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Table of Contents
Year : 2020  |  Volume : 21  |  Issue : 2  |  Page : 135-142

Need and relevance for English language training in oral case presentation of student nurses

1 Lecturer, Sri Ramachandra Institute of Higher Education and Research, Porur, Chennai, Tamil Nadu, India
2 Director, Sri New Prince Bhawani Arts and Science College, Chennai, Tamil Nadu, India

Date of Submission28-Nov-2019
Date of Decision15-May-2020
Date of Acceptance01-Sep-2020
Date of Web Publication19-Feb-2021

Correspondence Address:
Dr. Cynthia Milton
Faculty of AHS, Sri Ramachandra Institute of Higher Education and Research, Porur, Chennai - 600 117, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJCN.IJCN_20_19

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Oral case presentation (OCP) is an important clinical skill for nurses. Literature shows that, generally, less attention is paid to the development of OCP skills. Most of these studies being done by native English speakers have given importance only to content development rather than English language skills needed for OCP. This article explores the English language difficulty and its associated psychological barriers underneath the presentation of clinical cases of student nurses with limited English proficiency. This descriptive needs analysis study was done amongst the student nurses in South India. It has used a mixed method of exploratory interview and a standardised quantitative tool uniquely designed to bring out the hidden barriers in the effective use of English for OCP. The findings show that the most of the student nurses were not satisfied with their language ability to perform OCP. Amongst the language difficulty, the highest perceived difficulty was related to grammar usage and the inability to correct grammar mistakes, which had a mean value of 5.00 and 4.96, while explaining with good pronunciation had been their next concern with 4.96. The findings show that psychological aspects related to learning of second language influence their OCP skills. This language audit will furnish information on key linguistic skills that need to be focussed while developing English for specific purposes lessons for OCP training. The study will help to bridge the gap between classroom teaching and clinical communication requirement and significantly improve the performance of the English as a Second Language student nurses.

Keywords: English for specific purposes, English as a second language student nurses, limited English proficiency, oral case presentation

How to cite this article:
Milton C, Prabakaran M. Need and relevance for English language training in oral case presentation of student nurses. Indian J Cont Nsg Edn 2020;21:135-42

How to cite this URL:
Milton C, Prabakaran M. Need and relevance for English language training in oral case presentation of student nurses. Indian J Cont Nsg Edn [serial online] 2020 [cited 2021 Jun 23];21:135-42. Available from: https://www.ijcne.org/text.asp?2020/21/2/135/309856

  Introduction Top

Student nurses' case presentation is an integral part of nursing curriculum; a preparatory task that significantly contributes to health-care realm. Oral case presentation (OCP) skills being the core competency for nurses, it is highly momentous to prepare the student nurses to master this skilful presentation of a clinical case. Maughan et al.[1] points out that less attention is paid to the development of case presentation skills.

Most commonly, every nursing student at the 2nd year starts with an oral presentation of their clinical cases in the presence of their clinical mentors and classmates, where expressing in English is obligatory. Here, the case presentation is defined as a comprehensive report of the care given to a patient from the time of admission to discharge. This includes health information of the past and present medical history that is significant to the present diagnosis.[2] The guidelines for OCP define it as a formal narrative act done mostly from memory with expected good fluency. It is described as an art form that requires concerted effort and repeated practice, developed out of their observation.[3] Although the real purpose behind OCP is to develop sound, critical-thinking skills, clinical reasoning and to incorporate evidence-based care in practice, yet possessing a good fluency is prerequisite to attain the expected standard.[4] As OCP has distinctive linguistic skills, good English competency is required to deliver good and high-quality OCP.[5] Ultimately, possessing a good speaking skill is the foundation for a good clinical case presentation. Similarly, to possess good English speaking skill at a tertiary level, a good previous English learning exposure, say at school and family environment that had offered plenty of speaking opportunities is needed.

Unfortunately, there is a lack of uniformed exposure to English language learning experience in South India due to urban–rural disparities, which has given way for ineffective teaching approaches.[6] This has contributed to the increase in students with Limited English Proficiency (LEP). Gaudio[7] identifies poor vocabulary, slow naming speed and low verbal participation as characteristics of LEP.

