Radiography (2008) 14, 216e225

ava i lab le at www.sc iencedi rect .com

journa l homepage: www.e l sev ie r.com/ locate/rad i

The experiences of English as second languageradiation therapy students in the undergraduateclinical program: Perceptions of staff and students

Amanda Bolderston*, Cathryne Palmer, Wendy Flanagan, Neil McParland

Radiation Medicine Program, Princess Margaret Hospital, University of Toronto, Department of Radiation Oncology,Room 5-969, 610 University Avenue, Toronto, Ontario M5G 2M9, Canada

Received 18 July 2006; accepted 14 March 2007Available online 10 May 2007

KEYWORDSEnglish as a secondlanguage;Undergraduatestudents;Qualitative research

* Corresponding author. Tel.: þ1 41E-mail address: amanda.boldersto

1078-8174/$ - see front matter ª 200doi:10.1016/j.radi.2007.03.006

Abstract Introduction: This qualitative study explores the experiences of undergraduate ra-diation therapy students who have English as a second language (ESL) in the clinical environ-ment, as well as the experiences of staff members who teach these students. Specific studyaims were to increase understanding of the issues faced by this subset of students, includingidentifying potential barriers to clinical learning.Methods and design: A qualitative methodology was utilized with focus groups as the data col-lection tool to gain insights from students/recent graduates whose primary language was not En-glish, as well as from staff members who educate this group of students in the clinicalenvironment. Two focus groups were conducted; Group 1 (n Z 6) consisted of ESL graduates/students and Group 2 (n Z 5) consisted of radiation therapy staff members and clinical coordi-nators who are actively involved in the education of ESL students. Comparative data analysis ofthe transcribed discussions was carried out using content analysis and categorized according tothe emergent themes.Results: Three overarching themes were identified for both groups, ‘‘Communication’’, ‘‘Differ-ences’’ and ‘‘Dealing with it.’’ The primary barrier for ESL students was seen as proficiency inEnglish, which manifested in a number of ways. This resulted in a lack of confidence and a subse-quent sense of alienation. External challenges identified were unfamiliarity with Canadian sys-tems and cultural differences. Support strategies identified included the use of mentorship,professional development and external support for teaching staff and journaling, among others.Conclusions: There are identified challenges for ESL students in the clinical environment, thus itis important to provide support for this population to improve learning outcomes. Recommenda-tions for practice, arising from the study as well as the available literature included: allowing

6 946 4501; fax: þ1 416 946 2019.n@rmp.uhn.on.ca (A. Bolderston).

7 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.

The experiences of ESL radiation therapy students 217

extra time, assisting with improving English proficiency, improving confidence, different learningapproaches and ensuring the message is clear.ª 2007 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.

Significance, framework, and review ofliterature

There is a body of literature examining the experiences ofstudents, for whom English is a second language (ESL), inboth nursing and medicine; however this has been a rela-tively unexplored area in the medical radiation sciences.Many of these studies examine aspects of the academic ordidactic environment, as opposed to clinical learningexperiences. There are also very few studies pertaining tothe attitudes and perceptions of staff teaching ESLstudents.

The increased numbers of ESL students admitted intoradiation therapy training programs poses a unique set ofchallenges for students and their teachers. ESL students areoften immigrants who speak a language other than Englishin the home, and bring ‘‘cultural, linguistic and academicbackgrounds that are often unfamiliar to faculty’’1 (p. 204).Recruitment and retention of minority radiation therapistsare needed to meet the needs of the increasingly diversepatient population in a culturally competent manner. Thishas been long recognized in the United States, where mi-nority populations are selectively recruited for nursingand medical schools.2 However, despite these initiatives,ESL students are at high risk for failing courses, withdraw-ing from the program altogether or failing the national li-censing examinations.3,4 In addition, ESL students oftensuffer higher rates of anxiety and depression,5 which mayadversely affect their academic outcome. Newly qualifiedESL radiation therapists often also require organisationalsupport to help them succeed.

Canada is recognized as a vibrant, multicultural society.4

Toronto in particular has a high percentage of residentswho were born outside Canada (43.7%). Unsurprisingly thecity also has a large number of residents whose mothertongue is not English. About 58% of the Toronto populationspeaks English; of the remainder, the most popular lan-guages are Chinese (including Cantonese, Mandarin andHakka) at about 7% of the population, followed by Italian(approximately 4%), Portuguese, Punjabi, Spanish, Polishand Tagalog (all about 2% each).6 In 1998, the Universityof Toronto and the Michener Institute for Applied HealthSciences created a collaborative degree/diploma programin Medical Radiation Sciences (MRS). Students enteringthe program are reflective of Canadian multiculturalismwith diverse ethnic and cultural backgrounds. ESL studentsmeet the admission criteria for the MRS Program for appli-cants who speak a first language other than English orFrench. However, despite passing the entry criteria, manyESL students within the program experience problems. Pre-liminary work in this area by Palmer et al.7 demonstratedthat of those students who have encountered serious aca-demic difficulty, (n Z 69), 20% (n Z 14) have done so be-cause of ‘‘poor communication skills’’ generally identifiedwithin the clinical environment. This initial work has

enabled the MRS faculty to establish a programmaticapproach during the didactic component of the programto address the complex issues of professional communica-tion skills including utilizing an ESL expert during the inter-view process. All first year students are assessed for theireffective communication skills during a Rapid First Impres-sion Interview (RFII), and for those identified at RFIIa ‘‘Communication in Healthcare for ESL’’ course is a pre-requisite to entering the clinical portion of the program.Faculty development enhancements have also been estab-lished to inform pre-clinical and clinical faculty on topicssuch as diversity and providing feedback.

