services in NSW PublicHospitals. www.lawlink.nsw.gov.au/Lawlink/Corporate/ ll_corporate.nsf/pages/attorney_generals_department_acsinquiry.
S.P. Hillege et al. / Nurse Education in Practice 14 (2014) 686e691 Haggis, T., 2006. Pedagogies for diversity: retaining critical challenge amidst fears of 'dumbing down'. Stud. High. Educ. 31, 521e535. Heatley, S., Allibone, L., Ooms, A., Burke, L., Ackroyd, K., 2011. Providing writing and language support for students who have English as a second language e a pilot study. J. Vocat. Educ. Train. 63, 101e114. Hocking, S.,C., Cooke, S., Bowl, M., 2007. 'Academic engagement' within a widening participation context-a 3D analysis. Teach. High. Educ. 12, 721e733. Huber, M.T., Hutchings, P., 2005. The Advancement of Learning. Building the Teaching Commons. Jossey-Bass, San Francisco. Komarraju, M., Nadler, D., 2013. Self eefficacy and academic achievement: why do implicit beliefs, goals, and effort regulation matter? Learn. Individ. Differ. 25, 67e72. Lea, M., Street, B., 1998. Student writing in higher education: an academic literacies approach. Stud. High. Educ. 23, 153e172. Lillis, T., 2001. Student Writing. Routledge, London. Murray, N., 2010. Conceptualising the English language needs of first year university students. Int. J. First Year High. Educ. 1, 55e64.
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Murray, N., 2013. Widening participation and English language proficiency: a convergence with implications for assessment practices in higher education. Stud. High. Educ. 28, 299e313. Russell, D., Lea, M., Street, B., Donahue, T., 2009. Exploring notions of genre in 'adacemic literacies' and 'writing across the curriculum': approaches across countries and contexts. In: Bazermann, C., Bonini, A., Figueiredo, D. (Eds.), Genre in a Changing World Perspectives on Writing. WAC Clearinghouse/ Parlour Press, Colorado, pp. 459e491. Salamonson, Y., Koch, J., Weaver, R., Everett, B., Jackson, D., 2010. Embedded academicwriting support for nursing students with English as a second language. J. Adv. Nurs. 66, 413e421. Salamonson, Y., Ramjan, L., Fernandez, R., Griffiths, R., 2012. Diversity and demongraphic hetergeneity of australian nursing students: a closer look. Int. Nurs. Rev. 59 (1), 59e65. San Miguel, C., Townsend, L., Waters, C., 2013. Redesigning nursing tutorials for ESL students: a pilot study. Contemp. Nurse 44, 21e31. Wingate, U., 2006. Doing away with 'study skills'. Teach. High. Educ. 11, 457e469.
Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Discipline matters: Embedding academic literacies into an undergraduate nursing program Sharon P. Hillege a, 1, Janice Catterall b, *, Barbara L. Beale a, 2, Lyn Stewart a, 3 a b
School of Nursing and Midwifery, University of Western Sydney, Locked Bag 1797 Penrith, NSW 2751, Australia Student Learning Unit, University of Western Sydney, Locked Bag 1797, Penrith, NSW 2751, Australia
a r t i c l e i n f o
a b s t r a c t
Article history: Accepted 21 September 2014
In recent years the higher education sector in Australia has been increasingly concerned with ensuring that the English language proficiency levels of students are commensurate with the academic and professional tasks that they must perform. In many universities, this heightened attention to language proficiency has driven changes to teaching and learning practices. This paper reports on a project to embed academic literacies development into a core first year subject within a Bachelor of Nursing program in a large, culturally and linguistically diverse, metropolitan university. Prior to the commencement of their nursing program 747 students completed a Post Enrolment Language Assessment. Students who required additional support were advised to enroll in tutorials which included an additional literacy focus. These tutorials were part of the normal tutorial program for this nursing subject. Students with lower level language skills who attended the streamed tutorial with additional literacy support showed a greater improvement in their written communication than those with similar language proficiency who attended non-streamed tutorials. Evidence suggests that this improvement was transferred into writing tasks in other non-streamed subjects. The findings reported in this paper highlights that discipline specific embedded strategies are an effective approach to the development of academic literacies. © 2014 Elsevier Ltd. All rights reserved.
