Supporting Reconnecting Immigrant Families with English Language Learners in Rural Schools: An Exploratory Study of Filipino Arrivals to Alberta

Volume 2(2): 2018

M. GREGORY TWEEDIE, University of Calgary

ANJA DRESSLER, Calgary Board of Education

CORA-LEAH SCHMITT, Christ the Redeemer Catholic Schools

ABSTRACT. Immigration in Canada has traditionally been associated with urban areas, but rural communities are host to an increasing number of new immigrants. As students of these immigrant families arrive in rural schools, there is increasing pressure on rural school divisions to meet the needs of a diverse student population of English Language Learners (ELLs), though often with limited previous experience with such students. In many of these situations, the nature of the workforce has led to family separation during the immigration process, with subsequent reunification in Canada. Newly-arrived immigrant students are thus having to develop academic English language proficiency as well as adjust to the dynamics of family reunification. This article recounts exploratory qualitative research on how Filipino secondary school immigrant students in Alberta, who are reconnecting with parents, acculturate and develop a sense of belonging when language and content acquisition, social-emotional, and acculturation supports are in place. Data is drawn from interviews with immigrant families from the Philippines and from teachers’ written responses to reflection questions on their growth as educators of ELLs. Although the needs of reconnecting immigrant families are multifaceted and complex, the findings from this study suggest a supportive role can be played by schools in assisting such families both through enhanced coordination with the immigrant community, and direct and explicit teacher training in pedagogical strategies for teachers of ELLs.

RÉSUMÉ. L’immigration au Canada est traditionnellement associée aux zones urbaines, toutefois les communautés rurales accueillent un nombre grandissant de nouveaux immigrants. L’arrivée de ces familles immigrantes dans les écoles rurales augmente la pression sur les instances scolaires quant à la nécessité de répondre aux besoins de diverses populations d’apprenants de l’anglais langue seconde (English Language Learners), alors que leurs expériences précédentes avec ces élèves sont souvent limitées. Dans bon nombre de situations, la famille a dû être victime d’une séparation pendant le processus d’immigration, suivi d’une réunification ultérieure au Canada. Les nouveaux élèves immigrants doivent donc développer leur compétence en anglais tout en s’ajustant à la dynamique qu’entraine la réunification familiale. Cet article décrit une recherche qualitative exploratoire sur la façon dont les Philippins immigrants à l’école secondaire en Alberta, renouant avec leurs parents, s’acculturent et développent un sentiment d’appartenance lorsque les appuis d’acquisition langagière et de contenus, sociaux et émotionnels ainsi que d’acculturation sont mis en place. Les données sont tirées d’entrevues réalisées avec des familles philippines immigrantes ainsi que des réponses écrites d’enseignants de l’anglais langue seconde sur des questions réflexives quant à leur développement professionnel auprès de cette clientèle. Bien que les besoins pour aider les familles immigrantes soient multidimensionnels et complexes, les résultats de cette recherche suggèrent la nécessité d’un rôle de soutien pouvant être tenu par l’école en assurant une meilleure coordination avec la communauté immigrante, mais aussi par la formation directe et indirecte des enseignantes de l’anglais langue seconde sur les stratégies pédagogiques qui leur sont propres.

Keywords: family reunification; immigration; rural immigration; English Language Learners; English as a Second Language (ESL); language proficiency benchmarks; rural education.

Transnational Family Reconnection, English Language Learners, and Rural Canada

One effect of globalization is the vast movement of people across international borders with hopes for an improved standard of living, and Canada is host to a large number of new immigrants annually (OECD, 2018). While immigration in Canada is typically associated with urban areas (IRCC, 2005), the population of immigrants in rural areas is also increasing, facilitated through various municipal and provincial schemes (CIC News, 2016; O’Doherty, Katem, & Turner, 2017). In Alberta in particular, an Immigrant Nominee Program (AINP) allows skilled workers, along with their families, to make application for permanent residency (Government of Alberta, 2017), and several large Alberta employers with operations in rural areas actively recruit employees from abroad and support them and their families in seeking permanent residency (e.g., see Peterson, 2016). The result is that rural areas in Alberta are host to an increasing number of new immigrants.

These efforts to support families in transitioning from temporary worker to permanent resident status are certainly laudable, but the reality remains that extended family separation is often part of the migration process. Families facing limited economic prospects in their home country may opt for one parent to seek employment abroad while spouse and children remain behind; in some cases, both parents leave for employment while children are cared for by relatives. The separation period can be lengthy, with one study finding a median timeframe of eight years until reunification (Farrales & Pratt, 2012). The term ‘transnational family’ is often used to refer to “sustained ties of family members and kinship networks across the borders of multiple nation states” (McCarthy & Edwards, 2011, p. 188). Implicit in the term is the understanding that migration is not always a linear process, but frequently involves evolving relationships among family members spread across multiple borders. That Family relationships are enacted across international boundaries is in keeping with a larger trend in the modern world, where interactions and communications, as traditionally defined, appear increasingly fluid and flexible (Hawkins & Mori, 2018). Separation and reconnection of transnational families often contributes to considerable stress (Falicov, 2007; Suårez-Orozco, Todorova & Louie, 2002), and research suggests family separation during the immigration process impacts negatively on children’s academic success (Gindling & Poggio, 2009; McKenzie & Rapoport, 2011). The reality of family separation during the immigration process is an important factor for schools to take into account when considering how to best support newcomer students.

As students of these transnational families arrive in rural Alberta schools, there is increasing pressure on rural school divisions to meet the needs of a diverse student population of English Language Learners (ELL), though often with limited previous experience with such students, given the historical trend of urban immigration. Teachers in Alberta have access to a variety of resources to guide instruction and support the academic English language learning of students. These include documents such as the English as a Second Language Guide to Implementation (Alberta Education, 2007), materials included in broader discussions of instruction for diverse learners (e.g., Alberta Education, 2010), and the ESL Benchmarks (Government of Alberta, 2018a). It is, however, left to individual school divisions to determine how and when this information is disseminated to teachers. In many instances, professional learning sessions for teachers support the understanding of these documents, but to date, little research is available recounting their effectiveness in rural contexts. Additionally, much of the information in the documents focuses on language acquisition, and although language and culture are “inextricably bound” (Alberta Education, 2010, p. 144), strategies and assessment of the acculturation process are not explicitly identified in these documents.

This exploratory study will consider how the settlement process of such transnational reunifying families is affected when explicit support is offered for students’ academic language and content acquisition and families’ social-emotional needs. We examine the efforts of one rural school jurisdiction in its attempts to support students and their families during the challenges of reunification in settlement.

Literature Review

This section provides a review of the literature on students in families experiencing immigration and reconnection, presenting four different aspects of the transnational family and student experience: immigration as a whole; family separation and immigration; academic issues in reconnection scenarios; and culturally responsive pedagogies in schools. While literature on transnational families in general is referenced, readers will note a particular emphasis in this review on the Philippines, since, as will be discussed later, Filipino nationals make up the bulk of the transnational workforce in the school jurisdiction under study. Sources consulted range from peer-reviewed journal articles to news reports. The section concludes by stating the research question that guided this study.

Immigration in World Context

One impact of globalization is the movement of people across borders in search of a higher quality of life. As a world leader in both numbers of migrants received and in their share of the population percentage (OECD, 2018), Canada receives workers into a variety of jobs and careers, although mainly to urban centers (IRCC, 2005). Immigration to the Canadian province of Alberta—the site of this study—continues to increase. Between 2011 and 2016, over 207,000 people immigrated to Alberta (Simons, 2017), with only 15% of Alberta immigrants settling in rural areas (CIC News, 2016). However, numbers of immigrants to rural Alberta are on the rise.

Various municipal and provincial schemes have facilitated this increase (CIC News, 2016; O’Doherty et al., 2017), as well as the initiatives of several large Alberta employers for international workforce recruitment, often with the support of the AINP (Government of Alberta, 2017). Many immigrants have difficulty qualifying to bring their family to Canada after being separated, making employer support especially valuable in helping such workers realize settlement in Canada (Bragg & Wong, 2016). One particular employer in a rural Alberta town utilizes Canada’s Temporary Foreign Worker Program to recruit qualified employees and then works with them to quickly apply for Permanent Residence and bring their family to Canada (Immigrant Services Calgary, 2014; Peterson, 2016). These efforts have led to an influx of immigrants into areas encompassed by the school jurisdiction in this present study.

Certain countries provide more workers for Canada than others, and this is reflected in the workforce composition within this study’s rural school district, where the bulk of the international labour force comes from the Philippines. It is not uncommon for a significant percentage of the Filipino population to seek employment abroad, with over one-tenth of Filipinos reported to be doing so (Madianou & Miller, 2011), creating a “culture of migration” (Falicov, 2007, p. 162). While traditionally seen as the father’s responsibility to move abroad to work and provide for the family, in recent years, mothers have also started to fill this role (Madianou & Miller, 2011). In some situations, families choose to leave the Philippines permanently and reside elsewhere, such as in Canada.

Family Separation and Immigration

As noted above, family separation is often part of the immigration process. One parent may arrive on an employment contract, with spouse and children arriving later, with the aim of the whole family experiencing a better quality of life (Jimenez, 2015). In other cases, a child may accompany a parent upon initial entry, with a spouse joining the family later. In either situation, the process of family separation and reunification often encompasses multiple years (Farrales & Pratt, 2012). These separations may be emotionally difficult, and the longer the separation period, the more the lasting effects on the family (Black, 2005; Suårez-Orozco, Bang & Kim, 2011). This migration process of transnational families has been associated with significant impacts on mental health for both parents and children (Falicov, 2007).

While separated, families seek communication and closeness using technology as an effort to bridge the physical and emotional gap. Mothers and fathers often devote significant resources of time and money to parenting from afar via the internet and mobile phones (Black, 2005; Jimenez, 2015; Parreñas, 2005), ranging from scheduled weekly phone calls or texts to money and gifts sent on a regular basis. Throughout the history of transnational families in the Philippines, the decreasing costs of mobile phones and associated services have helped families stay closer during separation, something the government of the Philippines hopes will help alleviate some of the social cost of separation (Madianou & Miller, 2011). However, a gender gap exists in transnational parenting. Mothers can end up “perform[ing] all of the parenting and emotional work from a distance” (Madianou & Miller, 2011, p. 460). Even when the father is at home with the children, the mother often does more nurturing from afar than her husband, who is physically present (Parreñas, 2005). Although technology can assist (virtual) communication during family separation, parents still suffer negative effects from the (actual) separation and reunification characteristic of transnational families.