Worthy though these programmatic initiatives are theycan fail to address the needs of the ESL student enteringthe 48-week clinical practicum in the third and final year ofstudy. Students may have experienced problems adaptingto the didactic program and are now faced with a differentprofessional culture and set of expectations. The studentsneed to adapt to working with patients dealing witha cancer diagnosis as well as a rigorous technical environ-ment. In addition to this there is an expectation toseamlessly merge with a professional environment thatincludes such concepts as continuous and prolific verbal andnon-verbal communication with team members and main-taining accurate written records and paperwork. Moreover,some of the learning expectations may be unfamiliar. Forexample, some ESL students may presume a continuation ofthe transmission model of information used in the didacticenvironment and perhaps be unaccustomed to the moreactive learning involved in a clinical practicum.1 These dif-ferences can pose many challenges for clinical faculty, whoare charged with fostering a supportive and mutually re-spectful learning environment.

The purpose of this study was therefore to:

1. Determine the perceptions of the ESL radiation therapystudents of the radiation therapy clinical environment

2. Determine the perceptions of the clinical teaching staffwho interact with ESL students

3. Compare the differences and similarities in the percep-tions of the two groups

4. Identify potential barriers to clinical learning for theESL students

5. Suggest improvements in the clinical teaching programto help overcome any identified barriers

Methods and design

A qualitative methodology was utilized with focus groupsused as the data collection tool to gain insights from ESLstudents and recent graduates (qualified within 1 year) aswell as from staff members who educated and interactedwith this group of students in the clinical environment.Qualitative research is indicated where little is knownabout the area to be studied; it serves to formulate

218 A. Bolderston et al.

theories and hypotheses about situations and behaviours.8

Purposeful sampling was used to target individuals with in-formation and experiences pertinent to the research topic.Ethics approval was gained from the Toronto AcademicHealth Sciences Network (TAHSN) and the Michener Insti-tute for Applied Health Sciences Research Ethics Boardsprior to data collection.

Two focus groups were conducted in total; Group 1(n Z 6) consisted of ESL recent program graduates and finalyear students, and Group 2 (n Z 5) consisted of radiationtherapy staff members and clinical coordinators for whomEnglish is their first language (EFL) who are activelyinvolved in the education of ESL students. Relative partici-pant homogeneity was attempted in each group to encour-age the participants to share their ideas and perceptions ina non-threatening environment. Participants were providedwith a consent form highlighting the purpose of the study,the risks and benefits, and confidentiality. Four key ques-tions guided the discussions within the focus groups:Framing questions for Group 1:

� What were the challenges for you as an ESL student inthe clinical environment?� Did you encounter any barriers to learning in the clini-

cal environment?� Did you find an approach to learning that worked for

you?� What action, or method of teaching benefited you the

most as an ESL student?

Framing questions for Group 2:

� What were the challenges for you as a teacher of ESLstudents in the clinical environment?� Did you perceive any barriers to learning in the ESL

group in the clinical environment?� Did you find an approach to teaching that worked for

you?� What action, or method of teaching did you perceive

benefited the ESL group the most in the clinicalenvironment?

An independent facilitator from another radiation ther-apy institution conducted the sessions to reduce thepossibility of researcher bias, and to eliminate any powerdifferential that may occur between the participants and

Table 1

Theme 1: Communication Theme 2: Differen

Similarities between groupsGetting the words out Lack of confidenceDifferent practice situations External challenge

Differences between groupsGroup 1 Emotional reactionGroup 2 General students i

High percentage o

Group 1. ESL undergraduate and recent graduates.Group 2. EFL radiation therapy staff members and clinical coordinato

the researchers. Discussions were tape recorded andtranscribed verbatim. Comparative data analysis of thetranscribed discussions was carried out using contentanalysis and categorized according to the emergentthemes. The data were analyzed independently by tworesearchers (AB and CP), to verify trustworthiness andcredibility.9 The remaining two researchers (NMcP andWF) then checked the emergent themes.

Study limitations

Data saturation was not achieved as only 2 focus groupswere conducted due to time and resource constraints. Inaddition, EFL students were not included in the focusgroups; this is an important future research direction toclarify whether issues raised are unique to ESL students orperhaps common to both ESL and EFL individuals. MemberChecking, a means by which interpretations of the data areshared with participants to ensure that meaning has beenpreserved was not conducted in this study, primarily due topower differential between the participants and the re-searchers.9 In addition, qualitative research is not consid-ered generalizable thus the conclusions drawn may nothold true for all institutions and practice settings. The re-sults can, however, provide insight into a specific situationand may serve as a signpost for similar investigation inother areas.