In the present South Indian scenario, the scope of the nursing profession invites many students from rural setup to pursue the course. With English being the medium of instruction at most of the Indian nursing colleges, the learning experience of these students who have come from other media is highly challenging. The students face the negative experience of their inability to cope with the expected standard of achievement.[8] They also have less possibility to work independently as their language ability poses barriers.[9] When a student nurse with LEP joins a class of multilevelled language population, their academic and clinical functioning is crippled. They may undergo feeling of frustrations due to their inability to explain the same in English. With the underdeveloped speaking skill presenting a case well in English is a great challenge. Therefore, identifying the existing English gap will help to improve their OCP skills. The present study reports on English language needs analysis conducted to: (1) assess the overall level of perceived language difficulty experienced by student nurses in presenting a clinical case in English and (2) assess selected psychological aspects, related to English speaking, which affect the student nurse's ability to present a clinical case in English. This is a first-of-its-kind study done amongst student nurses in the Indian context to identifying English language needs to strengthen OCP Skills.

  Methods Top

The needs analysis was done as a cross-sectional study using mixed method through observation followed by an exploratory interview and a tool assessment.

Participant eligibility

There are a set of guidelines to help identify the LEP learners. Wille[10] identifies socioenvironmental factors such as family constellation, parental education background and previous language exposure cause language disability. First, these guidelines were used to identify the participants. The student nurses pursuing Diploma course called Diploma in General Nursing and Midwifery or Bachelor's Degree who had studied in vernacular (Tamil) medium were considered eligible.

Second, an audit of the quality of schooling and educational level of parents was taken for confirmation. Further, every participant underwent a general English speaking proficiency test conducted using analytic oral language scoring rubric adapted by English as a Second Language (ESL) teacher's portfolio assessment group of Virgina. The rubric was found to be suitable as it was designed to assess ESL learners. It has six levels with clear descriptions of grading components such as speaking, fluency, structure, vocabulary and listening. Each component was given a score range of 1–6, with a maximum of 30 for all five components. Students falling into the overall score range of 6–12 with a characteristic display of single word utterance, with limited vocabulary and fragmented structures were considered LEP.

Ethical considerations

The investigator sought the ethical permission of a nursing college attached to a tertiary hospital in Chennai. Participation was voluntary, and information was collected after obtaining written consent from each respondent by assuring confidentiality throughout the data collection period.


Convenient sampling technique was used to select the sample. The sample comprised 23 internship student nurses pursing Diploma in Nursing from a selected School of Nursing at Chennai, Tamil Nadu, India, and who were screened and identified to be at the beginner level of language learning as mentioned above.

Descriptive background variables that identified the socioeconomical influence of language acquisition were elicited from the participants. The survey covered their home details, previous English learning exposure and the present English learning exposure.

Amongst the participants, 56% were in the age group of 21–23 years old with and all were females. Sixty per cent of the sample's fathers were semi-skilled workers, with an education up to middle school. Similarly, the majority of the sample's mothers, 87%, were semi-skilled workers, with 47% being educated up to middle school. All the participants spoke the regional language, Tamil at home and 47% had a maximum of only one member who could speak English with a basic fluency. The details on their previous learning experience showed that all the participants were from a rural type of schools with a maximum of 91% of them from vernacular medium (Tamil) of learning. All of them had spoken Tamil at school and a majority of 87% of them had learnt their school lessons through Tamil.

Considering the present place of study, all the participants have moved to English medium and were learning at an urban college. A maximum of 60% of participants admitted that all learning took place in English at college. All the participants have had English learning exposure of 30 h at the initial period of the programme (i.e., I year). Nearly 74% of them have had a bare minimum of <5 h assigned for English speaking practice and most of them did not seek any additional help to learn English, whereas those few who had sought had taken it from their English teachers at a weekly basis.

Needs analysis procedure

A mixed method of needs analysis was followed.

Method 1 – observation

The researcher had spent a month time to observe the clinical activities of the student nurses to know the choice of language and the person to whom they had used.

With the help of clinical mentor, a schedule was fixed on the basis of 2 days for each participant. Generally, the students were posted in wards during morning sessions, and so the researcher made herself available in the allotted unit as per the schedule and passively observed all their speaking activities without any interruptions. Before observation, the students were informed about the purpose and their consent was taken. The researcher created a simple language frequency checklist sheet with a table of three rows allotted for three language choices – English, Tamil and other. Each time when a language was used by the student, a bar line was drawn in the appropriate row with indications of communication partners (doctors, staff nurses, nursing mentors, other health professionals, patient and caregiver) mentioned in the corresponding column. At the end of the observation, the total number of bars drawn under each language was counted to calculate the most frequently used language by student nurses during their clinical posting.

