Constructing a Collaborative,Emergent Syllabus of Communicative Performances in a Nursing English Course in Taiwan

Introduction

Reflecting global trends, nurses in Taiwan, where English is generally spoken as a foreign language, need to develop their communication skills in English to interact with the growing number of foreign healthcare clientele and workers (Chien, 2008). Although it is widely recognized that practical workplace English needs to be taught in nursing programs in Taiwan, methods of English for General Purposes (EGP) centred on teacher, textbook, lexicon and grammar still prevail. Seeking a more communicative approach, we conducted a curriculum development study of a nursing English course for third-year students in a Bachelor of Science in nursing (BSN) program in Taiwan. In the classroom, we used action research to implement and research an emergent, collaborative process of language needs analysis and syllabus construction designed to engage students in communicative performances of nursing workplace English.

Study Design and Methods

The authors conducted action research in an 18-week elective, two-hours-per-week ENP course for third-year BSN students at a university in Taiwan. The course was set up by the course’s teacher (first author) with the assistance of the second author using an action research framework of introducing, reflecting on, and reformulating classroom innovation in an iterative manner that involves teacher and student collaboration (Collins, 2009). In addition to providing a means of guiding student participation in and reflection on improving the process of learning and teaching, action research is a method by which the teacher, other researchers, and/or the students and teacher can document and reflect on the teaching, learning, and research process to the benefit of self and others. The basic learning and research goals in the course were designed to form a weekly action research cycle (cf. Yang, et al., 2012) involving teachers and students:

Students were also asked to observe several ground rules: change their small-group membership regularly, limit discussion in Chinese, take notes in class, not use written scripts in formal performances, and write weekly group progress notes online.

Findings

Content analysis revealed that, as teachers and students fleshed out the details of the course, four types of interactional language (Empirical, existential, transactional, and discussion language) emerged along with eight strategies that helped the students develop their weekly performances (‘Asking questions’, ‘Performance idea’, ‘Researching’, ‘Making’, ‘Practicing’ and Revising, ‘Acting’, ‘Thinking about what we did’, and Building an adaptable performance repertoire), within four stages that basically correspond to our action research design: Preliminary Needs Analysis and Brainstorming, Needs Analysis, Creating, and Reflecting and Building. (Participants’ grammar has not been altered in quotations).

Strategies in the Development of Weekly Performances

We engaged in weekly cycles of question-and-answer dialogues, terminology discovery, and pronunciation practice, and making performances; in the first two weeks, these involved one-on-one introductions, conversations about students’ current practicum courses, and introductions of others. Engaging in strategies 1 and 2 (‘Asking questions’, ‘Performance idea’), students also determined in the first weeks the settings for their future performances: small, private outpatient clinics; hospital outpatient clinics, patient wards, and emergency rooms (ERs); nursing homes; and home care nursing. The weekly communicative events (culminating in weekly performances) were outlined by purpose/setting/roles in an evolving online syllabus actualized through classroom interaction and documented via the first author’s class notes, video recordings, and students’ online notes. Table 1 shows the outcome of this building-up of performances from simpler to more complex ones, which were folded into each other in a spiral of action; the column ‘Integrated performances (by week no.)’ indicates which weekly performances were integrated into later ones.

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Table 1.

Emergent Syllabus: Weekly Nursing Workplace Events Created.

Week	Communicative event	Setting	Roles	Integrated performances (by week no.)
1	Greeting for first time	University campus	Students, teachers
2	Talking about healthcare specialties	Hospital, clinic	Students, nurses, patients	1
3	Giving directions	Hospital registration desk, clinic, ward, etc.	Nurse, patient, patient’s companion	1-2
4	Receiving a patient	Hospital outpatient clinic, inpatient ward, (also ER, neighborhood clinic, nursing home, private home)	Nurse, information staff, doctor, patient, patient’s companion	1-3
5	Eliciting symptom-descriptions, diagnosing, and treating	Hospital clinic, neighborhood clinic	Nurse, doctor, patient, patient’s companion	1-4
6	Explain prescriptions and give directions to a pharmacy	Hospital clinic, pharmacy	patient, nurse, pharmacist	1-5
7	Referring a patient to a specialist	Hospital clinic	Nurse, doctor, patient, patient’s companion	1-5
8	Receiving a patient in a specialist clinic	Hospital specialty clinic	Nurse, doctor, patient, patient’s companion	1-5 and 7
9	Referring a patient to a technician	Hospital lab, X-ray, physical therapy, radiotherapy, etc.	Nurse, doctor, technician, patient, patient’s companion	1-5 and 91-5 and 7-8
10	(Preparation time for midterm performance)
11	Admitting, treating, discharging a patient(Midterm performance)	Hospital, ward	Nurse, doctor, registrar, technician, social worker, administrator, pharmacist, patient	1-5 and 7-8 and 9 and 6
12	Caring for a patient pre- and post-surgery	Hospital, wards	Nurse, doctor, patient, patient’s companion(s)	1-5 and 7-8 and 11
13	Responding to communication issues (cultural, ethical)	Hospital clinic, ward	Nurse, doctor, patient, patient’s companion(s)	1-5 and 7-8 and 11-12
14	Caring for someone in an emergency	Public place, emergency room	Nurse, doctor, patient, patient’s companion	1-5 and 6 and 7-8 and 9 and 11-12
15	Caring for a nursing home patient	Nursing home	Nurse, doctor, elderly resident, resident’s family member, foreign nurse aide	1-4 and 13
16	Helping a home caregiver	Private home	Home-care or community health nurse, elderly resident, foreign caregiver or nurse aide	1-2 and 13
17	(Preparation time for final performance)
18	(Final performance)	(Students’ choice)	(Students’ choice)

Next, we will describe the eight strategies of weekly performance development and briefly illustrate their relationship by drawing on the activities of just one week and one group: Group 3, leading up to and during Week 15.

