- Email: [email protected]
How do nurses acquire English medical discourse ability in nursing practice? Exploring nurses' medical discourse learning journeys and related identity construction
Nurse Education Today 85 (2020) 104301
Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/locate/nedt
How do nurses acquire English medical discourse ability in nursing practice? Exploring nurses' medical discourse learning journeys and related identity construction
T
Yi-Ling Lu Language Centre, National United University, 1 Lienda, Miaoli 36003, Taiwan, ROC
A R T I C LE I N FO
A B S T R A C T
Keywords: English medical discourse Nursing professionals Hospitals Professional identity
Background: In Taiwan's hospitals, English medical discourse underpins nursing and medical practice. Much patient care work is done through language work, by both text and talk. This means that when nurses start their nursing careers in the hospital context, where English medical discourse is shared to produce knowledge and engage in practice, knowledge of medical discourse and the ability to use it are prerequisites. In the process of learning and using such specialist language, the formation of professional identities is assumed. Objectives: This study aimed to explore nurses' learning journeys relating to medical discourse and the development of their professional identities. Methods: This research adopted a qualitative approach, using data from 10 nurses working in different hospitals in Taiwan. Results: The findings revealed that English medical discourse was employed in Taiwan's hospitals not only for fulfilling professional purposes but also for socialising nurses into the healthcare community. Nurses acquired it through interactions, small talk, relationships, discussions, and nursing tasks. Their professional identities were formed through engaging in meaningful nursing practice based on English medical discourse. However, in the learning process, they encountered difficulties in the areas of listening, speaking, and reading, which raised concerns about patient safety. Conclusion: Sufficient support is needed to ease nurses' difficulties in learning. We propose having primary and secondary preceptors, establishing a mentorship policy, and creating a learning environment that is supportive of nurses' learning experiences.
1. Introduction English medical discourse serves as an indispensable tool in both written and spoken discourse among healthcare personnel in Taiwan's clinical practice. Although the Chinese equivalents of medical discourse do exist, nurses and doctors code-switch into English whenever medical terms are mentioned. This phenomenon is distinctive. Unlike Singapore, where the population speaks different mother tongues and where English thus functions as a lingua franca in the workplace (Goh, 2010), the majority of healthcare professionals speak the official language, Chinese, in Taiwan's hospitals. According to statistics from the Gender Equality Committee of the Executive Yuan (2018), the percentage of in-practice foreign nurses who may resort to English to communicate in Taiwan is less than 1%. In such a context, the reason why English medical discourse is dominant is worth exploring. English's privileged place in the hospital context dates back to the
colonial period from 1895 to 1945, when the Japanese government introduced Western medical education to Taiwan, establishing formal institutions and offering medical instruction in order to improve the sanitary environment and maintain political stability (Chang and Su, 2014). From there, the privileged place of medical English in Taiwan's healthcare education was established. Western medical education and its influence were not terminated with the end of the Japanese government's reign; instead, they have been continuously developed and advanced. Today, Taiwan's medical care, compared to nearby countries such as Japan and Singapore, although being less expensive, is of a high quality (Yang, 2011). English medical discourse is widely used to circulate information in medicine and nursing. Therefore, when nurses enter a healthcare community, where English medical discourse is shared to produce knowledge and engage in nursing practice, they must possess medical discourse ability to fulfil their job demands (Bosher and Stocker, 2015; Yang and Su, 2003). In the process of learning and using
E-mail address: [email protected]. https://doi.org/10.1016/j.nedt.2019.104301 Received 17 April 2019; Received in revised form 16 September 2019; Accepted 18 November 2019 0260-6917/ © 2019 Elsevier Ltd. All rights reserved.
Nurse Education Today 85 (2020) 104301
Y.-L. Lu
Second, medical discourse, which appears incomprehensible to outsiders, is employed by healthcare personnel to delineate their membership. They share knowledge, ideas, habits, and norms in using medical discourse and demonstrate their competence, specialisation, and knowledge through the expert discourse (Little et al., 2003). Third, medical discourse symbolises a form of expert knowledge. Individuals speaking in medical discourse are deemed to have professional knowledge so that they are considered authoritative. For example, in Taiwan, doctors usually use medical discourse in English to communicate with nurses (and their patients) to reinforce their authority (Bosher and Stocker, 2015).