Results

The same 3 overarching themes were identified from thedata generated from Group 1 (ESL undergraduate and recentgraduates e henceforth referred to as ‘‘students’’) andGroup 2 (comprised of EFL radiation therapy staff membersand clinical coordinators who are actively involved in theeducation of ESL students e henceforth called ‘‘teachers’’).The themes were ‘‘communication’’, ‘‘differences: fitting in(or not)’’ and ‘‘dealing with it’’. Underpinning these over-arching themes were several sub themes, which differedsomewhat between Group 1 and Group 2 (see Table 1).

Theme 1: Communication

Unsurprisingly, the primary theme identified in Group 1 wasissues with communication that cause challenges to the

ces e fitting in (or not) Theme 3: Dealing with it.

Times External support

s Self-initiated strategiesssues Staff supportf problems with ESL students

rs actively involved in the education of ESL students.

The experiences of ESL radiation therapy students 219

clinical education process. There were 2 sub themesassociated with communication, the first is entitled ‘‘get-ting the words out’’ which can be subdivided into 4 areas asdetailed below.

Getting the words out(i) Difficulty understanding the accent/pronunciation

Having a distinct accent and/or pronouncing wordsincorrectly were seen as a barrier to communication withboth staff and patients. It was seen as a possible source ofteasing or ridicule by one participant, who commented thatstaff were making fun of one of her classmates because ofthe way that she spoke.

(ii) VocabularyBeing unable to express oneself because of a lack of

English vocabulary was also seen as a problem for manystudents. This issue might affect everyday discussion withstaff and patient interactions but also clinical presentationsand class tutorials because:

‘‘.There is no way for you to sound as good as some ofyour peers when you don’t have that vocabulary for youto use’’.

Because of a limited vocabulary participants identifieddifficulties with speaking up, asking questions and partici-pating in conversations. One therapist explained the situ-ation as a problem:

‘‘.Receiving the message . from others. the wholeconcept or situation is hindered by the languagebarrier.’’

Stemming from a lack of English vocabulary, some partic-ipants mentioned that they have difficulty sometimeschoosing the right words for a situation. The lack offamiliarity with the nuances of the English language canlead to misunderstandings; for example an inappropriateword choice may be inadvertently offensive. In addition,the participants’ lack of vocabulary made it hard for themto hold a social conversation with staff, which maynegatively affect socialization and team development.

(iii) Translation into/from own languageESL new graduates and students need to mentally

translate to and from their primary language when com-municating in English. This may take extra time andconcentration, which participants identified as a problemas it may slow the conversation down and can be mentallytiring:

‘‘By the end of the day, or maybe by the end of theweek, they are asking questions and I end up saying yesor no in my language.’’

(iv) Decoding the conversationThe participants identified circumstances where they

had problems extracting the ‘‘buried meaning’’ in a con-versation. When therapists talk in a clinical situation, thereis often discussion that might appear unconnected with theclinical situation that may be missed by the ESL staffpopulation as they struggle to translate and decode theconversation.

The participants felt that they had a high need toconcentrate on translating and understanding conversa-tions, instructions and written information:

‘‘Especially when you are controlling the machine andsomeone is talking over you; it is hard for you to noticethe information’’.

This single-minded focus can make dealing with more thanone task at a time difficult. In addition, when the ESLindividual ‘‘blocks out’’ other stimuli, they can misssomething else going on that may be important (forexample, when listening to instructions at the treatmentconsole they may pay less attention to the readouts).

Different practice situationsThe second sub theme in the communication categorydiscusses interactions in various work-related situations:

(i) Speaking to staff versus patientsIn general, participants felt more comfortable talking to

patients as opposed to staff members. Patient conversa-tions were seen to be more standardized, similar issueswere discussed at various points along the treatmentcontinuum, thus the individual could prepare somewhat,either by writing down what to say or by mentally re-hearsing the situation. Discussions with staff members wereseen as less predictable and consequently more stressful.

(ii) Phone conversationsSome participants preferred to communicate over the

phone as it is more impersonal and there is less pressure.However, other participants found that the most difficultchallenge in the beginning was to pick up the phone.

(iii) Reading or writing EnglishSome group members also saw written communication as

problematic. More time is often needed to translate writtenmaterials or find the right words when writing clinicalnotes.

Theme 2: Differences e fitting in (or not)

Theme 2 deals with how the participants perceived differ-ences influence their working or learning situation. Thereare 3 primary sub themes, ‘‘lack of confidence’’, ‘‘emo-tional reactions’’ and ‘‘environmental challenges’’.

Lack of confidenceMost participants identified lack of confidence as a problemfor them. One participant described this as a ‘‘weakness’’which further diminished their ability to effectively com-municate with staff and patients.

‘‘It affects the confidence; sometimes they look down onyou because of your pronunciation, if you pronounce itin one way.’’