Stage I: Preliminary Needs Analysis and Brainstorming

Stage II: Needs Analysis

Stage III: Creating

Stage IV: Reflecting, Building

Discussion

We introduced a way for teachers to develop a communicative nursing English course using an action research framework to pursue a full range of learner-centred activities, from language needs assessment to the design and enactment of communicative performances that make up an emergent syllabus (cf. Shaw, 2009). Students, facilitated by two teachers, engaged in eight emergent strategies of action to construct a series of intersecting performances consisting of smaller communicative events embedded within larger ones (cf. Munby, 1978). The outcome of these course processes can be seen in the artifact of the living syllabus which was recorded week-by-week through classroom and online interaction between teachers and students (see Table 1). These performances were scaffolded into manageable tasks (Applebee, 1986) in a process that encouraged self-directed learning backed up by timely guidance by a teacher (Spencer and Jordan, 1999). This process stimulated the integrated learning of multiple aspects of profession, culture, and language grounded in social relations. Instead of a teacher- and textbook-centred approach, the teachers engaged in ‘contextualized, supported practice and action (mental and physical)’ to help move students from Vygotskyan proximal to actual development (Mantero, 2002). In this respect, our study is reminiscent of an early ESP study in which doctor-patient transactions were broken down into stages that could be readily understood by learners (Candlin, et al., 1976).

We found that working out basic interactional language, particularly transactional and discussion language for ‘getting things done in a group situation’ (Maley and Duff, 1982: 17), provided a vital means of initiating the ongoing, collaborative course process of discovery, reflection, and cumulative building of communicative performances. Engaging in this process seems to have contributed to an overall positive and productive learning experience for our participants. Facilitated by teachers, the students were able to research and formulate their own configurations of knowledge – posing problems, exploring conventions, and crafting scenarios together – and thereby develop an evolving understanding of each other’s and their teachers’ subject-area knowledge-in-practice (see Belcher, 2009a). A precedent for this kind of study in ENP is that by Hussin (2002), a language teacher affiliated with a nursing department (as was the first author of this paper) who developed ENP course materials through interaction with nursing faculty, textbooks, co-teaching, and getting involved in nursing teacher and students’ subject-area community. In our study, the students combined reading, writing, listening, and speaking activities by consulting nursing and language textbooks, multimedia sources, and other students and teachers; then, determining the basic vocabulary and expressions needed, developing small tasks and making them into a communicative performance through staging, scripting, and rehearsing. Speaking and listening were at the heart of the performances, but students also engaged in reading and writing activities by taking notes on vocabulary, language forms (common phrases and their functions), and performance content, roles, and communication issues raised in class.

Other studies have also developed collaborative tasks and role-plays for nursing English students. For instance, in his comparison of four methods of generating ENP course material in the form of composed, authentic, role-play, and scaffolded teacher-student interaction texts, Ritchie (2005) found that transcribed unscripted role-plays of healthcare interaction between a healthcare professional and an ESP teacher worked relatively well because:

they may be expected to retain some features of spontaneous discourse while featuring fewer impenetrable context-dependent references as compared to authentic texts. As they involve medical professionals, the transcripts provide valuable information on the language demands of the target task (Ritchie, 2005: 74).

Ritchie (2005) also tried scaffolded teacher-student healthcare-related interaction that was recorded, transcribed, revised, and discussed by the teacher and students in the classroom, which he said gave students an active role and personal investment in the experience because it ‘raises awareness of the processes of communication, and creates opportunities for learning that are exquisitely tuned to learners’ needs’ (2005: 74). Thus, he recommends role-plays with supplementary use of other sources.

In Taiwan, a study by Chien and Tsao (2009) is the only one involving nursing students that, to our knowledge, completed the full cycle of needs analysis, course design, experimental course implementation, and evaluation of course outcomes (cf. Bosher and Smalkoski’s 2002 study on immigrant nursing students in the United States), which makes their study unusually useful because it offers, to some extent, a reproducible ESP course model. From a student needs analysis they derived six categories of communication issues revolving around language, culture, and healthcare. They made these into nine thematic course modules consisting of pair and small-group classroom activities which

included the learning of model dialogues along with relevant vocabulary, expressions and grammatical structures, watching videos that present the subject of the lesson, modifying and role-playing the dialogues, discussing related topics in pairs or in groups, and presenting group discussions or conclusions to the whole class (2009: 87).