medical discourse, nurses may develop beliefs regarding medical discourse in relation to their professional identities. This assumption is based on Wenger's (1998) seminal concept of community of practice, the significance of which centres on learning from participating in practice. Here, practice is doing ‘but not just doing in and of itself. It is doing in a historical and social context that gives structure and meaning to what we do’ (1998, p. 47). Learning propels practice. Everything individuals learn in order to fit themselves into a particular community—for instance, learning to talk, engage, and interact—gives rise to and shapes practice, and lays the foundation for developing competence in relation to the community. Identity is thus formed through the learning process. What inspired the current study is that if learning, as assumed by Wenger, takes place in a social context, where established members negotiate meaning to achieve a mutual understanding and to participate in a joint enterprise, nurses' learning of medical discourse in hospitals, where healthcare professionals interact, discuss, and cooperate with one another to promote patient well-being, may share this character and help construct professional identities. Therefore, this paper explores nurses' learning journeys related to medical discourse and the development of their professional identities.
3. Study aim The literature review helped me to understand that expert language used by a particular group defines membership and has authority and power; it excludes those who lack such knowledge. However, the previous studies also raised more questions, prompting the current study, where I look at the broader and more comprehensive picture of the relationships among learning, language, and identity. A particular interest in this study is the ‘process’ rather than the ‘product’; that is, how does learning take place in hospitals and how is professional identity forged through language use? These research questions are related to others worthy of exploration, such as how does medical discourse function in a hospital? How do nurses perceive the relationship between knowledge of medical discourse and clinical competence? Do nurses feel under pressure to use medical discourse when they are involved in the healthcare community? This study was intended to answer these questions.
2. Background According to Hyland (2009, 2010, 2011), language is able to represent one's identity. Speaking or writing in particular ways announces people's connection with and membership in certain communities, so that they become, as Lave (1996, p. 157) stated, ‘kinds of persons’. By using the community discourse that members belonging to the same communities use, individuals are recognised as insiders in a community, as ‘we position ourselves in relation to others using these discourses and in turn are positioned by these same discourses’ (Hyland and Tse, 2012, p. 156). In a hospital context, medical discourse, which refers to descriptions of a disease, medication, therapy, and relevant expressions in the medical domain (Wilce, 2009), is a paradigm for defining memberships and distinguishing the self from others. The members in a healthcare community share knowledge, norms, and habits in relation to the use of medical discourse, including in oral as well as written communication. This means that socialisation into this community requires mastery of knowledge about and attitudes towards the use of professional language (Gunnarsson, 2009). In the case of Taiwan, according to their official websites, 21 out of 23 nursing junior colleges and all 11 universities of science and technology in northern Taiwan's technical and vocational education system have developed professional English courses for their students, in the hope of equipping their students with professional English ability to meet both the entry requirements and demanding linguistic realities awaiting them. Lu (2016) introduced how English medical discourse was used in the context of shifting reports in Taiwan's hospitals and how nurses code-switched into English rather than using Chinese medical terminology. Nurses learned this shared and accepted way of speaking from their seniors, and they did this in order to be seen as professional in the eyes of others. The current study built upon the existing evidence base and further explored how medical discourse helped construct nurses' professional identities. The assertion of Allen et al. (2007) lends support to the basic assumption concerning identity in this study. For them, medical discourse identifies and consolidates nurses' membership in the healthcare community. Only those with professional knowledge within the community understand this specialist language, as meaning and understanding are shared among them, with the consequent exclusion of others not belonging to the community. In addition, Tonkiss (2012, p. 408) remarked that medical discourse has three functions: it ‘marks out a field’, ‘confers membership’, and ‘bestows authority’. As to the first function, medical discourse is devoted to the domain of healthcare professionalism and is used to address issues in the healthcare field.