It was observed that most of them 20 (87%) spoke mostly in English to the doctors and nursing clinical mentors as English was the preferred language for formal exchanges with a professional team, while little of English and largely of the regional language, Tamil were used by 13 (57%) to converse to other health personnel; on the other hand, Tamil was mostly used to converse with the patients and their caregivers, 21 (91%).

Evidently, it was found that English was more frequently used to speak with the health team superiors such as doctors, professional team and that a higher level of difficulty was faced, especially when they interacted with their nursing mentors to explain their cases in English.

Further, it was noticed during observation that many students who used English spoke with much difficulty, many pauses, insufficient vocabulary and erroneous sentences. On questioning whether they could communicate freely. They verbally admitted insufficiency and their lack of any training on clinical communication. Therefore, to identify the specific language difficulty of the LEP nursing students, an exploratory interview was conducted.

Method 2 – structured exploratory interview

The key purpose of the interview was to enable the participants to verbalise their English needs and identify a specific task that would need English language training. The questions were selected based on reviews that explored the learning experience of ESL nursing students but was modified to focus on identifying a task-related language difficulty.[11],[12] There were a totally six questions with two close-ended confirmation questions that lead to the asking of other questions. In order to avoid bias, the same predetermined questions were asked to all the participants. The interview was conducted at the end of their observation, the student nurse was taken to the clinical teaching room available in the ward area, and the interview was conducted individually. The questions were read out to them in the same order, and their responses were noted. The list of the questions is as given below,


  1. Do you use English for your clinical oral tasks?


  2. How frequently do they speak in English?

    Often/rarely/Not at all
  3. What are the various nursing oral tasks for which you use English?
  4. Which of the nursing oral tasks do you really perceive as a difficult clinical task to be performed in English?
  5. In the mentioned nursing task, with whom do you interact and for what purpose?
  6. Why do you consider that oral task as a difficulty?

All the participants admitted on using English for their clinical communication. Based on the interview questions, 3 and 4, 18 (75%) of the 24 student nurses perceived orally presenting a clinical case to be the most difficult English speaking task, while a few pointed to answering the doctors' doubts related to patients (4, 17%) to be difficult. With regard to perceived difficult in doing OCP (q.no. 6), various responses were received from the participants as quoted below;

…I have moved from Tamil medium, for the first time when my tutor asked me to present the case I sweated all over …She asked about the diagnosis and I couldn't understand what she was asking for…

…. When my teacher (clinical Instructor) asked me whether he (the patient) is the bread winner? I stood in silence not knowing what to say…, when it was my turn to present I begged my senior akka (sister) to write and give what need to say I just hold that paper and read it. I don't look at anyone.

…I know how to give good care but I don't know how to state the nursing intervention in good English. I have never learnt these in my classes…

… Often I plead to my mentor to allow me to use Tamil a little bit but she will usually say 'no' so I mostly stop in the middle not knowing how to say.

… Introducing patient details is not as simple as introducing a friend, I am always expected to say it quickly in brief. I wish I had learnt it in my English class.

The students felt that most of the time a poorly presented oral case had been underscored by their mentor. They expressed their anxiety in doing it and their fear of losing their marks. Hence, also the students mentioned that their present English course (furnished by Indian Nursing Council) provides very little of English preparation needed to nurture their clinical case presentation skills.

These substantiate the need for a systematic approach to quantify and understand the perceived language barriers in a clinical case in English to help them overcome the language difficulty.

Method 3 – quantitative assessment

Further, a quantitative assessment was carried out using a self-administered tool to screen the perceived level of language difficulty in orally presenting clinical cases.

Tool description

The assessment was done using a standardised tool to determine the perceived language difficulty and its associated psychological barriers of the nursing student with LEP in presenting clinical case language audit tool has been designed by the researcher in the earlier phase of her doctoral study.[13] The tool had been subjected to various standardising tested and published in a Scopus indexed journal.

The tool has a total of 53 items to quantitatively measure four major aspects – language difficulty (18 items), beliefs (18 items), anxiety (8 items) and self-esteem (9 items) related to OCP.