Keywords: Nursing education Academic literacies Undergraduate Strategies
Introduction The importance of good oral and written communication abilities in nursing cannot be underestimated Garling (2008) recognised that patient safety can be compromised through miscommunication in inter-professional communication, documentation and during clinical handover. Conversely, effective communication was found to reduce errors and improve patient safety (Garling, 2008). In the higher education sector the development of communication capabilities is increasingly viewed as the responsibility of academic programs, and attention has turned to the most effective ways of achieving these goals. The long term goal of this project was to embed academic literacies development across the curriculum for all students. The term academic literacies
* Corresponding author. Tel.: þ61 24736 0847; fax: þ61 24736 0853. E-mail addresses: [email protected] (S.P. Hillege), janicecatterall@gmail. com, [email protected] (J. Catterall), [email protected] (B.L. Beale), lyn. [email protected] (L. Stewart). 1 Tel.: þ61 24570 1926; fax: þ61 24570 1420. 2 Tel.: þ61 29685 9269; fax: þ61 29685 9599. 3 Tel.: þ61 29685 9411; fax: þ61 29685 9599. http://dx.doi.org/10.1016/j.nepr.2014.09.005 1471-5953/© 2014 Elsevier Ltd. All rights reserved.
is used as an umbrella term to cover a number of sub-categories commonly used in to describe language practices in higher education including academic writing, communication skills and English language proficiency. Whilst it is acknowledged that English language proficiency includes listening, reading writing and speaking, and these issues are being addressed in our school, the focus of this paper is on the development of essay writing skills. In order to gather evidence to support changes to teaching and learning practices, a program was designed that would focus on providing additional academic literacies support to students identified with lower levels of English language proficiency. The model entailed using a Post Enrolment Language Assessment (PELA), a brief writing task, and streaming, which involved separating students into tutorials for this specific subject. This streaming was based on the results achieved for the PELA writing task. This model was adapted from one used successfully in several disciplines at another university. In response to a need identified in one of these projects (San Miguel et al., 2013), this paper aims to supplement existing accounts of student satisfaction with evidence of academic achievement. The strategy described in this paper was an early initiative in a holistic program adopted by the School to improve the academic literacies of nursing students. This
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constantly evolving program remains a core feature within the School. Context of the strategy The nursing program is situated in a large metropolitan Australian university which caters for a diverse multicultural community representing more than 170 cultural/ethnic groups. It attracts a student population that is diverse culturally and linguistically, as well as, in socio-economic background and age. In 2010, 2122 students were enrolled in the Bachelor of Nursing. Of these, 17% (361 students) were international and 27.7% (588 students) came from lower socio-economic postcodes. In 2009, Smith and Taylor reported that (44.4%) of students in this program did not speak English as their main language at home. Salamonson et al. (2012) found that 38% of local students in the nursing program at this university were born overseas and tended to be mature-aged, and engaged in high hours of paid work. Currently around 16% of students enter through the traditional schooling pathway, while others are admitted through vocational education and training pathways, mature age provisions, foundation courses or from overseas. Nursing lecturers at this university cater for a student population that is heterogeneous in terms of the English language proficiency, prior experiences and preparedness for academic study. In seeking to cater for this diverse group of students, the teaching team in this study was also responding to standards set by the professional nursing and registering authorities and increasingly by the higher education sector. An increasingly regulated environment The National Competency Standards for the Registered Nurse require the nurse to effectively communicate with individuals and professional groups in order to facilitate provision of care (The Australian Nursing and Midwifery Council (ANMC), 2006). Registration with Australian Health Practitioners Registering Authority (AHPRA) (2011) requires English language skills at a level where all registered health practitioners can provide safe and competent practice. This level is considered to be an International English Language Testing System (IELTS) level 7 in each of the four components (listening, reading, writing and speaking) or attaining at least a B score across all four components of the Occupational English Test (OET). Evidence of completion of five years of fulltime equivalent education taught and assessed in English in a recognised country also fulfils the requirement (AHPRA, 2011). Therefore if there is a disparity between the English language proficiency of students at entry level and the level required at registration, then nursing programs have a responsibility to develop the communication skills of students throughout the BN program. On a broader scale, the tertiary sector has reacted to fears that low