4. Methodology 4.1. Methods This study employed a qualitative approach to fulfil the research aims. Nurses' views result from their interactions within their practice and within the context in which they are involved; therefore, a potential approach to fulfil the research aims was to question nurses and talk interactively with them in order to understand and comprehend the meanings they created for their world. Semi-structured interviews with 10 nursing professionals from 5 large-scale hospitals in Taiwan were conducted by the researcher in the hospitals, where the participants were working, over the 6-month period from October 2017 to March 2018. 4.2. Participants The inclusion sampling criteria for selecting participants were that they must have at least 2 years of clinical experience working in 1 of 3 main clinical departments—namely, the Department of Internal Medicine, the Department of Surgery, and the Specialist Centre (a common way of classifying speciality in a hospital)—at District Teaching Hospitals with more than 600 beds in Taiwan. 10 voluntary nurses were recruited from 5 hospitals in northern Taiwan. Nurses from large-scale hospitals were purposefully selected because these hospitals may have similar language needs related to nursing practice. In addition, selecting nurses from different hospitals helped reduce bias when reporting the perspectives of nurses who were involved in a particular context. Table 1 provides basic information on the participants. 4.3. Data analysis The process of data analysis followed Chang's (2010) five steps for analysing qualitative data, which are (1) transcribing, (2) conceptualising (coding), (3) propositionalising, (4) graphing, and (5) 2
Nurse Education Today 85 (2020) 104301
Y.-L. Lu
Table 1 Profiles of interviewees. Hospital A hospital B hospital
C hospital D hospital E hospital
a
Name a
Wendy Justina Karena Sallya Amya Chua Abbya Bensona Maya Jennya
Position
Ward/attribute
Work experience
Lead nurse Registered nurse Registered nurse Nursing practitioner Registered nurse Registered nurse Registered nurse Registered nurse Registered nurse Lead nurse
Medical ward/internal medicine Psychiatry ward/specialist centre General surgery ward/surgery Emergency room/specialist centre Neurosurgery ward/surgery Colon-rectal surgery ward/surgery Operation room/specialist centre Cardiology ward/internal medicine Medical intensive care unit/specialist Paediatrics ward/internal medicine
3.5 years 2.1 years 3 years 3.8 years 2.11 years 3.7 years 4.4 years 3.11 years 2.10 years 2.9 years
Pseudonym.
development of professional identity in relation to medical discourse.
theorising. The recorded interview data were transcribed verbatim in the first step. In the second step, codes were assigned to the collected pieces of data. The developed codes were ranked by forming a tiered system. The codes and transcriptions were read repeatedly until no new data and codes appeared. Another coder who was not involved in the study was invited to read the transcriptions and verify the developed codes. The third step involved identifying themes emerging from the data set. A schematic diagram was drawn to test out the themes to see whether they were appropriate for describing the research findings. The last step concerned finding evidence to revise (or support) the existing theories.
5.1. Learning in practice The participants learned English medical discourse mainly from engaging in nursing with the guidance of their preceptors when they were novices (AKA preceptorship). Their learning journeys began with observation. They observed how their preceptors read the nursing Kardex and patients' progress notes written in English medical discourse, extracted information, used jargon to shift reports, and performed patient care activities. In accordance with previous arguments (Marañón and Pera, 2015; Price, 2009), the preceptors were crucial figures in shaping the participants' professional identities. 8 out of 10 nurses indicated that their preceptors were their nursing models and believed that the image of professional nurses should resemble that of their preceptors, who were competent in performing nursing tasks and in using medical discourse in intercommunication.
4.4. Researcher identity Before working as an English language instructor, I was a nurse in a district hospital in Taiwan. Because I was involved in nursing for some years, I came to understand the use of medical jargon and also used it a lot to facilitate nursing tasks in my career. During the interview process, I defined my role as an active participant, producing knowledge with people whose stories were to be studied. Due to my nursing background, nurses were more open and direct, and were willing to share their stories and experiences with me. They even used medical jargon many times in the interviews. Important to mention here is the issue of a ‘personal lens’ (Fusch and Ness, 2015, p. 1411). In order to avoid exerting an influence on the integrity of the data collected, I clarified the meanings of the medical jargon in the interview encounter, as I did not wish for my subjective assumptions about these medical terms to influence the data's integrity. Therefore, this study truthfully reflected what the nurses said, although to some degree my own subjectivity and judgment were unavoidable.
I imitated my preceptor's way of doing nursing duties, for example, checking the nursing Kardex first, shifting reports and making the plans for shifts. She was my model at the time. A professional nurse should be good at English medical discourse, just like her. (Sally) Preceptorship, according to nurses, was useful when they were new to nursing, as this kind of learning provided opportunities to experience and see tacit elements that may be difficult to explicate in a lecture and that are able to lead to improved practice (Khomeiran et al., 2006). However, it was when they were actually involved in the internal communication events, in the relationships with their colleagues and patients, and in the engagement in nursing care on their own, that a better idea of what nursing was about and how to effectively use medical discourse was clearly developed. This is what Wenger (1998, p. 100) called ‘legitimate peripheral participation’, a process by which newcomers learn how to be a part of the community.
4.5. Ethics The study was conducted in accordance with the regulations of and with the approval of the Institutional Review Board Committee of the Central Regional Research Ethics Centre (CRREC-106-073) and the study hospitals. A consent form clearly explaining the purpose of the study and the manner and process of data collection was given to the nurses before the interviews. Each participant was orally informed again in accessible language and was assured that their participation was voluntary and that they could withdraw from this study at any time without any reason. The confidentiality and anonymity of the participants were protected. This was achieved by not mentioning their names (pseudonyms were used throughout the study) and by not reporting findings related to individuals.