Validity and reliability of the tool

The tool was validated by experts from nursing, English and Psychology for its use of terminology and chances of ambiguity. Further, the tool had been subjected to interrater test for agreement amongst experts, using the statistical analysis of Cohen's Kappa. The analysis showed that all the 53 items had a significant value of 0.701 and had substantial agreement. Similarly, the intrarater test was conducted to bring out the consistency in answering the tool on repeated administration to the same raters. The comparison of test and retest showed that Pearson's correlation between the two test values was significant at 0.01. The questionnaire had dependable Cronbach's alpha reliability value = 0.791.


The tool has a five point rating scale of 5 for strongly agree, 4 for agree, 3 for not sure, 2 for disagree and 1 for strongly disagree for grading the level of perceived difficulty. The tool has 44 negative items and 9 positive items. The highest total score was 265 and the lowest score was 53. It was assumed that the higher the score more was the language difficulty.

  Results Top

A descriptive statistical analysis was done to understand the levels of difficulty in presenting the case in English. The collected data were analysed with IBM. IBM Corp. Released 2015. IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp was used to describe about the data descriptive statistic frequency analysis [Table 1], percentage analysis [Table 2] and item analysis for categorical variables [Annexure Table 1],[Annexure Table 2][Annexure Table 3][Annexure Table 4][Annexure Table 5].
Table 1: Overall level of English language and its associated psychological difficulty in presenting clinical cases

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Table 2: Percentage distribution of oral case presentation related perceived English language and its associated psychological difficulty of student nurses

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[Table 1] shows how the data obtained were used to determine frequencies, which are the basis of such descriptive measures as the mean, median and standard deviation were used for continuous variables. The overall score ranged between 153 and 227 [Table 1] which shows that the students experienced high-level difficulty in presenting the cases in English due to language deficit.

The total score allotted for the subdomain-Language difficulty [Table 2, i] as 90. The score range between 18 and 36 was treated as low level of difficulty, while the range 37–54 was considered as some and the range between 55 and 90 was considered as high. The item analysis revealed that almost all the aspects were perceived with significant difficulty. The highest perceived difficulty was related to 'inability to explain', 'inability to speak with grammar accuracy' and 'inability to correct grammar mistakes' with a mean value of 5.00 and 4.96 (maximum value 5.00), while 'explaining the case and speaking with good pronunciation' had been their next concern with 4.91 [[Annexure Table 1], item i, ii xv, xvi and xii].

The beliefs related to language learning in doing the specific task act as a motivational factor that determines their further learning of language to fulfil their language needs. Here, the beliefs are categorised as positive and negative ones. Positive beliefs are the desired ones, whereas the negative beliefs have detrimental effects. The subdomain, negative beliefs [Table 2, ii] had a maximum score of 45, with a range of 9–18 for low, 19–27 for some and 28–45 for high. The item analysis shows that all presumed English to be 'a difficult language to learn'(mean value4.96) (maximum value 5.00) and felt 'inadequate to use English for CP' (mean value4.87) [[Annexure Table 3], item i, ii]. However, on the whole their positive beliefs overtone their negatives with a higher mean value of 5, assigned for positive belief items, 'speaking English would help them with their task' and 'importance to learn English' [[Annexure Table 2], item iii, ix].

The total scores allotted for anxiety related to OCP were 40, with a range of 8–16 for low, 17–24 for moderate and 25–40 for high level. It covered anxiety issues such as worries, nervousness due to 'being criticised by others' and 'fear of being ridiculed' that student nurses experience in doing the CP in English. The assessment showed that anxiety issues related to their performance were rated as high by the majority, 87% [Table 2, iv] of the participants. Of all the items, 'fear of being criticised' by others was with the least mean value of 4.22 which could be attributed to the homogeneity of the group's language ability [[Annexure Table 4], item v].

The statements that analysed the influence of language difficulty on their self-esteem [Table 2, v] had a total score of 45, with a range of 9–18 for low, 19–27 for moderate and 28–45 for a high level of influence of language difficulty on their self-esteem. The analysis shows that all of them experienced dissatisfaction related to their performance due to their language difficulty, and they strongly felt that their clinical task was being underestimated (mean value – 4.96). However, the confidence in coping being very strong with a mean score of 1.00, the students have expressed a positive outlook [[Annexure Table 5], item ii, viii].