English language proficiency levels might be impacting on academic standards (Birrell, 2006). This concern, raised in the context of the English proficiency of incoming international students, came at a time when a number of studies were highlighting the difficulties that international students were experiencing with the complexities of analytical and critical writing (Heatley et al., 2011). In a similar vein, Borglin (2011), writing with a European nursing perspective, reported that students often leave Higher Education Institutes without meeting acceptable levels in academic writing or critical thinking, attributing this to a number of factors, including the prevalence of ‘non-traditional students’, the theoryepractice divide and the relative paucity of teacher training among nursing lecturers. Experience in Australia suggests that concerns about levels of English language proficiency should not be confined to international students only (Murray, 2013). One
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outcome of this debate in Australia has been the release of the ‘Good Practice Principles for English Language Proficiency for International students’ which highlight the responsibility of universities for ensuring the development of English Language proficiency (Department of Employment, Education and Workplace Relations (DEEWR), 2009). Universities are required to put in place measures that ensure language needs of students are identified early and that there is adequate support (Murray, 2010). Of particular relevance to the nursing pilot project reported on in this paper is Principle 6 which requires that the development of English language proficiency is integrated with curriculum design, assessment practices and course delivery through a variety of methods (DEEWR, 2009, p. 4). There is a good fit between this principle and the context of many newer universities in that local students, both native English speakers and those who speak English as an additional language, are as likely as international students to require additional support to successfully engage with their studies. Rationale for the selection of an embedded approach In developing this program, the project team was primarily informed by an academic literacies approach which views the development of ability in reading and writing as a social practice linked to disciplinary knowledge and discourses (Lea and Street, 1998). The model is useful to nursing education because it recognises the complexity of switching between literacy practices as students move from theoretical to practical literacy settings and between various assessment and professional genres. In the development of teaching resources and classroom strategies the teaching team also drew on the pedagogical traditions of the “Writing Across the Curriculum” movement, in particular, the importance of genre-based, student-centred activities that allow students to understand and reflect on the language features of disciplinary discourses (Russell et al., 2009). In keeping with this tradition, the project team sought to create space in the curriculum for disciplinary specific writing practice and feedback. An important advantage of a disciplinary specific approach is that students learn the conventions of writing that will be relevant in their nursing studies (Andre and Graves, 2013). The term ‘embedded’ refers to disciplinary specific approaches where student capabilities in required academic literacies are developed within the content and assessment framework of the program and within the timetabled classes of the program. While there are undoubtedly places in higher education today for more generic approaches to writing instruction, adjunct, study skills approaches are increasingly seen as less effective and less attractive to contemporary students than more embedded approaches (Wingate, 2006). Similarly, Haggis (2006) has argued that it is no longer possible to ‘remediate’ for the diversity of prior experiences and types of preparedness in the student body, because it cannot be assumed that students are sufficiently prepared for completion assessment tasks. Murray (2010) proposes that abilities related to both academic literacies and professional communication should be embedded into curricula as a part of the normal responsibility of the subject lecturer. Yet, not all subject lecturers are confident language teachers. This embedded team teaching model was attractive to nursing lecturers and language experts because of the opportunity to build professional capacity by exchanging expertise through the collaborative development of resources and through teaching partnerships. Another advantage of an embedded model is that explicit development of academic literacies can occur within timetabled classes. It is often students who are judged to be most at risk of academic failure by their lecturers who are least likely to attend additional ‘bolt on’ classes (Wingate, 2006). This is most likely due