Separation and Reunification: Challenges for Parents

Parents in transnational families face various issues related to separation from children and spouse to work abroad and then subsequently reuniting. While separated, the parent abroad is torn between their work–the reason they left–and being connected to family back home (Hertzsprung, 2004). If it is the mother who leaves to find work, she and her family may face the criticism that mothers should be physically present to care for their children (Hertzsprung, 2004). Once the family has been reunited abroad, parents may find that childcare is expensive and hard to find compared to the availability of extended-family childcare back home. In many cultural contexts, family means more than just the nuclear family, and so adjustments to the lost familial support network can be taxing on both mothers and fathers upon settlement in their new country (Falicov, 2007; Jimenez, 2015).

Reuniting as a family poses many challenges as well. Stepping back into the parenting role after years of absence is often delicate and awkward, as cultural differences between their previous and new context get in the way of sleeping arrangements, food, discipline, and parenting styles (Hertzsprung, 2004). The ability of mothers and fathers to once again assert parental authority over children they had been separated from for years is frequently difficult (Suårez-Orozco et al., 2011). Children of transnational families also face struggles during the migration process.

Separation and Reunification: Challenges for Children

Children and youth of transnational families encounter various challenges indicative of their circumstances. When one or both parents leave to find employment in a new country, children can feel abandoned, and attachment trauma due to migration, separation, and reunification is not uncommon (Jimenez, 2015). In one study, the length of separation, especially from the mother, correlated with rates of anxiety and depression in adolescents (Suårez-Orozco et al., 2011). Even upon being reunited, children may continue to struggle. Parents who had left can sometimes feel like strangers and the reunion is often problematic (Jimenez, 2015; Suårez-Orozco et al., 2011). Children are not always prepared and willing to have their parents once again fill parental roles in the new country (Suårez-Orozco et al., 2002). Children miss family and friends left behind when they go to reunite with parent(s), especially when those they left behind were surrogate primary caregivers in lieu of the parent(s) during the time apart (Black, 2005). The separation experienced by children during the immigration process is thus twofold: first from their parents who leave to work abroad, and then later from their primary caregivers when children migrate to join parents in the new country (Suårez-Orozco et al., 2002). These emotional struggles coupled with academic issues paint a fuller picture of the challenges that children of transnational families face.

Academic Challenges

Education is an important aspect of future success for all children new to Canada and is of particular cultural importance to Filipinos. Education itself is poorly funded in Philippines, but it is still highly valued (Hertzsprung, 2004). As a priority within families, education is viewed as the most valuable gift parents can give their children (Jimenez, 2015). In transnational families, parents abroad will often stipulate that pay remittances sent home go toward a better quality of education for their children (Dreby & Stutz, 2012).

Many parents in transnational families make education a priority and perhaps even migrated partly because of it; however, students from these families often suffer negative educational outcomes (Black, 2005). Overall, separation from parents has negative impacts on education in forms of depression, education gap, and higher dropout rates (Gindling & Poggio, 2009, 2012; McKenzie & Rapoport, 2011). Education gaps and dropout rates are higher compared to students native to the country and students in families who did not migrate (Gindling & Poggio, 2009). Also, the older a child at time of migration, the more troubles encountered in school; this is true also if separation was from the mother (Gindling & Poggio, 2012). The simultaneous experiences of being a newcomer and being separated from parents and extended family contribute to negative school performance (Gindling & Poggio, 2012; Patel, Clarke, Eltareb, Macciomei, & Wickham, 2016). With transnational Filipino children in particular, placement in Canadian ESL classes has been associated with lower educational success, in part due to non-credit programming, the lack of credits assigned and possible mismatch between the level of the content and the level of the students (Farrales & Pratt, 2012). Overall, the literature suggests experiencing separation from and reunification with family members may negatively impact the schooling of children of transnational families.

Strategies that Promote Academic Success

Research points to some factors that can impact the educational success of students in transnational families both positively or negatively. As noted above, mismatched ESL placement of transnational Filipino students is one factor (Farrales & Pratt, 2012). Trauma is another factor, any kind of which negatively impacts students’ abilities at school. Herman (1997) characterizes traumatic events as situations that “overwhelm the ordinary systems of care that give people a sense of control, connection, and meaning” (p. 33), and knowledge of trauma-informed teaching practice is increasingly important for Canadian teachers given the realities of global events (Tweedie et al, 2017). Efforts to combat trauma, such as trauma from separating from loved ones multiple times, should include strong teacher-student relationships, classroom exercises to build self-regulation, and a focus on students’ strengths (Brunzell, Stokes & Waters, 2016a, 2016b).

Many elements of the school life of a student with a transnational background can be used to promote academic success. Factors leading to success in school for migrant students include feelings of appreciation from teachers and peers, teachers having high educational expectations of migrant students, and migrant families highly valuing education (Hoti, Heinzmann, Müller & Buholzer, 2017). These students succeed when they perceive that their teachers truly care about them, because students need to feel safe and cared for in order to learn (Dallavis, 2014). In this vein, creating a positive relationship between the family and the school is crucial to success for students new to the country to bridge the gap between home and school cultures (Szente, Hoot & Taylor, 2006; Tran & Hodgson, 2015). Course offerings also affect how transnational students feel about school. Music education in particular can be very beneficial as it transcends the language barrier through supporting students emotionally, socially, and cognitively (Skidmore, 2016). Finally, students with access to a community of their own home culture have better academic success in school, regardless of any other factors inside the physical school building (Wilkinson, 2002). Through this study we endeavour to explore how these, and other factors might promote educational success for transnational students in a rural context, through supporting both them and their families as they reconnect after being separated in the immigration process.

Research Question

Among the literature surveyed above are persistent calls for further research addressing the issues faced by transnational families. Black (2005), for example, called for studies looking at education programs for parents and other family supports. Other studies, such as Suárez-Orozco et al. (2011) ask researchers to further consider academic performance of children in transnational families. This study contributes to these gaps by exploring the following research question: How is the acculturation process of rural immigrant students affected when the language and content acquisition of students and the social-emotional needs of reconnecting immigrant families are explicitly supported?


The site of this exploratory qualitative study is a school district in Alberta, comprised of 22 schools, serving approximately 3,000 students and over 500 teachers. The school district encompasses areas classified either as rural or small population centres (Statistics Canada, 2017).

After permission from an institutional ethics body and corresponding approvals at district and school levels, potential participants were invited to take part either in semi-structured interviews exploring experiences of the immigration and reconnection process (students and their parents) or written reflections on experiences at supporting ELLs (teachers), as described below. After the interviews were transcribed, each of the three researchers worked individually to read through the transcripts and the teachers’ reflections, seeking to gain a holistic perspective. As the study’s objective was exploratory in nature, researchers attempted, as far as possible, to avoid allowing preconceived perceptions to be read into the data. Researchers then worked individually to hand-code themes; in subsequent research team meetings, these codes were subjected to further analysis to reach team interpretive consensus as interrelated themes were synthesized. Merriam’s (2009) constant comparative method informed the process of differentiating data sets between levels of conceptualization.

Given the circumstances of these newcomer families, every effort was made in the recruitment and data collection process to align with principles of fairness and equity for vulnerable research populations (Tri-Council, 2014). To keep participant recruitment confidential from the school jurisdiction and its schools, a third party (a local immigration agency) contacted families in their network who met the study criteria to explain the study and invite participation. After this initial step, the agency facilitated contact between the research assistant and interested families, in order to remove the possibility that particular schools or the school jurisdiction might be aware of who did/did not participate in the study. Two interviews were conducted with each family: first in the initial quarter of the academic year, and then again in the final quarter. At the interviews, the research assistant made explicit the voluntary nature of participation, and participants were given the option of being interviewed individually or together with their spouse or siblings if they so wished. Pseudonyms were chosen by participants at the initial interview, and any identifying features revealed during the interview (family names, school names, etc.) were removed during the process of transcription.

Teacher Reflections

Teachers attending professional development workshops conducted by the school district were invited to complete written reflections in response to prompts exploring understanding of the second language acquisition process as experienced by ELLs in their classrooms; teacher confidence levels with respect to teaching ELLs; and use of the Alberta Education ESL Benchmarks (see Appendix). To preserve anonymity, teachers who wished to participate were instructed to complete and return the reflections anonymously at their leisure, with no identifying features included in the response. Teachers were asked to mark their reflection with a symbol of their choosing (e.g.,* [asterisk]), which would then be used to match respondents in subsequent reflections. In total, six content area teachers, spanning various subject areas in grades 7 to 12, all with ELL students in their classes, completed reflections in the initial months of the school year. A second round of teacher reflections was completed by the same teachers in the final quarter of the academic year.

Family Interviews

A semi-structured interview with families was utilized to facilitate the use of planned questions based on the research question, but also to allow the latitude to explore other lines of inquiry that arose during the discussion. The questions were constructed following Wengraf’s (2001) model of underpinning Interview Questions (IQs) with Central Research Question(s) (CRQs) and Theory Questions (TQs); and were informed by surveyed research on the dynamics of family separation and reunification during migration, as described previously in the literature review section. In the second round of interviews, questions surrounding the family workshops and their effectiveness were added. Interviews began with a brief demographic survey regarding their immigration background (see Appendix).

Seven families participated in interviews: twelve parents (six female; six male), 13 children (six female; seven male), and one parental figure (female, older sister). All participant families were recent immigrants: One parent came first to Canada, and then after obtaining permanent residence, was able to bring their children and spouse to the rural area of the study. The country of origin for all participants was the Philippines; however, some participants had also lived in intermediary countries prior to arrival in Canada. Some families remained partially separated–for example, one parent remained in the Philippines–during the period of the study. Table 1 details the families within the study; all names are pseudonyms self-chosen by participants.



Parent(s) /

Parental figures

Students Interviews / Workshops attended
Ford Dustin (male; father) Rob (male; sr. high)

Bob (male; sr. high)

All family members were interviewed twice; attended 3 family workshops
Smith Sam (female; mother)

Jun Jun (male; father)

Gel (female; jr. high) All family members were interviewed once; did not attend family workshops
Applebaum Criselda (female; mother)

Sarah (female; elder sister of students)

Not included as participants: two teenage sons Parents/parental figures interviewed twice; attended 1 family workshop
Brown Ester (female; mother)

Julius (male; father)

Michelle (female; sr. high)

Candice (female; sr. high)

Jeyden (male; jr. high)

All family members interviewed twice; attended 1 family workshop
Bautista Michelle (female; mother)

Michael (male; father)

Angel (female; jr high) All family members interviewed twice; did not attend family workshops
Schumann Lyn (female; mother)

Tony (male; father)

Lisa (female; sr. high)

Jake (male; jr. high)

All family members interviewed twice; attended 4 family workshops.
Torres Hannah (female; mother)

Mike (male; father)

Ashley (female; jr. high) All family members interviewed twice; attended 3 family workshops.