Emotional reactionsSeveral personal reactions to the situation were discussed,including feelings of alienation and discomfort at beingthe target of jokes or humour relating to the way onespeaks.

(i) AlienationAn inability to effectively communicate can lead to

feeling separate from the group; participants described thisin various ways:

‘‘You can’t become part of them. It’s difficult. itinterferes with interpersonal relations and teamwork’’

220 A. Bolderston et al.

(ii) Making fun/rudenessBeing the butt of (presumably) good-natured humour

was not appreciated by all participants, who may notunderstand what the joke is about, fear ridicule or havea different cultural perception of the situation:

‘‘Even if it is a small joke, it might affect you because, ohmy, they are laughing at my pronunciation. Most of usmight end up not showing it, but it just sticks to your mind’’

External challengesApart from communication issues, there are several otherchallenges facing staff and students from differentcultures.

(i) Unfamiliarity with Canadian systemsSeveral participants described difficulties understanding

or accessing resources such as libraries, student supportservices and even transportation. This made reports, tasksand examinations more problematic and preparation timefor ESL students for academic work could be much greaterthan non-ESL individuals.

(ii) Cultural differencesThe expectations of the student-teacher relationship in

Canadian culture may differ considerably from the partic-ipants’ place of origin. Several participants discussedsituations where verbal and non-verbal cues had beenmisunderstood when they were students. One participantillustrated one such cultural disparity as follows:

‘‘I tend to smile by nodding, that’s my culture. Butfinally I found that they didn’t like it, and they thinkthat’s not a good attitude. So I look at their faces veryseriously, and take in everything very seriously.’’

(iv) Clinic versus classroomThere were a number of comments dealing with learning

environments and the advantages and disadvantages of theclinical versus academic environment. On the whole, theclinical environment was preferred because of the visualand experiential nature of the experience (compared to thefocus on reading, listening and writing in the classroom).

Theme 3: Dealing with it

ESL students and staff had used several strategies to helpfacilitate communication and learning.

TimeThis was the dominant theme throughout the discussion andunderpinned many of the participants’ other comments.The participants were well aware that extra time wasneeded to carry out tasks, talk to patients and colleagues,prepare for tests, write assignments and read patientinformation or textbooks. This often caused stress for thestudents and even guilt, as they perceived that theirpresence might affect the department’s functioning:

‘‘It takes a longer time than the other staff when theunit is on a tight schedule and you feel the pressure andeven slowing them down’’.

However, time was also a strategy that could be used,reading and preparation ahead of time could serve to levelthe playing field somewhat and allowing more time for

certain tasks (such as talking to patients) could meana better outcome for the student:

‘‘If you can really try to figure out what kind of morningyou are going to have.you are going to know inadvance, that is the best approach for me.’’

External supportApart from being cognizant of the ways they could takeextra time to help their clinical practice, students men-tioned several other ways they had obtained externalsupport from the institution or their colleagues.

(i) Mentorship

‘‘It’s OK to go back home and talk to your family, but thething is that your family or your friends might notunderstand what you are going through.’’

Several students felt that having a mentor was a usefulsupport strategy, whether they had self-selected a graduatetherapist who had had similar experiences or relied on thehelp of their clinical coordinator. One participant hadmentored a younger student and had found that to bea positive experience.

(ii) School staffThe clinical coordinators were seen as key to identifying

problems at an early stage and initiating individualizedhelp. This help included vocabulary coaching, and otherspecific interventions dealing with communication issues.Class tutorials and individual knowledge testing were alsoseen as important in dealing with language issues. However,there was some discomfort in discussing problems withdepartment staff with the clinical coordinator,

‘‘There is so much you can say, and so much you can’t,because we all have to get along with each other.’’

In this case, students may chose to talk about staff issueswith their fellow students, instead of their clinicalcoordinators.

A fairly recent resource for MRS students is the role ofthe student counselor who provides confidential, one-on-one support for students experiencing personal or academicdifficulty. Some of the participants in the focus groupidentified this service as a good source of assistance.

(iii) Clinical staff

‘‘I agree that if the staff is friendly and the environmentis tolerant to different accents and different difficultiesin speaking it helps students to open up and pick upquicker’’

In general, participants felt that welcoming and friendlystaff contributed to a positive learning environment, wherethey felt accepted and more able to ask questions.

(iv) Working with ESL staff/studentsWhen the participants were working with someone who

had ‘‘been there’’ e a staff member or student whoseprimary language was not English e they felt a sense ofcomfort, as theyperceived thatperson wouldbe empathetic.

Self-initiated strategies(i) Asking questions/for help from staff

Open communication with staff was seen to be veryimportant. The expressions ‘‘double checking’’, ‘‘keep

The experiences of ESL radiation therapy students 221

asking’’ and ‘‘troubleshooting’’ were used to describea process of ensuring the staff member’s message hadbeen received and understood. Moreover, the participantssaw the importance of discussing upcoming patients andtheir technical and clinical issues, as well as listeningto team members’ conversations about work-relatedissues (as well as questioning to clarify any areas ofmisunderstanding).