Preceptorship is useful at the beginning stage. You familiarise yourself in routine work and learn medical discourse. The more you learn from it the more ease you feel when you start to care for patients independently. But the real challenge begins after you start to work on your own. You meet difficulties, you make mistakes, you look for help, and you solve the problems. All of these are about learning and make you a professional nurse. (Justin) This finding indicates that participants learned language and nursing, including knowledge and skills, through participating in the sociocultural process (Dennen and Burner, 2008), where they interacted with established members of the healthcare community and engaged in practice under their support and guidance. The finding also echoes McLaughlin and Parkinson's (2018) study, in which the process of learning specialist language of carpentry in a practical environment was studied. ‘We learn as we go’, said one of the interviewees in their study,
5. Research findings While the nurses interviewed came from different wards and hospitals, they were similar in their recognition of the assimilation process, particular language practices in the healthcare community, and the 3
Nurse Education Today 85 (2020) 104301
Y.-L. Lu
to doctors, they particularly demonstrate their professionalism and knowledge. Doctors, based on the nurses' accounts, are more willing to have a direct discussion and share medical knowledge with nurses.
succinctly illustrating how learning took place in contextual practice; that is, through communication and participation in a real-world situation. Similarly, through repeated practice and guided participation, the participants in this study accumulated experience and developed competence from the periphery to full participation. Patients' conditions are constantly changing, and knowledge and skills in nursing are continuously advancing so that nurses' learning is an ongoing process. Even though the nurses interviewed were viewed as senior members of the community, they still stressed the importance of constant learning to their nursing career—they learned new English medical terms, they learned to read research papers written in specialist language, they learned how to operate new medical machines, they learned new medical concepts from foreign doctors in clinical placements in their wards, and they even learned how to get along with newcomers to medicine and nursing. As one of the participants indicated,
Particularly, when discussing your patients' conditions with doctors, you must be knowledgeable enough to let them respect you. I mean, you need to understand the very professional terms doctors are using. Otherwise, you may give doctors an impression that you are a nurse who simply knows how to do routine work. (Benson) To this point, the above evidences English medical discourse use in internal professional contexts and events; however, there are occasions in which jargon is not solely for professional purposes, but for the purpose of social integration into the workplace. Jokes, stories, complaints, and small talk are important parts of the workplace discourse and help create both relations and a pleasant working atmosphere. In interactions alike, nurses indicated that their Chinese is still mixed with a large amount of English medical discourse, which they use unconsciously because that is the accepted and shared way of communication. This finding illustrates that the act of speaking in English does not always imply the necessity of speaking in English. However, the social and professional aspects are often bound up with each other and hard to separate. As Cope et al. (2000) indicated, social inclusion increases familiarisation and eases the process of professional acceptance, and vice versa.
Knowledge in relation to heart diseases is changing and advancing. So, you need to be equipped with English language ability in order to keep abreast of medical research and treatments. I read a lot because I want to learn the latest knowledge in medicine so that I can keep up with advancing nursing practice. (Benson) 5.2. Identity construction through engaging in nursing All of the participants acknowledged the importance of English medical discourse in the hospital context. Its importance is related to professional identity, which forms through practice, interactions, and relationships based on nurses' roles. Medical discourse is embedded in nursing practice through both spoken and written discourse. In their daily engagement in practice, nurses read patients' progress notes and doctor orders, discussed their patients' conditions with their colleagues, participated in morning meetings, provided quality nursing care, operated life support machines, observed and comforted their patients, gave clinical instructions, and shifted reports. All of these practices in which English medical discourse is partially involved are meaningful to nurses and actualise their values—to help patients recover from illness and to promote patients' well-being. Through engaging in these meaningful nursing activities, nurses see and value their professional identities. In addition, nurses experience their competence in these nursing practices—they know how to talk, what to talk, how to interact with people inside (or outside) of the community, how to act, and how to use the shared resources in the community. Such positive feelings are important in realising their professionalism and solidifying their membership (i.e. being seen as insiders) in the healthcare community. Everything we do in the process of caring for patients is related to English medical discourse. For example, before doing any nursing interventions, we check doctors' orders written in medical discourse. Shifting reports, one of the very important activities among nurses, is also done through medical discourse. So, we learn medical discourse through doing in nursing. (Amy)