Table 1: Demographic Information of Family Participants (Pseudonyms)

In qualitative research, trustworthiness is said to refer to the veracity of findings “based on maximum opportunity to hear participants’ voices in a particular context” (Hays & Singh, 2012, p. 192). The research team undertook a number of measures to strengthen trustworthiness as defined in this way. Throughout the study, the researchers endeavored to exercise reflexivity (Denzin & Lincoln, 2005; Merriam, 2009) through ongoing reflection on biases and assumptions via discussions with each other and colleagues. The researchers were also aware of a position of power imbalance with participants, and thus undertook to redress this in a number of ways with respect to data collection. Interviews opened with a thorough discussion of the consent form and its implications, with the interviewer making clear that participants were free to avoid answering any question with which they were uncomfortable, and that they were able to stop the interview at any time, or even withdraw from the study entirely. In several instances during interviews, matters of a sensitive nature arose that were pertinent to the study; however, the research team only committed to pursue further questions with a clear indication to do so from the interviewees. The research team also stressed to interviewees the study’s commitment to confidentiality, and therefore explained the data anonymization process to reduce the possibility that participants would only share what they perceived the interviewer wanted to hear. The research team deemed such measures to play an important part in enabling the voices of participants to be heard.


Findings, as guided by the research question, are presented according to data type.

Interviews: Families

As described previously, researchers working individually identified overarching themes from the data. Upon subsequent group discussion, these initial themes were collapsed into four (Challenges, Perceptions, Changing relationships, Strategies), with 27 identified sub-themes. Table 2 presents selected examples with extracts.

A number of themes grouped under Challenges included the loss of support networks of family and friends (parents linked this loss of support with difficulties in parenting). For students, there was an expressed lack of confidence in both understanding and speaking English in the classroom, along with adjustments to a new school system and school subjects. Particularly emphasized in the second round of interviews were reflections on the economic realities of Canadian life. For some families, a half-year from the first interview, spouses had still not yet managed to secure employment, and so any savings brought with them rapidly depleted as they navigated the high cost of living in Canada. In families where both parents worked, a common theme was the challenge of finding time together as a family, especially when parents’ jobs required shift work. In relation to this, one participant expressed the irony that bringing parents and children together had been a primary reason for whole-family immigration to Canada.

Theme Sub-themes Selected Extract [pre- or post-intervention interview]
Challenges Canada
Parent 1: The hardest things [about being a parent in Canada] I know that because it’s different, the children in here and back home in the Philippines you can discipline there. . .physically, but here you are not allowed to. [Pre-]



Parent 2: You don’t have time to talk to our native language even for a while, so it makes harder even for a little while maybe. That maybe it helps that there is a Filipino classmates for them to talk to especially during their early months that they are in Canada. [Pre-]
Strategies For success


Student 1: Sometimes my classmates, Pilipino classmates, they teach me how to do it. [Post-]
Perceptions Canada


Student 2: When I came here, when I’m speaking English, I feel like nervous to talk to everyone, but now I like have confidence, but sometimes not. [Post-]

Table 2: Interview Themes/Sub-themes – Selected Examples

Included among the theme labelled Perceptions were sub-themes such as (perceptions of) cultural differences; school in Canada relative to the home country; and the settlement process. Striking in this overarching theme of Perceptions was the positive framing of participants’ experiences with Canada in general, and the school system/school in particular, a theme sustained across data from both first and second round of interviews. Among the benefits of living in Canada expressed by the participants were secondary schools without tuition fees, free access to healthcare, and the relatively safe environment.

The theme of Changing relationships served to capture some of the dynamics at play as families reunited after separation caused by the migration process. Analysis of interview data revealed that responses from parent participants differed significantly from student responses. Student participants were more likely to note the positive features of family reunification. For example, one student, (pseudonym: Angel) described her relationship with her father when he was employed in a different country as “kind of awkward,” but here in Canada, she said, “I’m so happy because we are together now.” Three siblings (student participants) positively described “a lot of bonding” among their now reunited family.

Parent participants expressed gratitude at being reunited, but in contrast also remarked on challenges encountered through changing relationships. One mother referred to such shifting dynamics in Canada: “They [her children] have more changes outside [the home] that I don’t know. . .some things I don’t understand sometimes.” Parents from two different families expressed unease at how expectations concerning norms for child discipline differed in Canada. As one father explained the contrast, “In our country we can do what we want to discipline our kids. Even if we are using our hands, we can do it in our country.”

The theme Strategies evidenced the efficacy of social networks. Here, the importance of the existing Filipino community in providing practical support to newcomer families, both to parents and students, emerged as a key component in navigating the challenges of the settlement process. Parents described social networks as instrumental in undergirding emotional support and finding employment or other practical assistance, and students shared how Filipino classmates helped bridge the knowledge gap with respect to school expectations in general, and better understanding assigned work in particular.

Written Reflections: Teachers

A number of themes emerged from analysis of teachers’ written responses to the reflection prompts. Table 3 below lists these commonalities with accompanying interview extracts, followed by a discussion of these themes.

Theme Selected Extract [pre- or post-intervention reflections]
Valuable role of direct and explicit instruction for teachers My understanding of how students acquire a second language has increased as a result of the SIOP training; however, I now realize how little I understood in the first place! [Post-]

The sessions with [the professional development instructor] were beneficial in helping me to be more aware of the opportunities that arise during each lesson. [Post-]

I feel that my current understanding of second language acquisition has grown far more than I could have expected. I feel I have an excellent grasp on language acquisition. In this, I better understand how language can be learned, but also how to support learners who are struggling. [Post-]

Teachers’ interactions with the ESL Benchmarks I try to use the benchmarks to inform my teaching, but not as regularly as I should. [Post-]

I have attempted to use points from the benchmarks to inform my instruction and certainly I can see the potential for their use, but I have not been successful in using them on a consistent basis. [Pre-]

The tracking of these items can, at times, detract me from supporting students as I get lost in all the bullet points. As much as I now understand the necessity of each point to language acquisition, I also feel that there is too much in there for monitoring sake. [Post-]

My current relationship with the benchmarks is simply to do them for the sake of getting them done. . . I don’t have a meaningful connection between those numbers and any specific or effective classroom practices for students who are stalled or struggling in their language acquisition. [Pre-]

The document is too large, and the time it would take to assess a child on all of those points is huge. With the large number of ELL students I have, it is actually difficult to make use of all of the information provided in that document. The amount of information is actually also overwhelming. I still do not refer to these documents to inform my instruction, rather, I refer to students writing, speaking, and ability to comprehend texts. [Post-]

Professional learning as a tool to overcome challenges After explicitly trying some techniques [from the professional learning sessions] geared towards helping ELL students learn, I am more confident in my ability to provide the appropriate supports for my students. Having worked with more ELL students I am also more confident in understanding where they are at and what they could benefit from. I am confident that given more time in a day to prepare, I could create a class that has multiple activities and strategies implemented to meet the needs of a variety of ELL students. It will take me a few years to integrate all that I have learned, but my ability to understand and meet the needs of my students has already begun to improve. [Post-]

The strategies provided [in professional learning sessions] have been extremely useful, especially the focus on vocabulary development. I spent a lot of time focusing on vocabulary strategies with students so that they could use them in all classes. The growth seen with the student’s ability to write and read was amazing after only a few lessons. [Post-]

The additional resources that we were provided with were (and continue to be) quite helpful in building my confidence in the field of meeting the needs of the ELL students. [Post-]

Table 3: Teacher Reflection Themes – Selected Examples

Firstly, the importance of direct and explicit instruction for teachers was highlighted, both in terms of enhancing awareness of the second language acquisition process, and in increasing recognition of how the ESL Benchmarks might be better utilized. As one participant reflected in a post-training response: “I feel that my current understanding of second language acquisition has grown far more than I could have expected.” With respect to the Benchmarks, direct and explicit instruction were seen to be of particular benefit in helping participants develop awareness of what they thought they knew, but actually did not. One teacher, for example, expressed a strong sense of self-efficacy in the first reflection, self-describing as “very confident with the Alberta ESL Benchmarks. I have a strong working knowledge of all areas and what is entailed in each level of learning.” Post-professional development session, however, the same participant’s reflections contrasted sharply with their earlier self-confidence: “Although I felt I had a strong understanding of it before starting, I realized quickly that my understanding was more basic. The training in SIOP [Sheltered Instruction Observation Protocol] and other strategies have supported me in understanding the Benchmarks much more, especially in regard to informing instruction.”

Improved knowledge of the Benchmarks notwithstanding, two-thirds of participants expressed doubts surrounding the document’s application. Of six participants, two gave positive assessments of the Benchmarks in their post-reflection: One teacher described them as “useful to helping students”, and another remarked on the Benchmarks’ role in providing “a better sense of the steps required in the development of English proficiency.” Four of six teachers, however, were less positive. One post-reflection indicated the participant felt “pretty much the same” about the Benchmarks after the training sessions, expressing the view that “the document is too large,” making its application for assessment to each ELL impractical. This view was echoed by another participant in a pre-training reflection, who described the Benchmarks as “far too unwieldy to be practical or meaningful.” This same participant’s post-training reflection did not result in a more positive view, but equated use of the Benchmarks with “using a screwdriver to pound in a nail. . .I can do it, but it’s not the right tool for the job. . . [there are] way too many categories to assess any of them meaningfully.”

A commonly expressed theme was an understanding gap in how the Benchmarks might apprise classroom instructional practices, one of the stated purposes envisioned by its creators (Government of Alberta, 2018b). As one teacher put it, “As a tool to inform instruction, I do not refer to the [Benchmarks] document at all, simply the final Benchmark number.” Another participant expressed a similar view: “As a general tool I am confident in using the [Benchmarks‘] level to gauge where a student is and what supports are required in the classroom,” but went on to add that, “Aside from using the overall [number] as a tool to see what the general understanding of a student/class is, I have not explicitly used the Benchmarks to inform my instruction.” Given the ambiguities expressed by teachers in this study, the use and application of the Benchmarks by teachers presents intriguing possibilities for further research.