However, we have tried to demonstrate that developing tasks and role-plays to reflect contexts of nursing workplace English can go further by collaborating with students to develop dramatic performances in integrative stages of growing complexity.

Performance was used to socialize (from exploration to acquisition) the students into the role of dramatic performer, and, moreover, into the social roles and relations found in healthcare settings, in an emergent process based on systematic yet flexible preparation involving diverse sources. Anthropology of performance scholars have suggested that engaging in performance can promote awareness of self and other, a reflexive or critical view of cultural conventions, and habitual dispositions for anticipating the predictable and adapting to the unpredictable (Bauman, 1977). In the performance about a nursing home resident, the participants in our study, by concretely thinking through and enacting caring for a person with AD, learned or reinforced valuable nursing content (including ethical practices) along with embodied knowledge of English-language form and content grounded in an intercultural Taiwanese healthcare context.

This study affirms prior research that learner-centred communicative approaches are quite feasible in East Asian contexts (Littlewood, 1999: 75; Sampson, 2010), where students commonly have extensive experience working in teams in classroom and club activities. Our performance-centred, mixed language/subject-area approach also corroborated prior evidence that comprehensive role-playing in nursing English (Bosher and Smalkoski, 2002) and simulation in nursing training (Berragan, 2011) are useful approaches. We found that participants were most focused and motivated when working together in small groups with differentiated roles centred on a common goal. This suggests to us that decentring of the teacher’s authority – by teachers stepping away from centre stage in the classroom – is an important aspect of the engaged attitude of students during their teamwork activities.

In our study, the slowing down of learning progress in the second half of the course to some degree reflects the rapid improvement in students’ communication skills in the first half of the semester, which then, however, plateaued somewhat in the second half once they had become familiar with the course approach to performance-building. A more significant factor, as indicated by the students, was that their attention became increasingly directed toward their clinical training and preparing for final exams in their major area of study. Although their classroom interaction was reinforced by sharing posts online (see, Chen et al., 2009), some students at times found it difficult to carry out course activities outside the classroom. On a related note, perhaps the greatest challenge faced was managing class time to fit in both the weekly performances and preparations for the next week’s performances, in part because Taiwanese undergraduate students’ course loads are heavy, and third-year nursing students spend much of their time in clinical training.

Even though objective evaluation of EMP/ENP courses has generally been problematic within the few studies that have been done (see Shi, 2009), the absence of a quantitative pre-test/post-test comparison of the students’ English level is a limitation of this study. Nevertheless, in action research, the participants’ iterative reflexivity and contribution to the research outcome embody and express evaluative actions. Students’ progress can thus be measured, in part, by the extent to which they are able to assess and construct their own communication needs and the form, content, and contexts through which they can realize those needs in performance. Mantero (2002, paraphrasing Wiggins, 1990) explains that this kind of emergent approach to evaluation ‘offers opportunities to plan and revise dialogue and discourse, collaborate with others, and help students “play” within contextualized worlds inside of the classroom that are based on the culture(s) of the language being studied’.

Another possible limitation of our study is that ESP teachers reliant on teacher-fronted material such as textbooks, as is common in Taiwan (Yang, 2005), may be reluctant to introduce the unpredictability of emergent needs analysis, syllabus, or dramatic performance into their classroom. Yet Belcher observes that ‘it would make little sense to seek needs assessment data as input for ESP courses’ only ‘then to choose generic, ready-made commercial materials unresponsive to the specific target needs so carefully identified’ (2009a: 7). The course featured in this study has subsequently been taught successfully with one teacher, larger and smaller student numbers, students at lower and mixed levels of language ability, and some male students and students from related health disciplines, with no significant changes being made to the course design. However, research is needed into whether this approach is useful for collaborative learning among teachers and students with more or less English ability or advanced content knowledge.

In educational action research, the course form and content will to some extent mirror the research agenda (of innovation) since teachers and students together learn through a process of discovery and course development. If misunderstood, this point could be judged a confounding of evidence by research method. The purpose of action research, however, is to work with students within a dynamic, emergent process of reflection and action (Collins, 2009). As Shi et al. observed, ‘the process of data analysis and its use for teaching purposes [is] essentially recursive. Learners are thus involved in the process of curriculum design and can give immediate responses to needs as and when they arise’ (2001: 286). The action research cycle (Yang et al., 2012) or spiral (Crawford and Candlin, 2012) of discovery can be used not only as a means of researching course development and designing future course materials; it can also serve as a framework for developing the basic structure of a course – in our case, as an ongoing process of constructing communicative performances.

Conclusion

Through their development of an emergent ‘living’ syllabus, participants built and tied together a series of events that they came to embody as an adaptable communicative performance repertoire – a syllabus for working, and living. Built on interactional language, the weekly needs analyses, emergent syllabus and scaffolded performance spirals deepened the participants’ knowledge of nursing English communication form and content in context. They learned an approach to learning that they, as well as their teachers, can carry into their future study, teaching, and use of nursing English. This study contributes to the ENP/EMP course development literature on Taiwan, which has been largely prospective. This approach may also be useful in other countries where nursing English has become an important aspect of nursing care, and in other areas of communicative course design and teaching/learning.