(ii) JournalingWriting was seen as a useful tool to help guide emergent

clinical practice. Several participants described usinga book to list unfamiliar terms, or jot down questions forthe clinical coordinator that they did not want to ask theunit staff. They also described preparing ahead of time bylisting steps to be taken for a given situation on paper, thusgiving them a template for action.

Theme 1: Communication

Getting the words out(i) Difficulty understanding the accent/pronunciation

‘‘Students quite often know the words that go withradiation therapy.but they don’t know how to saythem’’

The teachers saw a strong accent as a possible communi-cation barrier, and this could coincide with mispronuncia-tion of certain technical terms that may also confound theissue.

(ii) VocabularyThis was from the point of view of both teacher and

student. Often the student would struggle with the rightchoice of words, but the teachers also had to be careful tochose simple words and avoid (or explain) jargon. Jargonwas seen as multidimensional, and included technicalterminology, department-specific terms and phrases andunfamiliar use of everyday expressions (such as bed, couch,table and so on).

(iii) Difficulty in ascertaining comprehension

‘‘It’s gauging .whether the message has beenreceived’’

This was seen as a significant problem for many of theteachers and they commented that non-verbal communi-cation varies between cultures and can confuse themessage. For example, one participant mentioned that hesaw ‘‘a lot of nodding’’ when explaining a point to an ESLstudent but subsequently found that the student did not, infact, understand the issue as he had assumed. Theimportance of clarifying by asking questions was alsoraised.

(iv) Decoding the conversationWhile Group 2 generally agreed that a student could miss

information because they may lack the ability to mentallycategorize the conversational components into ‘‘not clini-cally relevant’’ and ‘‘clinically relevant’’, they also feltthat ESL students might also misunderstand some culturallyspecific non-verbal communication such as:

‘‘Those little subtle kind of flippant comments that wemake . and also differentiating between professionaltalk . and social talk.’’

Different practice situations(i) Speaking to staff versus patients

Whereas Group 1 generally felt more comfortable talk-ing to patients; Group 2 perceived that the studentsgenerally had more problems talking with patients. Therewere a variety of issues raised:

� Patients may be unwilling to expend the extra effort tounderstand a student who has an unfamiliar accent.This can also lead then to interacting with the supervis-ing staff member, instead of the student.� It may take more time for a student-patient interaction

with an ESL student than a non-ESL student.� The interaction may be difficult for the student, which

can lead to problems with confidence for the student oreven unwillingness to interactwithpatients in the future.

Theme 2: Differences e Fitting in (or not)

Lack of confidenceThis was seen as a distinct barrier to clinical education,a lack of confidence could cause the student to not fullyinvolve themselves in the day-to-day processes of thedepartment. Staff felt that ESL students might have to‘‘prove’’ themselves more in the clinical setting if the staffhave already perceived them as slower (or less competent)than other students:

‘‘Once the staff has an impression, OK, I don’t reallythink you know what you are doing here, the only realway to overcome that is to show confidence’’.

ESL students were felt to be generally less confidentthan their non-ESL counterparts, this may in part becausethey were perceived as being less successful generally andhad had previous difficulties. However, some participantscommented that language is the only factor that impactsconfidence because:

‘‘When they are talking in their own language (topatients) it is totally different, it’s like night and day.’’

Environmental challenges(i) Cultural differences

As well as the previously discussed difficulty in ascer-taining comprehension (which some participants felt wasa cultural difference), teachers felt that ESL students oftenhad had experiences in a different type of educationsystem that would influence the way that they learnedand preferred to be taught. One participant recalled a frankconversation she had had with an Asian ESL student whohad not been actively participating (and had been identi-fied as ‘‘lacking initiative’’). The student’s perception hadbeen that ‘‘the therapists were the masters, so as anapprentice their role was to observe, stand back, and askquestions’’. When roles were clarified and expectationsmade explicit, the student’s grades improved. The partic-ipants felt that instruction needed to be direct and timely.

General student issuesThere were some issues identified that seemed (to theinvestigators) to be general student issues but participants

222 A. Bolderston et al.

felt were especially present in the ESL population. Theseincluded:

(i) Micro focusing e missing the big picture

‘‘They go from A to D because they want to get it done,but they are missing a whole bunch of stuff in themiddle’’

ESL students were seen as ‘‘missing the big picture’’ egetting inappropriately focused on a minor detail whileoverlooking the important elements of the situation.Students were seen as needing hard and fast rules forsituations that may be clinically grey areas, and beingunable to work outside the boundaries of the well docu-mented and familiar:

‘‘I have seen it many times, where they can quote yousomething from Khan (physics text book), page 7, andthey know that’s what it’s supposed to be but if thereis any deviation from that they are lost.’’

(ii) Students wanting to be seen as capableAnother explanation for the difficulty ascertaining

whether students had understood teaching was that:

‘‘They don’t want to be perceived as not beingcapable.’’

Thus it was felt that some students sometimes feignedunderstanding.