Finally, participants’ written responses highlighted the role of professional development sessions in helping to overcome challenges associated with instruction of ELLs within mainstream classrooms. Cited challenges included a lack of time to prepare specific strategies for ELLs in the midst of the demands of other classroom preparation; the sheer numbers of ELLs in any one class; the masking of low reading proficiency by spoken language ability; and instruction of content-specific vocabulary. However, participants highlighted professional development sessions as positive steps toward supporting these learners. One teacher described the resources provided in the training sessions as “quite helpful in building my confidence in the field of meeting the needs of ELL students. . . . With my increased level of confidence, I have been able to offer them concrete ways in which they can participate in their language acquisition.” Another teacher’s post-training response remarked that strategies provided in the professional development sessions were overall “extremely useful,” and identified in particular “the focus on vocabulary development.” Describing application of vocabulary strategies to a specific class, the teacher noted “the growth seen with the student’s ability to write and read was amazing after only a few lessons.”


The belonging and acculturation needs of transnational and reconnecting families settling within a rural school jurisdiction were seen to be multifaceted and complex, even within the small sample considered in this study. The discussion presented here, therefore, set in the context of an exploratory inquiry, must be seen in light of this complexity. However, we assert still that these findings offer insight into how other rural school jurisdictions might offer support to ELLs and their reconnecting families.

First, the findings serve as an efficacious reminder to a reality unfortunately too often forgotten: That students’ academic progress cannot be considered in isolation but must be viewed as a subset of the larger complexities of challenges involved with the migration process in general, and family separation/reunification in particular. Such pressures are invariably brought to bear on student learning, and so to view academic language acquisition without consideration of the impact of these broader family dynamics is to overlook a critical dimension of the process. Schools and teachers of migrant students must look past the more apparent need for language learning and realize that adjustment to life in Canada involves considerably more (Due, Riggs, & Mandara, 2015). The findings of this study serve to underscore the import of a holistic perspective on education (Miller, Nigh, Binder, Novack & Crowell, 2018).

Second, as schools attempt to support ELLs within the context of reunifying families, this study’s findings also reinforce another obvious, but often overlooked point: the importance of forging support partnerships with the immigrant community that the school jurisdiction seeks to serve (Tran & Hodgson, 2015). Offering support for, rather than with, the community a school jurisdiction wishes to assist overlooks a critical element. A central benefit of the family workshops conducted, beyond the actual content, proved to be the networking afforded by bringing together families in similar circumstances. These families then began to forge informal networks for practical assistance ranging from help finding employment to sharing household responsibilities like cooking. We therefore recommend that schools/school jurisdictions, before rushing to provide programming to lend practical assistance, first consider opportunities to partner with existing networks–formal or informal–within the target community itself. Such an approach may represent a more sustainable and effective means of both identifying and supporting the complex and multifaceted needs of reconnecting transnational families.

Third, the findings affirm the important role of direct and explicit training for teachers in classroom strategies appropriate to ELLs. Comparative analysis of data from pre- and post-training teacher reflections indicate growth as practitioners, underscoring the benefits of such training. This serves as a reminder that teacher knowledge of the unique learning needs of ELLs cannot be assumed, and that targeted in-service professional development can play an important role in helping teachers better support these learners. Data also yielded a complex picture of teachers’ relationship with the Alberta K-12 ESL Benchmarks. While findings showed both teachers’ apprehension toward the Benchmarks as well as the valuable role of explicit teacher training in supporting their use, much work remains to be done with respect to utilizing the Benchmarks as a tool informing classroom instruction.


This study explored how support offered by a rural school district to reunifying families might impact the language acquisition of ELL students. Data drawn from semi-structured interviews with families and written reflections from teachers of ELLs pointed toward the multifaceted and complex challenges encountered by families separated and subsequently reunified during the immigration process. Findings underlined the relevance of a holistic approach to students’ learning by schools and their jurisdictions in seeking to support reunifying families. The results also pointed to consideration of support networks already extant within migrant communities, with the aim of offering support with, rather than simply for, intended recipients. Data from teacher reflections highlighted the benefits of direct and explicit professional development on instructional strategies for ELLs for teachers, with particular attention to expanding the role and use of the Alberta K-12 ESL Benchmarks. While this study is exploratory and preliminary in nature, the initial conclusions drawn are proffered forward in the hopes that other rural schools and school jurisdictions might benefit in their own endeavours to support the increasing number of families who are making rural Canada their new home.


Funding to conduct this research was provided by the Alberta Education Research Partnerships Program.


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Data Collection Instruments

Teacher Reflection Questions

Please reflect on and respond to the following questions regarding your current thoughts on teaching English Language Learners. Be as comprehensive as possible in your responses.

  • What is your current level of understanding the second language acquisition process that the English Language Learners in your content classes are going through?
  • What is your current level of confidence in understanding and meeting the needs of the English Language Learners in your content classes?
  • What is your current level of understanding and confidence in using the Alberta Education ESL Benchmarks as an assessment tool and as a tool to inform instruction?

Interview Questions – Students

Central Research Question (CRQ) Theory Question (TQ) Interview Question (IQ)
CRQ1: How is the acculturation process of immigrant students affected when the language and content acquisition of students and social-emotional needs of reconnecting immigrant families are explicitly supported? TQ1: Are children separated from families during migration experience anxiety and depression (Suårez-Orozco et al., 2010)?

TQ2: Does family separation during migration result in a negative impact on educational success (Gindling and Poggio, 2009, 2012)?

IQ1(a): What are some of the challenges you face within your family relationships?

IQ1(b): How might these affect your learning at school?

IQ2(a): How are the relationships between you and your parents different now than they were in your home country?

IQ2(b) How might this affect your learning at school?

IQ3: What do you think is most difficult about being a student in Canada?

IQ4(a): Are there adjustments to social life in Canada that make it difficult for you to learn in school?

IQ4(b): How about emotional adjustments that might make it difficult for you to learn in school?

IQ4(c): Are there any cultural adjustments that might make it difficult for you to learn at school?

IQ5: In general, what things help you learn at school?

Interview Questions – Parents

Central Research Question (CRQ) Theory Question (TQ) Interview Question (IQ)
CRQ1: How is the acculturation process of immigrant students affected when the language and content acquisition of students and social-emotional needs of reconnecting immigrant families are explicitly supported? TQ1: Are parents separated from children during migration experiencing stresses of separation and reunification (Falicov, 2007)?

TQ2: Do parents perceive that family separation during migration results in a negative impact on educational success (Gindling and Poggio, 2009, 2012)?

IQ1(a): What are some of the challenges you face within your family relationships?

IQ1(b): How might these be affecting your children’s learning at school?

IQ2(a): How are the relationships between you and your children different now than they were in your home country?

IQ2(b) How might this affect your children’s learning at school?

IQ3: What do you think is most difficult about being a parent in Canada?

IQ4(a): Are there adjustments to social life in Canada that make it difficult for your children to learn in school?

IQ4(b): How about emotional adjustments that might make it difficult for your children to learn in school?

IQ4(c): Are there any cultural adjustments that might make it difficult for your children to learn at school?

IQ5: In general, what things do you think help your children to learn at school?

Listening instruction and patient safety: Exploring medical English as a lingua franca (MELF) for nursing education

Volume 2(1): 2018

M. GREGORY TWEEDIE, University of Calgary

ROBERT C. JOHNSON, University of Calgary – Qatar


This study examines the intelligibility of interactions in Medical English as a lingua franca (MELF), in relationship to patient safety. Fourteen nursing students from six different first languages (L1s) listened to a recorded MELF health assessment scenario discussion involving two nurses with differing L1s. Comprehension questions measured intelligibility of: recognition, comprehensibility, and interpretability. Results indicated that perceived intelligibility generally aligned with actual intelligibility; areas of misalignment pertained to matters of critical import to patient safety. Senior nursing instructors’ views were explored through semi-structured interviews and all deemed that patient safety in the scenario was threatened by issues of intelligibility, particularly at the phonological and lexical levels. While hospital settings demand exceptional communicative precision for patient care, findings underscored challenges when English was a lingua franca. Results point toward the inclusion of interactive, authentic listening, and content-specific vocabulary instruction as critical components in the language curriculum of MELF nursing education contexts.


Cette étude examine l’intelligibilité dans les interactions de l’anglais médical en tant que lingua franca (MELF), en relation avec la sécurité des patients. Quatorze étudiantes en soins infirmiers ayant six langues maternelles (L1) différentes ont écouté une discussion sur le scénario d’évaluation de la santé du MELF, dans laquelle deux infirmières ayant des L1 différentes ont été enregistrées. Les questions de compréhension mesuraient l’intelligibilité dans les catégories de reconnaissance, de compréhensibilité et d’interprétabilité. Les résultats indiquent que l’intelligibilité perçue correspond généralement à l’intelligibilité réelle ; cependant, les zones de désalignement se rapportent à des questions d’importance critique pour la sécurité des patients. Les opinions des instructrices chevronnées en soins infirmiers ont été explorées au moyen d’entrevues semi-dirigées ; elles ont jugé que la sécurité des patients dans le scénario était menacée par des problèmes d’intelligibilité, notamment au niveau phonologique et lexical. Alors que les contextes hospitaliers exigent une précision communicative exceptionnelle pour les soins aux patients, les résultats soulignent les défis particuliers rencontrés lorsque l’anglais est une lingua franca. Les résultats indiquent l’importance de l’inclusion d’une écoute interactive et authentique, et d’une instruction de vocabulaire de spécialité en tant que composantes essentielles du curriculum de langue dans les contextes d’enseignement infirmier du MELF.

Keywords: Medical English as a lingua franca (MELF); English as a lingua franca (ELF); English for Nursing Purposes (ENP); English for Specific Purposes (ESP).


Qatar, as with many of its Arabian Peninsula neighbours, has seen massive infrastructure expansion due to the development of oil and gas resources in the region, which has been carried out by a largely expatriate workforce. In 2012, out of a total population of just under 1.8 million, Qataris accounted for only 15% of the citizenry. The countries representing this sizeable expatriate population includes: India (24% of Qatar’s total population), Nepal (16%), and the Philippines (11%), while non-Qatari Arabs accounted for 13% of the nation’s total (Paschyn, 2012).

Theoretical discussions of English as a lingua franca (ELF) in the Arabian Peninsula are rather forcibly moved to a practical level, given the reality that such interactions characterize the region’s health care settings. The influx of large numbers of expatriate health care workers has given rise to English becoming the lingua franca of many hospitals and clinics across the Arabian Peninsula; this phenomenon has been linked to concerns over patient medication errors (Bladd, 2008), thus making this discussion one of grave practical import. For the purposes of this article, Seidlhofer’s (2011) definition of ELF will be employed: “any use of English among speakers of different first languages for whom English is the communicative medium of choice, and often the only option” (p. 7).