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to a multiplicity of factors including a lack of confidence, lack of self-awareness and competing demands outside the academic workload for paid work and family (Hockings et al., 2007). Salamonsen et al. (2010) reported low attendance at a noncompulsory workshop, even when content was specifically related to nursing learning outcomes and where students with low English language proficiency levels had been specifically targeted. Description of the embedded program The primary goal of the teaching team was to embed academic literacies development within the learning and teaching framework of the subject. The teaching team was aware that tertiary academic literacies would be new to all commencing students and that diverse student populations would command a range of cognitive, linguistic, cultural and experiential resources. However, in this program, constraints on staffing, particularly the availability of the academic literacies experts to team teach meant that face to face teaching had to be directed to students with lower language proficiency levels. These students included native and non-native speakers of English. Students in this category were advised to attend tutorial classes that were team taught by nursing lecturers and academic literacy experts. However for student equity language-focused learning resources were made available to all students in both paper-based and online modes. The nursing subject selected for the explicit development of academic literacies was a core first year professional orientation subject in which the major assessment task was an essay. The essay assessment task is reasonably common in the nursing degree and presents students who are less prepared for academic study with particular challenges. In her important contribution to academic literacies pedagogy, Lillis (2001, p 39), has argued that essayist literacy “privileges the discursive routines of particular social groups” and that often the pedagogic practices that surround the task are implicit, rather than explicitly taught. The teaching team devised a number of changes to existing pedagogic practices including more active student involvement in the teaching and learning process, plentiful opportunities for dialogue related to academic literacies practices, and more opportunities for writing and feedback. Particular attention was paid to writing as a process in the context of nursing. Students engaged in guided critical reading of nursing literature and tasks, related to the development of overarching thesis statements, structuring arguments and draughting and editing, were carefully scaffolded. In addition, the teaching team involved students more actively in discussions about learning practices that would help them to develop the capabilities necessary for professional nursing practice. Huber and Hutchings (2005, p. 116) have coined the term ‘pedagogical intelligence’ to describe the adoption in the classroom of learning stances that are more intentional and reflective.
students to write a 100e120 word sample of their writing about a topic familiar to everyday life, using formal language. 2) These language assessments were graded by Teaching of English to Speakers of Other Languages (TESOL) qualified staff which included Nursing Academics. The assessments were graded numerically according to predetermined literacy criteria as a level one (proficient), level two (borderline) or level three (requiring additional support). There were 747 students screened; 147 students (19.7% of cohort) were identified as requiring additional support with academic writing. It was the view of the language experts that these students would find it difficult to engage successfully with academic writing tasks within the nursing curriculum. 3) These students were advised to attend the tutorial classes in which explicit academic literacies development would be a focus (streamed tutorial). These tutorials occurred at the same time as conventional tutorials and were taught by staff from the Student Learning Unit together with nursing academics with interest or qualifications in language development. 4) Core academic literacies activities were embedded into subject specific content, over seven two hour tutorial sessions. In addition the standards and criteria for the essay task were specifically orientated towards further assessment of academic literacy. In order to ensure equity, students graded as having a satisfactory level of literacy (conventional tutorials) had access to the same literacy support information on the subject website. Notably due to the success of this strategy, all tutors were required to integrate core academic literacies strategies into their tutorials in the following year. This process has been further refined and continues to be implemented in a relevant subject in the first year. In order to improve consistency in grading of assessment tasks across the streamed and non-streamed tutorial classes, workshops for the teaching and grading team were conducted prior to the marking of the essay task. The markers were unaware of the students' literacy levels when assessing the students’ work. Statistical analysis was conducted on the essay results of all the students comparing the mean score between those in tutorials with an additional literacy focus graded as three in the PELA (n107) and those graded as a level one or two (n 600)who were attending conventional tutorials. A further analysis compared students graded as level three, who did not attend the tutorials with an additional literacy focus (n ¼ 40) with those who did. At the end of semester essay results of all core units of study were compared. The final step was the administration of a survey to evaluate the effectiveness of the developed resources delivered in this core unit of study. This 5 Item Likert Scale Survey which included open ended questions, was conducted in the streamed tutorials with the additional literacy focus. Participants
Aim
The participants were seven hundred and forty seven commencing student nurses enrolled in a Bachelor of Nursing program in 2010.