(iii) Being left outA couple of the participants also commented that

clinical staff might intentionally omit ESL students fromsome conversations/decision-making processes due to timeconstraints:

‘‘You want to give information to those who will act onit.I don’t see that as bias, it’s only natural’’

Although one participant commented that all students areexcluded in this way to some degree, not just ESL students.

High percentage of problems with ESL students

‘‘I think if it was like a group of 10 people you hadtrouble with, the majority would be ESL’’

There was a perception that, although any student couldcome up against learning barriers within the clinic, themost likely students who may present as needing extra timeand support would be ESL students.

Theme 3: Dealing with it

TimeOnce again, the biggest single thing that the group feltwould help ESL students was extra time.

‘‘I think it is more important with an ESL student toseparate from what everyone else is doing around youand not have these little snippets e interrupted conver-sations that are mixed in with verifying treatment fieldsand so on.’’

The staff also felt strongly that sometimes extra timewas not available and, in the interests of optimizing patientcare, the students ‘‘ran out of time’’:

‘‘I am probably one of the first people in the treatmentroom to say, you know, OK, let’s move along.’’

However, staff recognized that they sometimes mademore accommodation for ESL staff than with students:

‘‘ESL therapists, once they have graduated, now theyare working with you so you have to do it (give themmore time)’’

Staff supportGroup 2 recognized several intrinsic ways that they couldsupport ESL students.

(i) Clarifying expectations and being clear/open

‘‘Right in the beginning, if they know what you expect,then they are going to achieve it’’

Roles should be defined up front; both the teacher’s roleis as well as the student’s. One participant pointed out thatoften we assume people know what a ‘‘teacher’’ is, but itmight be a Western construct and unfamiliar to othercultures. As previously mentioned, feedback should beclear and honest. One participant commented that wetend to ‘‘dress up’’ criticism but in her experience, somestudents missed the main message (you need to improvethis) and only heard the positive comments before andafterwards. Later (after the student failed an evaluation)they felt the teacher had not ‘‘done their job’’ by pointingout the area they needed to improve (although, from theteacher’s point of view, she had!). She concluded thatmany ESL students ‘‘want concrete, am I doing well ornot?’’

(ii) Staff teaching abilityParticipants pointed out that ESL students might benefit

from continuity, having the same point of contact duringa clinical rotation. It might also be beneficial to the studentto have staff on the machine that spoke their language, andcan act as their coach. Unfortunately, it was also notedthat:

‘‘You do have some therapists who aren’t teachers, andthose ESL students may fall into the hands of a therapistwho doesn’t want to teach and doesn’t want to spendthe time’’.

(iii) Using visuals and demonstrationMixing teaching methods was seen as being helpful in

getting the message across. Drawing pictures, using labsand demonstrations are useful adjuncts to verbal teaching.

External support(i) Provision of external support/knowing how to help

‘‘Students have to be unsuccessful to access support,and it is unfortunate we do that because then they haveno confidence.’’

Participants felt that better external support might bebeneficial for ESL students, for example, an ESL expert onstaff, extra English courses or teaching clinical staff aboutbetter ways to teach ESL students.

(ii) Course structureThe current course structure is such that students spend

the vast majority of their clinical time in the last year of

The experiences of ESL radiation therapy students 223

their program. This was seen as problematic, and it wassuggested that moving some of the clinical time earlier inthe course might help ESL students better acclimatize tothe clinical environment and be able to access moresupport from their education institution.

(iii) JournalingAs in group 1, some participants felt that ESL student

might benefit from keeping a notebook of questions todiscuss with teachers.

Discussion

In general, themes were fairly similar between the 2groups, although there were some interesting differences.Both groups saw the time issue as paramount, and theteachers worried that they were doing a suboptimal jobwith ESL students because they didn’t have time to spare.There was also a strong agreement from both groups on theimportance of English proficiency (which includes accent,vocabulary and pronunciation) and the need for variousways to improve verbal communication. In the only studyidentified that compared (nursing) faculty’s perception ofESL student’s learning difficulties with the student’s them-selves, there was considerable difference between thefaculty and student’s perceptions of both the way ESLstudents learn and the difficulties they experience,4 whichis not congruent with the results of this study e althoughthe differences in subjects and methodologies preclude di-rect comparison.

The students viewed the most helpful characteristic ofa clinical teacher was to be open, welcoming and friendly.The teachers, on the other hand, discussed a variety ofteaching methodologies and expressed a desire for moresupport as they felt that they lacked specialized knowledgeto deal with issues arising from ESL status. The studentssaw the clinical coordinators as a vital component toimproving comprehension and adaptation to the clinicalenvironment, but the teachers did not seem to regard theschool staff as a source of help. There was a troublingimpression from the teachers that ESL students werepossibly not getting the same opportunities as non-ESLstudents, because time was short and the staff wanted toensure that patient care was not compromised (for exam-ple, by a longer set up). Teachers felt this was exacerbatedby a lack of confidence on the part of the student, whichmay cause them to step back, or withdraw from a situation,and thus participate less than the average non-ESL student.In addition, while students felt generally more comfortabletalking to patients, teachers felt that this was a problemarea for them as a student-led patient teaching sessionswhere the patient may have difficulties comprehending thestudent might take more time. Teachers saw difficulty inascertaining comprehension as a significant problem, al-though students did not mention this directly (althoughthey did feel they were sometimes hard to understand,which is a related issue). Students felt hampered by a lackof familiarity with the system, although the teachers didnot identify this as barrier. Also, while teachers werecognizant of many of the obstacles ESL students faced(for example, cultural differences), they did not discussthe emotional issues, while the students identified feelings

of isolation and discomfort at being the subject of jokesand teasing.