Despite this multilingual environment, English has become the functional language for health care settings in the State of Qatar. This is largely due to the present and historical roles of English—the dominant language of the expatriate workers’ countries of origin—and also the growing dominance of English as the linguistic vehicle for medical communication (Maher, 1987). In such a context, intelligibility among different varieties of English, in order to deliver safe and effective patient care, is a critical concern. As Smith and Nelson (2006) noted, given the global expansion of English, it is largely unimportant if a particular group of English users are unintelligible to another linguistic group; what matters is that they are intelligible among themselves. English users in Nepali, for example, may utilize phonological or lexical features unfamiliar to speakers of Philippine English (who interact among each other with their own English variety); the subsequent shortcomings in intelligibility between these two groups will be of no import—until they find themselves in a situation where English is used as a lingua franca. In many Arabian Peninsula clinics and hospitals, such a situation is a daily occurrence (Almutairi & McCarthy, 2012; El-Haddad, 2006). Indeed, such interactions formed a foundational impetus for this present study. For example, while visiting a Qatar clinic, one of the authors noted multiple English dialects in the following communication: “an Indian pharmacist deciphered the instructions of a Filipino doctor to a Qatari patient, mediated through a Sri Lankan nurse” (Tweedie & Johnson, 2018, p. 73).

Despite widespread ELF interactions in health care contexts, due to the global migration of medical professionals (Lu & Corbett, 2012), the nature of Medical English as a lingua franca (MELF) interactions has been understudied. The present investigation examines the extent to which differing English varieties among nurses in the State of Qatar are intelligible to one another, and whether issues of intelligibility impact the quality and safety of health care delivery. Additionally, this study also investigates the intelligibility of these communications (between practicing nurses) to nursing students in the Bachelor of Nursing Program.


Intelligibility among Varieties of English

The global number of English users is estimated to be two billion or one-third of the world’s population (Crystal, 2008). The remarkable spread of English and its role as the “default mode” for global communication (McArthur, 2002, p. 13) has led to discussions around the extent to which the many varieties of English are (un)intelligible to one another (e.g., Kachru & Nelson, 2006; Kachru & Smith, 2008; Nelson, 2011). The present study provides an opportunity to investigate this issue in the medical context in Qatar where a largely expatriate workforce, from a myriad of linguistic backgrounds, use English to communicate across different varieties of the English-language.

Defining intelligibility might begin with what Kachru (2008) terms the “Smith paradigm,” referring to Smith’s (1992) division of intelligibility into three elements: intelligibility (word recognition), comprehensibility (word meaning, locutionary force), and interpretability (the meaning behind the word, or illocutionary force) (see also Smith & Nelson, 1985). Nelson (2011), in an exercise intended to aid readers in defining the above three elements of intelligibility, recounts “When I was being taught my manners, my primary caregivers made it clear to me that ‘When somebody says ‘Would you like to stay for supper?’ it’s time for you to go home”‘ (p. 26). In this case, comprehensibility would involve the listener’s knowledge that the modal question form “would you like” means an offer or invitation, “supper” as a meal eaten in the evening, and so on. Interpretability, the illocutionary force, involves an understanding of the implications underlying the utterance: presumably, in Nelson’s cultural context, a question about staying for supper was not an invitation at all, but a way of informing the guest that his or her visit was nearing an end.

Interpretability (locutionary force) is the most complex level of the three divisions in Smith’s framework for intelligibility (Nelson, 2011), referring to “the recognition by the hearer/reader of the intent of purpose of an utterance, i.e., the perlocutionary effect the speaker/writer is aiming at” (Kachru & Smith, 2008, p. 63). It includes contextual familiarity, background information, and can be informed by both linguistic and extra-linguistic awareness (Nelson, 2011, p. 37). Given the broad acceptance of the Smith paradigm, its tripartite definition of intelligibility has been adopted for the analysis of MELF interactions in this study.

Studies measuring intelligibility have tended toward considerations of “native speaker” (NS) judgements regarding “non-native speaker” (NNS) speech, leaving a research gap with regard to interactions across English varieties—the focus of this present study.

Some studies have attempted to fill this void. Deterding and Kirkpatrick (2006) also drew upon the Smith framework on their analysis of recorded semi-informal conversations among English users from South-East Asia to examine whether shared pronunciation features of an emerging lingua franca interfered with intelligibility. They largely did not, and the researchers asserted that these non-standard features, when shared among speakers, served to augment intelligibility. In cases where pronunciation features were unshared, this led to unintelligibility.

Meierkord’s (2004) analysis of informal ELF conversations found that at the syntactic level, interactions adhered to the grammatical patterns of standard English; thus, evidencing that L1 transfer features, along with processes of simplification, regularization and levelling, all contribute to intelligibility being achieved in such contexts.

As noted, studies of intelligibility primarily focus on the perceptions of those from English as a Native Language (ENL) contexts (UK, US, Canada, etc.), ignoring the reality of non-ENL, ELF interactions. A review of the literature on linguistic barriers in health care contexts reveals a similar propensity.

Language Use and Patient Care

Despite the potential for practical application, the intersection between applied linguistics and health care communication has, until relatively recently, been overlooked (Candlin & Candlin, 2003). While studies have found that language barriers in health care settings create difficulties in: physician-patient interface, inhibit access to care for patients, lower their adherence to treatment, and decrease patient satisfaction (e.g., Carrasquillo, Orav, Brennan, & Burstin, 1999; Schenker, Lo, Ettinger, & Fernandez, 2008; Wilson et al., 2005); the primary foci have been interactions between NS health practitioner to NNS patient in ENL settings (Cameron & Williams, 1997; Ian, Nakamura-Florez, & Lee, 2016; Shi, Lebrun, & Tsai, 2009). For example, Staples (2015) compared the discourse features of NNS internationally-educated and NS US-educated nurses when communicating with NS standardized patients. While they found much of the language used was similar, NNS discourse differed in terms of lexico-grammatical features. US nurses were shown to have a more patient-centred discourse through means such as “expressing empathy, developing rapport, reassuring patients, and more generally therapeutic communication” (p. 134), in contrast to the internationally-educated nurses “provider-centred” orientation (p. 216). While extensive in scope, Staples’ study differs from the focus of this investigation as it took place in an ENL setting rather than an ELF one, and the internationally-educated nurses in this study exhibited high proficiency in English (p. 123). Frank’s (2000) study of NNS international students and NS health care staff in a university clinic encountered difficulties in overall understanding, but particularly for medical terminology; however, this also took place in an ENL setting.

Previous studies have also identified potential risks to patient safety through language barriers, but again, mainly in ENL contexts. For example, Wilson et al. (2005) found that physicians who spoke the same language as patients (“language concordant”) “reduced reports of adverse medication effects and confusion with medication instructions” (p. 803). Another ENL-specific study, of nurse-patient cross-cultural communication in a surgery ward, examined perceived barriers in language and culture that, in the views of nurses, hindered “safe and effective care” (Boi, 2000, p. 387). Similarly, the nurses interviewed by Graham, Gilchrist, and Rector (2011) recounted language barriers as “challenging, frustrating and even dangerous” (p. 117), but were describing NS nurse – NNS patient interactions. A similar focus on ENL settings has been characteristic of studies on the teaching of English for Nursing Purposes (ENP), and scant attention has been paid to ENP communications in countries where English functions as an official language among other first languages, or where it is taught as a foreign or international language (Bosher & Stocker, 2015). Even less is known about ENP instruction in lingua franca contexts.


This study investigated two questions:

  1. In a MELF interaction, to what extent did miscommunications occur between two nurses? Further, in the judgement of nursing instructors, to what extent could issues of intelligibility observed during the scenario affect the quality of patient care?
  2. To what extent was the above MELF interaction intelligible to other nurses and nursing students?


Research Setting

This study takes places at a nursing education institution in the State of Qatar offering undergraduate and graduate nursing degrees with English as the medium of instruction. The student body at the time of writing comprised 39 different nationalities, representing multiple linguistic backgrounds. The Bachelor of Nursing Program consists of two study tracks: the Post-Diploma (PD) track, for nurses who have previously completed diplomas and are practising in the local health care system, and, the Regular Track (RT) for students who do not have any previous credentials or experience in the field.

Health Assessment Scenario in a MELF Context

Assessment scenarios have been utilized in nursing education for the development of integrative and critical thinking skills (Carter & Dickieson, 2010; Wales & Skillen, 1997), while minimizing strain to students and avoiding risks to patients (Zunzarren & Rodriguez-Sedano, 2011). Scenarios in nursing education can range from advanced use of technology in simulating “high-fidelity” to real-life conditions (Maneval et al., 2012, p. 125) through to constructed “dialogic exchange” based on scenario cards (Carter & Dickieson, 2010, p. 66). The content of this particular scenario (see Appendix A) was created with the assistance of a senior nursing faculty member, and was designed to be such that linguistic unintelligibility within the situation would impact patient care, and would also employ syntactical forms that nurses would regularly encounter in the course of hospital ward duty. The scenario’s focus was an end-of-shift handover of a patient from Nurse A, finishing a shift, to Nurse B, starting a shift.

The scenario was shown to two female student volunteers from an upper-year undergraduate nursing course. Both students, enrolled in the PD program, were experienced nurses currently practicing in the local health care system, and would have completed such patient handovers routinely as part of their responsibilities. Student A was given a description of the scenario, including her role as outgoing nurse and necessary patient information to be explained to her colleague. Student B, meanwhile, previewed only her role description as the recipient of the end-of-shift report. Student A described her L1 as Tamil, Student B as Arabic: both had met the university’s entrance requirements in terms of English proficiency.ii As seen in Table 1 below, Nurse A [L1 Tamil] displayed linguistic features of pan-Indian English (Sailaja, 2009, 2012), such as non-distinction between /w/ and /v/, the absence of the /eɪ/ dipthong, and a preference for progressive verb forms. Nurse B, [L1 Arabic] meanwhile, assigned the role of the incoming shift nurse receiving the report, demonstrated speech characterized by (lack of) do-support questions. Their discussion was recorded as a 3:08 minute digital audio file.

Scenario Role Played by Self-identified ‘mother tongue’ Selected linguistic feature Examples
Hospital nurse going off-shift Student A Tamil /w/ and /v/ non-distinction He has /wɒm.ɪtɪd/ twice today
absence: /eɪ/ diphthong He’s also stating that he’s feeling funny and um feeling /hə.ləʊs/ around the lights
preference for progressive verb forms I wonder maybe he’s crazy something he’s telling that way
Hospital nurse coming on-shift Student B Arabic lack of do-support in question forms You not take blood sugar?