The overall aim of this study was to evaluate the embedded literacy strategy in a core subject in the Bachelor of Nursing (BN) program.
Ethics
Research design A mixed method approach was used to collect the data. It is appropriate to use a mixed methodology when data is collected from both qualitative and quantitative sources (Borbasi and Jackson, 2012). T- Tests were conducted on the essay results. The program followed the pattern. 1) a Post Enrolment Language Assessment (PELA) completed by all the students pre commencement. The Post Enrolment Language Assessment (PELA) required
Ethical approval was sought and granted from the University Ethics Committee. Informed consent was gained from the students prior to completing the screening test and the evaluation. Participation in the project was voluntary and anonymous. Students who did not give consent were excluded from the study. Results/findings The results focused on the performance of the students who attended tutorials with an additional literacy focus. All students in the
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subject completed a 1200 word essay task which was worth forty percent. The essay was submitted after all academic literacies interventions had been completed in the tutorials. The mean of the essay mark in tutorials with an additional literacy focus was calculated. Fig. 1, illustrates that even though students graded as a level one (in the PELA) achieved marginally better in the essay results, there was no statistical difference between those that were graded as a level three who attended the streamed tutorials with an additional literacy focus, to students who attained a level two (p ¼ .723) or a level one (p ¼ .253) in their language assessment task. The mean of the student essays in conventional tutorials (for those students with a level one in the initial language assessment) was 22.09 and 21.55 for those with level two language skills, while those graded as a level three and attended the tutorials with an additional literacy focus had a mean of 21.25. This finding indicated that students beginning with a much lower language skill base were able to improve these skills if they were in tutorials with an additional literacy focus. An additional comparison was conducted using the mean essay mark between students who were graded as level 3 in the PELA who attended tutorials with an additional literacy focus and those who did not. Fig. 2. Results showed one hundred and seven students (N ¼ 107) (level three) attended tutorials with an additional literacy focus and forty (level three) attended conventional tutorials. The mean essay mark for students in the tutorials with an additional literacy focus, who had been graded as level three was 21.25, as opposed to, 17.5 for those graded three who had either chosen not to attend tutorials with an additional literacy focus or who were screened after the streaming process had taken place. Students in tutorials with an additional literacy focus had a statistically significant higher mark (p ¼ .007) for their essay than those graded as a level three who attended conventional tutorials. Evidence suggested that the students who had attended tutorials with the additional literacy focus were able to transfer this improvement in writing skills to other subjects. Results from essays in other subjects of study, submitted after the core subject essay, revealed that students in the tutorials with an additional literacy focus (in the core subject) had overtaken students in the conventional tutorials in their other subjects of study that required the essay genre. Again this reiterated the value of this intervention. Fig. 3. These encouraging results were further supported by a survey which was administered in the tutorials with an additional literacy focus. Data from the 5 item Likert scale revealed that students self -reported significant transference of writing skills to other areas (e.g. assignments in other subjects, professional writing). In addition, general confidence was perceived to be enhanced with 60% of respondents, indicating that the language focused input succeeded in making them more comfortable with both the expectations and processes of academic writing.
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Fig. 2. Comparison of the mean essay mark between students graded as a 3 in conventional tutorials and graded as a 3 in tutorials with an additional literacy focus Ttest ¼ 2.79,df ¼ 63, p ¼ .007.
60 50 40 30 20 10 0
regular streamed NHW Ban Essay Essay
BF Essay
UGH Essay
Fig. 3. Comparison of the essay results in percentage between subjects for regular and streamed students.