  Discussion Top

With English being considered a universal language, we need adequate provision in the curriculum to meet the language proficiency needs of nursing students. The present study looks at the English language communicative challenges faced by student nurses while orally presenting clinical cases. It shows that all the student nurses were dissatisfied with their language ability to perform OCP. This finding is in line with the study done by Jamshidi et al.[14] The participants in the study included 17 nursing students in the 2nd, 3rd and 4th year of study and aged 20–23 years from Shiraz University of Medical Sciences, Shiraz, Iran. The findings showed that the Iranian nursing graduates faced many challenges in the clinical learning environment due to lack of the communication skills necessary for effective communication in the clinical environment. Billings et al.[15] identified that the language problem of ESL student nurses overseas points to learning hundreds of strange, complicated hospital expressions in making out a chart or writing a hospital report to be a challenge even if they had been honour students in their English classes at home.

Many ESL learners regard foreign language learning as an anxiety-provoking experience which affects their language performance in one way or another. Apprehension and nervousness are commonly expressed by a considerable number of students with low proficiency, while speaking and writing in English.[9] In the present study, the anxiety of the students in presenting the case included 'Fear of doing CP in English' which had a mean score of 4.96, 'Worry about doing CP in English' which had a mean score of 4.91 and 'Fear of being ridiculed by others for poor English' which had a mean score of 4.78.

Stressors for graduate nurses included communicating with interns, residents and physicians.[16] A study on the perception of student nurses from non-English speaking background has identified that clinical placement and experience to be highly challenging and anxiety creating environment due to their poor verbal skills.[17] The learning experience of ESL student nurses had exposed feeling of shame to seek help from faculty and peers due to lack of understanding of nursing concepts.[18]

Self-esteem also can have a marked effect on academic performance. Unlike learning the mother tongue, the second language acquisition does not happen with a smooth transition, everyone tries to get through the language acquisition with many obstacles. These feelings are considered to exert a potentially negative and detrimental effect on communication in the target language. These negative perceptions results in low self-esteem. Students' judgements of themselves are likely to affect the kind of strategies they use for learning.

The feeling of an inferiority complex is mentioned by the Iranian Nursing students participating in the study of Jamshidi et al.[14] Low self-esteem can lessen a student's desire to learn, ability to focus and her willingness to take risks. Positive self-esteem, on the other hand, is one of the building blocks of school success; it provides a firm foundation for learning.[19]

Past failures in the foreign language (e.g., low exam grades) are often the main reason for students' lack of motivation and low self-esteem.[20] Extreme level of low self-esteem may influence the learners to drop out of the learning programme and even to commit suicide.[21]

Soureshjani and Naseri[22] states that a positive self-esteem gives the confidence to correct mistakes and prepares them to face the subsequent events in a learning, whereas a negative self-esteem may create a failure symbol within and hinder them from progress by magnifying their fear of being ridiculed.

The study has a few limitations. As the survey has been done at a selected hospital, the study results are specific and not generalised. The sample size was small due to the unique characteristics of the sample that could only comprise a minority in every class and so also as the research wanted uniform baseline data.

  Conclusion Top

Literature identifies OCP as an understudied area in teaching curricula.[23] Amongst the studies which exclusively focus on OCP skills, most of them focus on improving 'what to say', i.e., content-based OCP strategy, rather than 'how to say', i.e., language-based OCP strategy. The presumed reason for this could be that these OCP teaching modules had mostly been developed in Western context amongst native English speakers; therefore, the need for English teaching in such context may not have been felt. However, honing the English language of nursing graduates for OCP is the need of the hour in our Indian context. Identifying the right task that needs strengthening of English is pivotal for any language training. Here, the focus of this needs analysis study is to furnish information on the language challenges faced in presenting clinical cases in English and support information on linguistic skills that need to be focussed while developing English training modules for OCP. Their views on the genre of OCP confirm that it is teachable. Studies by applied linguists, Helán[2] and Gopikrishna[24] on analyses moves and linguistic and structural features of OCP have identified essential basic nuances that could serve as guidelines in framing English for Specific Purposes lessons on OCP.

Similarly, sociolinguists, Lysanets et al.,[25] on analysing the medical discourse for the lexico-grammatical structure have identified medical reports to possess the distinctive quality of communicative with specific lexical units and grammatical structures: past simple tense, personal pronouns and modal verbs. The research has also detected the occasional use of the present perfect, present simple and passive voice which also serves particular communicative purposes of medical case reports. These suggest the key grammar areas that need to be focussed. An authenticated OCP English language teaching can allow these language deprived student nurses to raise their level of achievement and attain a satisfaction in their clinical performance.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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[PUBMED]  [Full text]  
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