No any interferon?

This refer the file?

Table 1: Summary – Health assessment scenario discussion

Opinions Regarding Potential Miscommunications and Health Care Impact

The health assessment scenario recording was played to three senior nursing instructors at the institution. All possessed multiple years’ experience at both clinical and instructional disciplines of nursing and were familiar with the multilingual context in the clinical settings in which they and the student participants work. All held advanced degrees, were female, and were speakers of Canadian English (Walker, 2015), reflecting the institution’s instructor profile. A semi-structured interview explored their views on whether issues of intelligibility in the recorded discussion might impinge upon patient care. Interview questions were constructed following Wengraf’s (2001) tripartite question divisions of central research, theory and interview (see Appendix B). Interviews were recorded as digital audio files and coded for analysis. A thematic analysis approach (Braun & Clarke, 2014) served as a framework for examining the interview data in a manner consistent with the “bottom up” orientation of grounded theory (Corbin & Strauss, 2008).

Additionally, the researcher was cognizant of the need for interviews to probe a distinction between nursing practice content (Did the nurse in the recorded scenario lack the knowledge or experience in nursing practice to assess the patient?) and language (Was patient assessment hindered by pronunciation, unfamiliar grammatical forms, inaccurate vocabulary, inability to access necessary vocabulary, etc.?). In each assertion of inadequate health assessment then, the interviewer probed further to ensure the nursing instructor differentiated between these two areas, as illustrated by the following extracts.

Extract 1

Interviewer: That – so that the fact that there wasn’t information, that was an issue with nursing, not a language issue.
Nursing Instructor X: It’s a content issue.
Interviewer: A content issue.

Extract 2

Interviewer: So do you feel that that’s related to it being a second language or do you
Nursing Instructor Y: I don’t know. Sorry. Umm [pause] Yeah, I don’t know, I don’t – I think I would have the same concerns about an English speaker who said yeah, he’s acting crazy. I think I would still have to push them to say what does – describe that.

The next section begins with an overview of the findings, followed by specific examples.

Listening Comprehension Task for Nursing Students

For the final phase of the research, the recorded health care assessment scenario was played for Bachelor of Nursing students at the institution. Simultaneously, students completed 10 listening comprehension questions (Appendix C). These were developed, in consultation with a senior nursing instructor, to verify that the listening comprehension questions reflected areas of critical import for patient care in the context of the specific scenario. Further, construction of the comprehension questions followed Buck’s (2001) “default construct” for listening in that tasks were designed to involve the processing of realistic spoken language in real time, and the comprehension of both equivocally and unequivocally stated content (p. 114). Items in the first section (Questions 1-6) followed the order of discussion progression, and targeted content comprehension over attention to extraneous detail, a central feature of listening construct validity (Rost, 2002). A second section (Questions 7-10) asked listeners to reflect on perceived intelligibility; it included closed and open-ended items to allow for collection of unanticipated information (Wiersma & Jurs, 2009). Items were intended to gauge respondents’ perceived intelligibility of the health assessment scenario recording. The perception of understanding is of central concern in health care interactions, in that gaps in interactional understanding can have serious consequences for patient safety.

Participants were also asked to identify their “strongest language,” a term chosen to reflect the reality in Qatar of an “unbalanced multilingualism” (Cenoz, 2013, p. 6), where individuals typically differ in proficiency levels across two or more languages. Respondents were also asked to indicate programs of study (degree or diploma) and gender, but for purposes of confidentiality asked not to provide any further identifying information.

A total of 14 BN students completed the listening comprehension section of the study. The sample reflected the student population of the institution, with participants being predominantly female (14), a mix of RT and PD students (5 and 6, respectively, with 3 not indicating study track), and a variety of “strongest languages” (5 – Arabic; 3 -Tagalog; 2 – Farsi; 2 – Malayalam; 1 – Indonesian; 1 – Yoruba).


Senior Nursing Instructors’ Opinions Regarding Health Care Impact

Several themes emerged from the interviews with the senior nursing instructors, summarized in Table 2.

Theme Nursing Instructor X Nursing Instructor Y Nursing Instructor Z Comments
Expressed concern that English language ability could affect patient safety Yes Yes No Z identified imprecise expression (see Extract 9) as a threat to patient care, but not necessarily safety
Expressed concern regarding intelligibility of medications list Yes Yes No Z noted her background in cardiac care might have enabled inference
Expressed concern regarding intelligibility of phonological or syntactic features No Yes No Y noted differing pronunciations but expressed comprehension
Expressed concern that imprecision in expression could affect patient safety Yes Yes Yes

Table 2: Semi-structured interviews – Summary of responses

Patient Safety

First, two of the three nursing instructors (pseudonyms X and Y) explicitly stated that language-based miscommunications between the interlocutors could negatively affect patient safety. While the third instructor (Z) did not explicitly link any single miscommunication as jeopardizing patient safety, she did express concerns about miscommunications affecting patient care. The extracts below provide examples illustrating patient safety concerns expressed by nursing instructors.

Extract 3

Interviewer: In your opinion, were there areas of language, not nursing practice but language, that could affect patient safety, in this example?
Nursing Instructor X: Uh, yes, I think so, and I think it goes back to the the terms she used before: “funny” and “crazy” because those can be very umm, you know, funny what does that really mean, you know, is he unconscious umm , you know is he responding to verbal umm commands, to painful stimuli, like those all impact umm patient care. And she did mention that the potassium was high, so that would lead me to be believe that these were more serious concerns than acting funny. And that nursing umm other nursing intervention should be taken immediately, instead of just you know making a referral at some point in time.

Extract 4

Nursing Instructor Y: But I think there’s more – I think there’s cardiac issues going on and we might be overdosing them on potassium, right now. And that could be so the beginning of the confusion we might be sending him into a delirium which I didn’t hear anything about. But that would be my immediate thought, umm if I was diagnosing.


Two interviewees (X and Y) indicated concern about intelligibility in the reports of administered medications. Z felt she understood the list of medications the patient was receiving, but added that her background in cardiac care might have assisted with inferring the medication names and dosages. What she could not comprehend, however, was the type of fluid being administered to the patient intravenously.

Extract 5

Nursing Instructor Y: I didn’t get the names of all the medications. I got Lasix 20, didn’t get the frequency of it, didn’t get I think there were 3 meds, I didn’t get the next medication at all, and then I got potassium 20 millequivalents qd. I got that this patient vomited twice, pulse, I’ve got a question mark, I’m not sure if said they took the pulse, or they didn’t get the pulse . . . umm . . . I’m not sure what acting funny looks like? Umm , and not quite sure how that connects to seeing halos around the light.
Interviewer: So uh – so these – the fact that you didn’t get the medications –
Nursing Instructor Y: Huge issue!

Pronunciation and/or grammar

While nursing instructors noted areas of pronunciation from the two recorded interlocutors where comprehension was a challenge, none directly linked these to patient safety. Nursing Instructor X noted differing vowel articulations of two terms (C-difficile and Lasix) but indicated comprehension of both, while Instructor Z indicated a lack of comprehension surrounding the type of intravenous solution. The pan-Indian or Arabic linguistic features noted in Table 1 were not remarked upon by any of the three nursing instructors. None of the instructors mentioned grammar issues as a barrier to comprehension.

Precision in expression

All three nursing instructors indicated concerns that a lack of precision in expression evidenced in the scenario might negatively impact patient safety. In the recording, for example, Nurse A attempts to describe the patient’s mental state of disorientation, and does so with the patient’s own words “feel[ing] funny” and her own description “he’s crazy”. Instructors X, Y and Z all conveyed views that this indicated a lack of precision in expression necessary for effective nursing practice.

Extract 6

Nursing Instructor X: She she stumbled over her words, right? It wasn’t it the articulation wasn’t clear what I would expect it to be, You know she seemed hesitant over umm the information that she was conveying, like she didn’t I didn’t feel that she had a sense of confidence about what she was talking about umm you know that there she didn’t have really a umm a clear plan about what she wanted the next nurse to do. It was kinda left up in the air. Umm…
Interviewer: And are those problems of language, do you think?
Nursing Instructor X: I do, because maybe she probably couldn’t umm find the words to articulate what she said. So I don’t know if it it could be a content issue, maybe the person speaking didn’t know the content? But it could also be that they didn’t have the words to verbalize what they wanted to say.

Extract 7

Interviewer: And just to be clear, so I’m clear … they that uh that being unclear to the next nurse, you’re saying it could be a language issue, she may not know the words to say?
Nursing Instructor X: Right. So in my own personal experience, you know if I keep probing students, I can sense that they you know that they know kind of the content, but they’re not able to find the words. And if they translate what they’re saying into their native language, and that other person tells me what they were saying then it makes more sense. But here I don’t know if she really had the language to express what she wanted to say. Maybe she did do with her own cardiac assessment, and she didn’t have the knowledge, right? She talked about things like (pitting) edema, but umm she couldn’t clearly articulate you know the objectivity behind it, you know (pitting) edema plus one plus two plus three umm that kind of thing so umm perhaps she doesn’t have the the language ability to umm to portray that information.

Extract 8

Nursing Instructor Y: So then she talked about air entry, she talked about a moist cough. I would be concerned about this patient because of the KCL, and the high potassium . . . umm . . . And then so the other confusing part about this was that they said that this person is disoriented, but they’re responding well. So I don’t know what they’re responding well to. If they’re disoriented, and they’re crazy, and they’re acting funny, then to me, responding well is a bit of a misnomer.
Interviewer: Would would someone being a native speaker of English use responding well in an unclear kind of way?
Nursing Instructor Y: I don’t – I would hope not.
Interviewer: So it might be language?
Nursing Instructor Y: It might be language. I think maybe they’re responding well physically, but they’ve got a whole other psychodynamic going on here, that I’m concerned about. And if their potassium is is creeping up, then they’re not actually responding well, you need to attend to the potassium (be)cause that could kill them.