Issues for practice

The following recommendations for practice come froma consideration of the data from this study as well asa review of the available literature.

Allow extra time

Time was the most significant theme for both groups. ESLstudents ‘‘often take two or three times longer than(American) students to complete reading and writingassignments’’10 (p. 214). In addition, even if English classesare provided, ESL (nursing) students ‘‘progress through thecurriculum at a slower pace than their classmates’’2

(p. 153). Presumably this is true also for the clinical curricu-lum. Therapists are patient advocates and want to deliveraccurate and timely care. However, in a busy department,time is always short and teaching is often done ‘‘on thefly’’. This approach may not work with ESL students, whoneed more time to prepare, think through and assimilateexperiences as they are simultaneously filtering the lan-guage, the clinical and the cultural context. The studentcould alternate patients, for example, to allow extra timeto read set up notes and hospital charts and staff could ar-range regular short one-to-one sessions for the student. Thestudent may also benefit from individual tutoring sessionswith emphasis on medical and non-medical English; thishas been shown to improve identification and recall of im-portant information in verbal reports in small nursing casestudy.11 This may help with the issue of ESL students havingdifficulties categorizing conversational components into‘‘not clinically relevant’’ and ‘‘clinically relevant’’ as iden-tified in this study. Additional time for students often equa-tes to extra human resource support. Extra teaching staffwill be beneficial when the class has a high proportion ofESL students.

Assist with improving English proficiency

It has been noted, ‘‘English proficiency. is unambiguouslyrelated to satisfactory educational experiences’’12 (p. 24).Vocabulary, accent and familiarity with idiom and jargonwere seen as considerable barriers for both groups in thisstudy as well as studies in nursing.1,13,14 Thus efforts to im-prove English language should be seen as vital. Staff andfaculty should also attempt to keep their communicationsimple and avoid the use of colloquialisms, jargon, cul-ture-based idioms and so on. Various types of communica-tions courses throughout the period of clinical training(in nursing and medicine) have been demonstrated to bebeneficial in several studies including the use of weeklyinteractive conversational-skills sessions.15,16 However, tosound a note of caution, in a study comparing (nursing)faculty’s perception of ESL student’s learning difficultieswith the student’s themselves,4 the faculty rated the effec-tiveness of ESL classes (to improve English) higher thanstudents (who rated reading course textbooks and conver-sations with English speakers more highly).

224 A. Bolderston et al.

Utilize the expertise of school staff and/or theeducational institution

The student group in this study saw the role of the clinicalcoordinator as paramount and both groups recognized theneed for external support. The clinical coordinator is theliaison with the staff and student and can facilitate a frankdiscussion of the ESL issues and support strategies to beused. Documentation is key, both as a tool for opencommunication and a method of tracking progress. Someexperts advocate the preliminary use of a studentquestionnaire to find out more about the student’sexpectations, interests, linguistic expertise, academicbackground and to help create mutual understanding.1,13

As all students are culturally unique, this approach mayhelp to guard against stereotyping.17 The questionnairecan be followed up with a conversation to clarify the find-ings and to explain the active role students are expectedto play in their own learning. Role-playing has been foundto be a valuable way of increasing confidence and commu-nication for ESL nursing students13,18 thus modeling com-mon practice situations with students may be a usefulstrategy. Furthermore, attention should be paid to ensur-ing teaching faculty such as clinical coordinators (wherepossible) is also ethnically diverse to provide role modelsand provide an appreciation of culturally sensitive issues/challenges, etc.18,19

It is worth noting that staff teachers in this studyexpressed a need for more help and direction and maybenefit from information about the cultural background oftheir students as well as ESL teaching approaches. Ina study by Jalili-Grenier and Chase4 examining faculty per-ception of methods of assistance for ESL students, 80% ofrespondents required more assistance in dealing with ESLstudents. They ranked (in order of preference) workshopson instructional techniques, academic support forstudents, workshops on cultural issues and collaborationwith an ESL specialist as useful methods of assistancefor working with ESL students. All of these strategies,plus institutional commitment to the process are externaleducational strategies discussed in the nursing literatureto improve the retention and experiences of ESLstudents.20

Improve confidence

Lack of confidence was seen as an issue in both groups andhas been cited as a barrier in other (nursing) studies.10

Increasing comfort with English will bolster confidencebut students should also be encouraged to discuss theirneeds with clinical faculty and take an active role in theirlearning. Encouraging opportunities for the ESL student tointeract with patients from their own background will pro-mote confidence and may provide greater insight into thepatient’s situation.13,14