Student comments described how the academic literacies strategy was received by the students. One indicative comment stated: ‘The information was so useful that we could apply what we learnt in essays in all the subjects. Also to mention the general confidence as it was our first time in university and we didn't know exactly what to do. However, after these sessions everything was just clear and university writing was made easy.’ Most comments referred to an increase in respondents' appreciation of writing as an ongoing development as illustrated by the following comment:‘Writing is not easy for me, it will need a lot more practise to be more confident next time.’ Another student indicated:‘I used to write the way I talked, but now I can write differently in a scholarly, academic manner. I understand that if I don't write simply and clearly, reading can be difficult for other people to understand.’
Discussion
Fig. 1. A comparison of the mean essay mark between those graded as 3 attending tutorials with an additional literacy focus and those graded as 2 and 1 in conventional tutorials Graded 1 compared to graded 3 in an additional literacy focus tutorial Ttest ¼ 1.147, df ¼ 177, p ¼ .253 Graded 2 compared to graded 3 in an additional literacy focus tutorial T-Test ¼ 3.54 df ¼ 205.9 p ¼ .723.
The results of this strategy were positive. The TESOL trained lecturers who marked the initial screening task reported considerable differences in the English language competency of students ranging from the highly proficient to those graded as level three whose writing exhibited multiple challenges in coherence, structure and clarity. The embedded academic literacies program allowed students, who were initially less prepared for the writing demands of university, to develop their written language and their confidence with written language in the tutorial context of the core subject. These findings mirrored those reported by San Miguel et al. (2013) who found that forming streamed tutorials for ESL students in a nursing subject, contributed to deeper understanding of the
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content and to comfort and confidence. In order to achieve this level of confidence or mastery, a student needs to continuously work towards learning the basic rules and norms of the English language (Archee et al., 2013). Understanding these basic rules and norms, improves the clarity of the message conveyed between the writer and the reader (Archee et al., 2013). In nursing there are many instances when written communication is required. Report writing, for example, is extremely important, where clarity and accuracy of the information conveyed is essential and is a legal requirement. Additionally as highlighted by Komarraju and Nadler (2013) the development of academic literacies has the capacity to improve overall performance as students develop higher order learning skills, increasing their self-confidence and self-efficacy to become motivated self-regulated learners. This process is important in disciplines such as Nursing as students are expected to develop both critical thinking and complex psychomotor skills necessary for practice as a nurse or midwife. Therefore students who develop higher levels of self - confidence and selfefficacy through a higher degree of literacy performance will become confident learners who will become competent practitioners (Komarraju and Nadler, 2013). This has a flow on effect in the development of motivation and self empowerment. The evidence of academic achievement was particularly noteworthy. The results were extremely promising because they showed that, although the average marks for the streamed group appear modest, there were several critical outcomes that are worthy of recognition. Firstly, many students in the streamed group were able to pass their essay, a circumstance that would have appeared unlikely as identified by markers who had previously assessed the students' level of written proficiency. In addition, despite the significant difference in the initial written proficiency of each of the graded groups, the streamed tutorial groups almost bridged that gap to level results at similar to the overall cohort. Finally comparisons across the written assignments for three other subjects studied by this student cohort in the first session of their course, suggested that there is evidence to suggest that students were able to transfer these newly acquired academic skills developed through explicit teaching to other subjects. It appears that an explicit focus on language was beneficial to the diverse range of students who attended tutorials with an additional literacy focus. This again reiterated that this strategy was effective in developing written communication in students who exhibited weaker capabilities in this area, at the beginning of their studies. It was noted earlier that the decision to embed academic literacies development in only half of the tutorial groups of the subject was a compromise based on available face to face teaching resources. The teaching team would concur with Haggis (2006) and Lillis (2001) in recognising that the linguistic demands of tertiary writing are new to all students and those strategies to develop academic literacies should be widely available through multiple modes. The evidence of academic achievement gathered in this study has contributed to the greater integration of academic literacies pedagogy into all tutorials in this subject. Early indications suggest that this is leading to improvements in essay scores across all proficiency levels. The integration of academic literacies that has occurred over time and reflects a paradigm shift from previous years when academic literacies development was a more marginalised activity. The embedded approach reported in this paper relied on collaboration between experts in nursing and academic literacies. One of the positive outcomes has been the sharing of expertise between disciplines which has resulted in capacity building amongst staff who are charged with the responsibility of producing graduates who are effective professional communicators. The development of communication skills is critical to safe nursing practice and this embedded model offers nursing education a
strategic way forward. The challenge for the teaching team in future years will be to provide inclusive, explicit academic literacies development to all students in core first year subjects using face to face as well as a blended multi-modal learning and teaching approach. We would suggest that further research be conducted in other faculties, with linguistically diverse student populations, using a similar or modified model, to suit individual teaching and learning requirements. Indication that students may be able to transfer academic literacies skills developed in one unit to writing tasks in other units is particularly promising and further investigation of this trend could significantly enhance the potential value of similar interventions. Conclusion We believe that the findings from this study will contribute to the understanding of how learning and teaching methods within disciplines can be transformed to take greater account of the increasing diversity of student populations. In this study students with weaker academic English language proficiency who attended streamed tutorials included both native and non-native speakers of English. It was evident to the teaching team that all students could also have benefited from more explicit academic literacies development. Nevertheless, given the limitations on resources, the compromise position which introduced additional literacies support into designated tutorials, still achieved positive results for students with lower English proficiency levels. It is envisaged that the small but significant gains made in student academic literacies abilities and grades will give renewed impetus to ongoing, whole-of-curriculum change. Acknowledgement A Barthel, L Craven, ELSSA Centre, UTS. (Post-enrolment language screening assessment used with permission). Associate Professor Yenna Salamonson and Dr Sansnee Jirojwong for statistical analysis. Frances Williamson, Erst Carmichael, Lauren Ross, Maria Inglis (Student Learning Unit), and Fiona McDermid (School of Nursing and Midwifery) assisted with teaching in tutorials with an additional literacy focus. TESOL support staff Frank Allatt, Ros Allatt, Colin Helmstedt, Heidi Creed and Marian Martin. References AHPRA, 2011. New English Language Skills Registration Standard from 19th September 2011 available from: http://www.ahpra.gov.au/documents/default. aspx?record¼WD11%2F5840. Archee, R., Gurney, M., Mohan, T., 2013. Communicating as Professionals, third ed. Cengage Learning Australia Pty Limited, South Melbourne. Andre, J., Graves, R., 2013. Writing requirements across nursing programs in Canada. J. Nurs. Educ. 52 (2), 91e97. Australian Nursing & Midwifery Council, 2006. National Competency Standards for the Registered Nurse. ANMC, Dickson, ACT. Available from: http://www. nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/CodesGuidelines.aspx#professionalboundaries. Birrell, B., 2006. Implications of low English language among overseas students at Australian universities. People Place 14, 53e64. Borbasi, S., Jackson, D., 2012. Qualitative research: the whole picture. In: Borbasi, S., Jackson, D., Langford, R. (Eds.), Navigating the Maze of Nursing Research. Mosby, Australia, pp. 153e178. Borglin, G., 2011. Promoting critical thinking and academic writing in nurse education. Nurse Educ. Today 32 (5), 611e613. http://dx.doi.org/10.1016/j.nedt.2011. 06.009. Department of Employment, Education and Workplace Relations, 2009. Good Practice Principles for English Language Proficiency for International Students in Australian Universities. www.deewr.gov.au/Highereducation/Publications/ Documents/Final_Report-Good_Practice_Principles.pdf. Garling, P., 2008. Final Report of the Special Commision of Inquiry into Acute Care Services in NSW PublicHospitals. www.lawlink.nsw.gov.au/Lawlink/Corporate/ ll_corporate.nsf/pages/attorney_generals_department_acsinquiry.
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