Extract 9

Nursing Instructor Z: Crazy – that was a little off for me, yeah.
Interviewer: Off.
Nursing Instructor Z: When I heard that word uh that’s not a word I would use. Or I would hear a nurse use. So I don’t know what she meant by that. But then when they went on I assumed that she was talking about him being orientated or disoriented. So I I don’t what she meant, if she meant that his mental status wasn’t quite where it should be and I think that’s where the other nurse might have been pushing she asked had his blood sugar been tested which would be a normal thing for a nurse to think about because a person could be disoriented if their blood sugars were high or low? Um but they hadn’t checked that. The other nurse said they hadn’t checked that. So um yeah the crazy part was something I didn’t really care to hear. We you wouldn’t hear that that’s not something you hear a nurse say. It doesn’t mean anything um medical it doesn’t reflect assessment a nursing assessment. So that part was a little bit maybe she was struggling with language to describe what it was she was trying to say that that was one part, yeah. That wasn’t great.
Interviewer: That might be language?
Nursing Instructor Z: Well, maybe it’s maybe she didn’t know the right word to use? Because crazy’s not a word you hear in nursing assessment language, or medical language by a physician, nurse, anybody. It’s just, it’s a it’s a lay term, you know, it’s a it’s not a word that we would use.

Listening Comprehension Task for Nursing Students

Listening comprehension responses

Of the six listening comprehension questions, participants demonstrated little difficulty answering three correctly, while the remaining three proved challenging. A list of comprehension items and the number of correct/incorrect answers for each is provided in Appendix C. Table 3 below shows selected examples of variance in listener comprehension for the three problematic items.

Question # Information given in recorded discussion Number of incorrect responses /14 Incorrect response (number)
Q1: How old is the patient? ’84 years old’ 4/14 unanswered (3)

40 (1)

Q4: The patient’s pulse is 92. Is there any other information given about the pulse? ‘irregular’ 13/14 regular (13)
Q5: How is the patient’s blood sugar? ‘blood sugar, not take’ 5/14 normal (3)

within normal (1)

good (1)

Table 3: Variance in listener comprehension – Selected examples

Perceived intelligibility

Questions 7 to 10 gauged respondents’ perceived intelligibility of the health assessment scenario recording. Variable responses characterized listener perception of the recorded health assessment scenario, but overall, participants expressed confidence that they had understood the discussion. Thirteen of the 14 listeners, for example, indicated they understood 70% or more; only three felt inaccurate pronunciation interfered with meaning. Speech rate and interlocutor accent was reported as a barrier to comprehension by just over half of listening participants (9/14 and 8/14, respectively). Table 4 below summarizes participant responses.

Question 10 was an open-ended item which gave listeners opportunity to add any other remarks on the recorded discussion. Ten of 14 listeners provided comments, and these followed varied themes: four comments noted fast speech; four referred to accent as a comprehension barrier; and two comments used the phrase ‘easy to understand’. Some examples:

In general was OK, not very difficult, but the way they pronounce and the accent is little bit made the word meaning to change, but because we had a lot of experience in working with Indian nurse so it became a habit to hear it and I feel it’s OK and easy to understand. [Sic] [“strongest language”: Farsi]

Her spoke too quickly and needs to improve her accents. [Sic] [“strongest language”: Arabic]

The hand over was clearly communicate between them. It was easy to understand patient condition and what the nurse did for the patient. [Sic] [“strongest language”: Farsi]

No, only some litters that are going from nurse mouth is littel difficult to understand because all indina staff have this problem e speaking. [Sic]. [“strongest language”: Arabic]

‘It will be difficult for people who has no knowledge about medications to understand what nurse A said especially when it comes to medical words. [Sic] [“strongest language”: Indonesian]

Question # Responses (14 listeners)
Q7: How well did you understand the patient’s condition and symptoms? easily (7)

understood, but with some difficulty (7)

Q8: How much of what the nurses said did you understand? 90% or more (6)

70-89% (7)

50-69% (1)

Q9: Say whether you agree (A) or disagree (D):

(a): The nurses’ accents* made it difficult to understand the patient’s condition and symptoms.

Agree (8)

Disagree (6)

(b): The nurses spoke too quickly for me to understand the patient’s condition and symptoms. Agree (9)

Disagree (5)

(c): The nurses wrongly pronounced some words, so I couldn’t get the meaning. Agree (3)

Disagree (11)

(d): The nurses wrongly pronounced some words, but I could still get the meaning. Agree (7)

Disagree (6 )

No Answer (1)

(e): The nurses spoke Standard English. Agree (5)

Disagree (8)

No Answer (1)

Table 4: Perceived intelligibility – summary of responses

*bold type in original


Concerns over patient safety with respect to communication issues in an ELF context (Bladd, 2008) were echoed in this present study. According to the three nursing instructors who listened to the recorded assessment scenario, patient safety was threatened by issues of language intelligibility. With the 14 nursing students who listened to the recording, a high degree of perceived intelligibility generally aligned with actual intelligibility; however, areas of misalignment were on matters of critical import to the patient’s condition.

The “Smith paradigm” and its three-part division of intelligibility served as a framework for discussion in regard to the areas of (un)intelligibility evidenced in this study.


Nursing instructors

Word recognition difficulties with medication and its administration were highlighted in the semi-structured interviews. The effect on patient safety of misunderstanding in this area of nursing care, could be, as emphatically stated by Instructor Y, a “Huge issue!” All three instructors referenced difficulties in understanding medicines and/or administration, noting unintelligibility of the actual names and amounts and frequency of dosage.

Nursing students

Despite nursing student listeners’ perceptions about the effect of accented pronunciation, word recognition overall accounted for minor impact on intelligibility of the recorded scenario, as evidenced by comprehension instrument responses. Disconcerting, however, was the pervasive misrecognition of the patient’s irregular pulse (13 of the 14 heard “regular”), and that while the patient’s blood sugar level had not been tested, over one-third of the respondents (5/14) understood it to be “normal” or “good”.


Nursing instructors

It is in the area of locutionary force, in particular, where instructors noted the adverse effects of language ability on nursing care. The descriptors “funny” and “crazy”, uttered as Nurse A presumably searched for more precise nursing lexis like “disoriented”, were considered a threat to patient safety by the instructors. As mentioned by Nursing Instructor Y, imprecise terminology could delay diagnosis of a potentially dangerous issue, such as an overdose of potassium chloride (see Extract 4).

Nursing students

Unlike their instructors, who noted with alarm the imprecise use of the terms, the student listeners did not remark upon the use of “funny” and “crazy”. Certainly, although a precondition for inclusion in this study was completion of the institution’s health assessment course, the student nurses are not expected to demonstrate the same level of assessment skills as the instructors. Still, this may be a case of “they don’t know what they don’t know” – or, the failure to note the importance of precise terminology may perpetuate imprecisions.


From the standpoint of patient safety, it may be encouraging to note that the recorded health assessment scenario evidenced interpretability as indicated by nursing instructor comments and as measured by nursing student responses to listening comprehension questions.

Nursing instructors

Instructors demonstrated use of situational and contextual knowledge to apprehend the recorded scenario. Instructor Z described drawing inferences from her background in cardiac care, while Y noted differing vowel renderings but still correctly identified the condition and medications. Both X and Y noted that they would press for clarification if this were an actual hospital setting (e.g., Y: “Well, if I’d been sitting on this report, I would have pushed this nurse to say ‘Tell me what funny looks like to you.'”)

Nursing students

Respondents described a process that is likely very familiar to them in an environment where English is used as a lingua franca—drawing upon both linguistic and extra-linguistic contextual knowledge to gain meaning.

A nursing student who identified her “strongest language” as Farsi noted that “the way they pronounce and the accent is little bit made the word meaning to change, but because we had a lot of experience in working with Indian nurse so it became a habit to hear it and I feel it’s OK and easy to understand”. [Sic]

Another student listener (“strongest language” – Indonesian) thought Nurse A’s speech would be “difficult for people who has no knowledge about medications” [sic]; however, this student’s correct answers on the listening comprehension section indicated that she did possess the required background knowledge.

However, a note of caution needs to be sounded alongside these positive assessments of interpretability. Consider the following extract from the recorded assessment scenario discussion, and the nursing students’ responses.

Extract 10

Nurse B: Okay, why you um, take your uh, take the blood sugar? The uh the blood sugar, uh, it’s high?
Nurse A: Blood sugar, not take.
Nurse B: You not take blood sugar?
Nurse A: No.
Nurse B: Not diabetic, not diabetes.

Question 5 asked the nursing student listeners, “How is the patient’s blood sugar?” 11 of the 14 listeners correctly answered that the blood sugar levels had not been taken. However, three answered “normal”, one “within normal” and one described the levels as “good”. This example of interpretability misunderstanding serves as a reminder that critical care situations in general require an unusually high degree of communicative precision, with the possibility of heightened difficulties where a lingua franca language is vehicular.


A number of limitations need to be taken into account when considering the wider implications of this study. The first limitation is one common to many studies of listening: the “packaging” of a fundamentally interactive activity into a more static exercise. Conversational universals like backchannel signals for listener-speaker feedback and repair systems to restore comprehension (Goffman, 1974) are absent for listeners hearing a recorded discussion. While all listening is inherently interactive communication, Buck (2001) delineates listening assessment constructs based on a continuum of interactive collaboration. As noted previously, this particular study measured comprehension on a non-collaborative communication task in that the research construct gauged listening in a non-interactive context. In order to extend understanding of ELF interactions in health care settings, future research is needed in observing interactive contexts where listeners attempt to formulate meaning collaboratively.

When considering the broader applicability of the findings, it is also important to note the small sample size in the study. Future research might consider larger numbers of participants, representing even further linguistic variation; such a line of inquiry extends the range of possibilities in probing areas of (un)intelligibility. Consistent with the makeup of the institutional context, the nursing instructors evaluating the recorded scenario for patient safety in this study all listed English as their “strongest language”. A future study might broaden the sample to include similarly qualified instructors from other linguistic backgrounds to gauge their take on MELF interactions in the context of patient safety.

With the above limitations considered, we now turn to the implications for English language teaching’s intersection with nursing education, and how (M)ELF might contribute to belonging, identity and the development of medical professional practice in migrant destination regions.


Several implications for nursing education in ELF contexts present themselves from these findings. First, linguistic preparation of nursing students for whom English is an additional language will look differently in ELF contexts than in ENL ones. The teaching of listening skills should aim not just for comprehension of a single “standard” accent, as is often the pedagogical focus in ENL settings, but also effective comprehension across a wide variety of Englishes. Effective listening pedagogy should seek to enhance listening skills that are interactional in nature, which can be achieved by expanding upon the traditional listening task constructs to include more active listening techniques, like clarification, summarizing, etc.—thus, veering from a “receptive orientation”‘ toward a “collaborative” or “transformative” one (Rost, 2002, pp. 2–3). Pronunciation pedagogy should, similarly, deemphasize NS accents as the preferred target, in favour of being understood in MELF environments where the future nurse practitioners will find themselves in. Research-informed speaking pedagogy should also investigate and catalogue target areas for enhancing intelligibility in such contexts.