Provide social support

ESL students may feel alienated15; in this study ESL studentsidentified feeling separate from the group. They also sawother students as a source of assistance when dealing with

staff issues and appreciated the presence of fellow ESL staffand students for social support. Social interaction with EFLstudents in nursing studies increased effective adjustmentand allowed continued personal growth and English languagemastery.18,20 Having a student ‘‘buddy’’, being part ofa study group or tutorial session, taking on a social role(for example, helping to organize a student luncheon), orseeking out fellow ESL students or staff may help themfeel less isolated.1,2,14 However, study groups with primarilyESL nursing students have been negatively correlated withacademic achievement21 so heterogeneous groups (of ESLand EFL students) should be utilized. The use of a mentormay be helpful for the student; an informal mentorship ar-rangement can be made with a recent graduate who hasshared similar experiences.2 Mentored nursing students‘‘feel their own self-worth improved . and were more con-fident in their transition from student to professionalnurse’’18 (p. 265). The mentor can also help with languageacquisition, thus academic and non-academic interactionshould be encouraged between mentor and student. Stu-dents in this study had difficulty at first accessing academicand social resources thus concrete assistance in this areamay be beneficial (for example, a field trip to the library).Students should be encouraged to use all existing means ofsupport provided by their educational institution (for exam-ple, several students in this study found the student coun-selor to be helpful).

Utilize different learning approaches

As discussed by the teachers in this study; a variety oflearning approaches may benefit ESL students, includingactivities designed to stimulate a variety of senses.4 Exam-ples identified included demonstrations and visuals. Furthermethods cited in the literature are the creation of conceptmaps to help ESL students learn by visualizing the thinkingprocess.1 Students in this study found group discussionswith other students a useful way to reinforce learning;these settings can ‘‘create relatively therapeutic settingsthat encourage cognitive thinking and affective responsesfrom ESL students’’ (ibid, p. 205).

The students felt that they benefited from using a note-book to focus their conversations with staff, this could alsoinclude a list of terms they did not understand, as well asany clinical questions that arise. The student can share thiswith as few or as many people as they feel comfortablewith. Journaling (or the use of non-graded ‘‘clinical logs’’)has been identified in several studies as a useful source ofsupport for ESL students to aid in reflection and trynew vocabulary.1,13,22 Feedback is important for studentsutilizing journals as faculty can assist in correctingmisunderstandings.

Build respect and trust

Students revealed that they valued a warm and welcomingenvironment. While familiarity with adult teachingtechniques are always ideal, the most important character-istics of good clinical teachers demonstrated in this studyare that they are welcoming to the student, show patience

The experiences of ESL radiation therapy students 225

and understanding. Furthermore good clinical teacherscommunicate/liaise well with the clinical coordinator/school representative to identify any issues as they ariseand provide input into solutions that may work within theirclinical environment. Learning how to correctly pronouncestudents names, asking questions about their family/socialsituations/culture are all good ways to break the ice andbuild trust.22 There is limited data describing staff attitudesto teaching ESL students however, students in the past havebeen expected to change their behaviours to conform tothose of their adopted culture rather than staff adoptingculturally congruent methods of teaching.22 Finally, as wehave seen that while a sense of humour is a wonderful thing,staff teachers need to be aware that making jokes aboutmispronunciations for example may be culturally inappro-priate and inadvertently hurtful.

Ensure the message is clear

Communication should be clear and direct, and the sendershould ensure that their message is understood and allowtime for questions and clarifications. A lack of questionsfrom the student does not always imply understanding, forexample Asian students may be reluctant to question theteacher openly or answer directly posed questions (this mayresult in ‘‘losing face’’ for the student who may not want toappear foolish or ignorant, but also for the teacher if theydo not know the answer to the question). Head nodding orsmiling (for Asian students) may not mean the teacher hasbeen understood and ‘‘a response of ‘yes’ means only ‘Iheard you’ and may not be automatically equated toagreement or consent’’10 (p. 212). Culturally congruentteaching may involve creating a private space for the stu-dent to ask questions, away from the rest of the staff, orencouraging students to make appointments to talk to clin-ical coordinators.

Conclusion

To conclude, ESL radiation therapists bring unique andvaluable insights to the care of our culturally and linguis-tically diverse patient population and active measuresneed to be taken to support and retain ESL students withintraining programs. For nursing students, clinical courseshave been demonstrated to be significantly more difficultfor ESL than non-ESL students, possibly due to the highlevel of interactive communication required.4 However, ithas also been shown that faculty awareness, the attitudinalopenness to improve teaching practices, adapting to theneeds of the student and external support services canincrease retention of ESL students in nursing4,13 thus wecan assume the same to be true in the medical radiationsciences.

This research is a preliminary examination of this topicwithin medical radiation sciences and therefore moreinvestigation is required. Implementation of the recom-mendations outlined above and subsequent evaluation ofthe interventions will provide empirical data to supportthe outcomes, to ensure the specific needs of the ESLstudent are met.

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