Scholars have emphasized the goal of communicative effectiveness—as opposed to a strict attention to accuracy—in ELF interactions (Björkman, 2011). As Jenkins (2007) argued, in an international communication context, “the ability to accommodate to interlocutors with other first languages than one’s own is a far more important skill than the ability to imitate the English of a native speaker” (p. 238). Firth (1996) found that lingua franca interactions used a number of means to make unusual interactions appear more “normal”, such as a “let it pass” approach (waiting until an unclear meaning became clear) and “make normal” strategies (producing formulations of marked speech) (pp. 243-247). Other means of circumventing misunderstandings in ELF interactions include repetition, clarification, self-correction, direct questions, and error repair (Kwan & Dunworth, 2016). Nursing curricula for MELF contexts would do well to include explicit teaching of such strategies.

Second, the important role of the range and depth of nursing-specific lexis was highlighted by this study. Precise description is at the heart of effective health assessment, and providing such precision in a vehicular language adds an additional challenge. The formation of frequency-based nursing corpora (Shimoda, Toriida, & Kay, 2016) provides new opportunities for lexis-based pedagogical approaches in nursing education.

Third, listening has been considered an undervalued and under-taught area of language teaching, the “Cinderella of the four macro-skills” (Flowerdew & Miller, 2005, p. xi). This present study underscores its importance, even centrality, for the language teaching curriculum in MELF contexts. The findings suggest that listening needs to be extended from its traditional role as a static, receptive activity to a much more interactive one; the importance of authenticity and genuineness (Rost, 2002) are emphasized by the need for exceptional precision required in patient assessment. Fortunately, authentic and genuine opportunities for interactive listening is often already incorporated into many nursing programs in the form of the simulation laboratory. Simulation training, a mainstay of nursing curricula, provides “a unique educational strategy to facilitate the development of skills, competencies and clinical judgement that are mandatory to provide safe, quality patient care” (Decker, Caballero, & McClanahan, 2014, p. 2). In many cases, however, English language instruction is seen only as a precursor to participation in nursing programs, and not incorporated into nursing program simulations. This results in a largely underutilized pedagogical opportunity for “real-world” listening situations nursing students will encounter in future practice.


As a migrant worker destination, the states of the Arabian Peninsula are of special interest for the study of (M)ELF interactions, given the L1 language contact environment where English serves as a second or third language for many in the large expatriate workforce. In discussing the UAE, Boyle (2012) describes an environment where migrants accelerate language change, given the tendency to lessen enforcement of linguistic norms in such settings, and predicts language change to be observable not only in English, but Arabic and South Asian languages like Urdu and Malayalam, and in other languages which are represented in the UAE’s migrant workforce (p. 328).

ELF in this way provides an avenue for identity and belonging in an environment where permanent residence is highly unlikely, if not impossible (see Economist Intelligence Unit, 2009, for an explanation of residence/citizenship policies in the Arabian Peninsula). Migrant destinations like the Arabian Peninsula present a rich opportunity for researchers to consider whether ELF will not only stabilize, but become a norm-providing variety of English, rather than its current norm-dependent orientation, with a convergence of grammatical/lexical systems. Maurenen (2012) describes language users who, interacting over time, will eventually synchronize to norms. Might we envision a day when what is now ELF in the Arabian Peninsula will converge into a series of norms (and then eventually be codified and taught)? On several occasions, for example, we have been asked in Arabian Peninsula coffee shops, by migrant workers from the Philippines, for our “good name,” a feature associated with South Asian English (Kachru, 1993, p. 382), perhaps an illustration of ELF norm convergence in the region. This may exemplify the process described by Mauranen (2012), who predicting a regulation of speech norms over time, and the forming of discourse communities (Swales, 1990). The data in this study suggest that a MELF discourse community may already be in development. As noted previously, one nursing student (L1 Farsi) described her comprehension of an Indian nurse (L1 Tamil) in a patient handover: “the way they pronounce and the accent is little bit made the word meaning to change, but because we had a lot of experience in working with Indian nurse so it became a habit to hear it and I feel it’s OK and easy to understand.” [Sic]

The notion of community/communities of practice (COP) (Lave & Wenger, 1991; Wenger, 1998) has been drawn upon by ELF theorists to describe the nature of such speech communities (Mackenzie, 2014), and may be of particular relevance to MELF users. A COP depicts the inherently social nature of learning, framing the process as one of a learner participating in the social world, and contrasting with portrayals of the individual learner in isolation, depending on cognition exclusively. Mutual engagement, a joint enterprise and a shared repertoire characterize the social learning of the COP (Wenger, 1998). Utilization of the knowledge created by COP in organizations –often overlooked because of their informal nature (Boud & Middleton, 2003)—presents an opportunity for institutions that educate health care professionals to generate MELF linguistic resources, which transcend the limited term contracts of expatriate workers.


This study examined intelligibility of a health assessment scenario among different varieties of English, in a health care context where English is a lingua franca. As in all hospital settings, exceptionally accurate communication is necessary for patient safety, but the findings here underscored its importance in MELF contexts. The results point toward the inclusion of interactive and authentic listening, and frequency-based vocabulary instruction, as critical components of English language curricula as it intersects with nursing education for MELF contexts. As the findings of this study suggest, the neglect of communicative precision in MELF instructional contexts is done at patient peril.


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Appendix A – Health Assessment Scenario

Health Assessment Scenario 1 – NURSE A

Shift Change: You are giving shift report to the ongoing staff.

Mr. Saddi is an 84 year old male with congestive heart failure, who has developed pulmonary edema and has also acquired C-difficile in hospital and has become dehydrated. Medications include furosemide (Lasix) 20 mg PO qd, digoxin 125 mg PO qd, potassium chloride (K-Dur) 20 mEq PO qd. He has vomited twice today, and you are not sure he kept his pills down. He is also stating that he “feels funny and I’m seeing halos around the lights – I wonder if I am going crazy”.

You report on the following:

– admitting diagnoses

– report vital signs (BP 180/82, P 92 R 26)

– urinary output hourly over the last eight hours

– auscultation: diminished air entry with inspiratory crackles throughout (review what this could be)

– cough is wet and non-productive

– tachycardic

– pulse irregular

– recent lab values show potassium level increasing

– disorientation

– patient opening eyes in response to touch

Health Assessment Scenario 1 – NURSE B

Shift Change: You are the incoming nurse during shift change.

Listen to the outgoing nurse and the information they give you about a patient.

You are a participant in the conversation, so feel free to ask questions or do anything else you might want until you are comfortable you have the information necessary.

Appendix B – Interview Questions

Central Research Question (CRQ), Theory Questions (TQ), and Interview Questions (IQ) (Wengraf, 2001)

CRQ(1): To what extent do issues of intelligibility among users of different varieties of English threaten safe and effective patient care?

TQ(1): Are there linguistic misunderstandings that might threaten safe and effective patient care?

IQ(a): How well did you understand this shift report?

IQ(b): What things made it difficult to understand the report?

IQ(c): In your opinion, are there possibilities for misunderstandings in language that could affect patient safety?

IQ(d): In your opinion, are there possibilities for misunderstandings in language that could affect the overall quality of patient care?

Appendix C – Student Nurse Responses

Language Female






























TG011 F BNRT C C C I C C A 90+ A A
TG02 F BNRT C C C I I C B 50-69 A A D A D 2
TG03 F BNRT C C C I I C B 90+ A A A A D
YA01 F BNRT I C I I C I B 70-89 A A D D A 3
AC01 F I C I I C I A 70-89 A A D D D 4
AC02 F PDBN C C C I I I B 70-89 D A D D D
AC03 F PDBN C C C I C C B 90+ A D D A D 5
AC04 F I C I I I C A 70-89 A D D A D 6
AC05 F I C I I I C A 90+ D A D D A
FI01 F PDBN C C C I C C A 70-89 D D A A D 7
FI02 F PDBN C C C I C C A 90+ D D D A A 8
IN01 F BNRT C C C C C C B 70-89 D A D A D 9
MM01 F PDBN C C I I C C A 90+ D A D D A 10
MM02 F PDBN C C I I C C B 70-89 A D D D A 11


– 14 respondents

– In Q1-6, no answers were scored as Incorrect (I).

– Comments (see footnotes) are reproduced unedited, as written by the participants.

1: TG – Tagalog; YA – Yoruba; AC – Arabic; FI – Farsi; IN – Indonesian; MM – Malayalam

2: The nurse A was quite a fast talker and seems like she’s out of breath.

3: There is too much information during the endursement. I think endursement supose to be concise.

4: Her spoke too quickly and she needs to improve her accents.

5: It was not proper English language.

6: No, only some litters that are going from nurse mouth is littel difficult to understand because all indina staff have this problem e speaking.

7: In general was OK, not very difficult, but the way they pronounce and the accent is little bit made the word meaning to change, but because we had a lot of experience in working with Indian nurse so, it become a habit to hear it and I feel it’s OK and easy to understand.

8: The hand over was clearly communicate between them. It was easy to understand patient condition and what the nurse did for the patient.

9: I think the nurse A spoke too fast, so it was a little difficult to understand or catch up with the conversation; especially when nurse A tried to explain about the medications. It will be difficult difficult for people who has no knowledge about medications to understand what nurse A said, especially when it comes to medical words.

10: Spoke too quickly.

11: The explanation was OK, but it was mixed so difficult to understand.

i We are hesitant to wade into use of the terms “native speaker / non-speaker” for the purposes of our article, given the terms’ often social, rather than linguistic, construction. We prefer to conceptualize our discussion with the recognition (and affirmation) of varieties of English. In countries where English has a long history, and plays many official functions in government, the media and education (India, for example), it is often problematic to identify who/who isn’t a “native speaker.” In such environments, many multilinguals may be hard-pressed to tell you which language is their L1. We therefore prefer to frame our discussion in this article by referring to someone as a speaker of a particular English: Indian English, or Nepali English, for example. We use the term “English users,” following Deterding and Kirkpatrick (2006). It is important to us to both avoid the imprecisions in the terms NS/NNS, and to be consistent with the unbalanced multilingualism dominant in the research context, and so we have used the term “self-identified” L1 where we had asked study participants to identify their “strongest language.”

ii Institutional requirements: Foundation entrance requires TOEFL iBT 40, IELTS 4.0; degree entrance requires TOEFL iBT 80, IELTS 6.0.