5.3. Difficulties in medical discourse being a potential threat to patient safety The process of learning how to navigate English medical discourse is challenging according to all of the nurses interviewed. Nurses' difficulties include not understanding senior nurses' English in the shift report context, not being familiar with the sentence patterns in doctor's writing, not comprehending patients' documents, and having problems with using medical terms in discussions with other experienced members. These findings relate to the observations of Tzeng and Chou (2016) and Ho et al. (2010) that nursing practices exert institutional pressure on nurses and urge them to develop the ability to use medical discourse and meet the demands of nursing jobs. However, when asked if using Chinese equivalents of medical terms instead of English would be safer and easier in nursing practice, although they came from different wards and hospitals, their answers were identical: A firm ‘no’. Nurses in this study aspired to improve their English proficiency, as it was an indication of their professionalism and competence. They understood clearly that at both the local and international levels, English plays a dominant role and associated it with quality nursing care and the latest knowledge in the healthcare field. As one nurse said, I don't think using Chinese equivalents in English medical discourse would improve nursing practice. I mean, it [English medical discourse] is a workplace language and creates a link between nurses and internationalisation…yes, it is difficult, but it is something you have to learn and overcome. (Chu)
My role as a nurse makes me feel professional. I care for patients who depend on my professional knowledge and skills to maintain their basic needs and even to support their lives. Whenever my patients recover from illness, I feel professional in myself and I can see the value of work…I think this positive feeling is very important because you know you have the ability. (May)
Nurses' difficulties in English medical discourse lead to an important issue: patient safety. Although the preceptorship approach to learning exists, it was revealed that preceptoring cannot completely fulfil learner needs. 5 out of 10 nurses were strategic regarding how to ask, when to ask, and who to ask when they were new to nursing. They had experiences of being blamed by their preceptors, which stopped them from asking further questions for clarification.
Based on the accounts of the participants, English medical terms employed by doctors, which are more specialised and belong to the medical domain, created institutional pressure for nurses, even though they called themselves ‘old hands’. When nurses have a good understanding of these terms and demonstrate the ability to properly respond
Whenever I asked similar questions again, she [the preceptor] was unhappy. I knew it…I could tell from her facial expressions. I instead asked someone who was more willing to teach. I mean, after being here for one 4
Nurse Education Today 85 (2020) 104301
Y.-L. Lu
according to Wenger (2009), has a close relationship with the development of practice: ‘…the actual practice cannot be fully learned in the classroom. Health and social care delivery remains a practice located in relationships, in interactions and in the improvisation inherent in situated intelligence’ (p. vii). Nurses' ongoing process of learning has advanced nursing care and carved out the professionalism of nursing, developing the unique caring role alongside the curing role of doctors (Goodman, 2019), and contributing to the legitimate status of the healthcare community. In this research, through continuous learning from peripherality to full participation, the nurse participants developed their own knowledge, competences, repertoires, and styles, all of which exert influences on the community, making nursing practice what it is today. Second, I wish to emphasise that English medical discourse exists in many aspects in nursing practice through both spoken and written communication, upholding and solidifying the healthcare community. Through engagement and participation in meaningful nursing practice underpinned by professional English, nurses developed a deep understanding about their roles and valued themselves as professional nurses (Fagermoen, 1997). As Wenger (1998, p. 151) said, ‘who we are lies in the way we live day to day’ and ‘identity is defied… not merely because it is reified in a social discourse of the self and social categories, but also because it is produced as a lived experience of participation in specific communities.’ In this study, nurses' professional identities were formed when nursing values were actualised through meaningful practice: nursing interventions, actions, interactions, communication, and relationships with their colleagues and patients, all of which, for nurses, improved thier patients' well-bing. This may explain why nurses valued the importance of English ablity as it is related to their professionalism. What is important to mention here is ‘competence’ in identity construction. Wenger emphasised that it is not the case that when one joins a particular community and knows how to act in the community, identity simply forms. The generation of identity requires some kind of competence (Cope et al., 2000). In the current study, to the nurse participants, to be recognised as a competent nurse in the eyes of doctors and their fellow colleagues was important because it was closely related to their professional images. They felt that they were competitive insiders in the community when they had the ability to discuss medical issues with doctors, when they understood medical jargon that their fellow nurses did not understand, and when their patients recovered their health. This finding is in line with Lin's (2008, p. 218) argument that ‘people have a psychological need to construct for themselves identities that are positive and empowering’ and that they want to perceive themselves as ‘having competencies that are valued and valuable in… some reference groups significant to them.’ Besides, the result also corresponds to the finding of Pratt et al. (2006) study in which a group of medical students' professional identities were explored. Competence, according to them, is one of the important factors. The participants reported that when developing the ability to deal with their work and the responsibilities of the medical community, they knew better about their identity as doctors and better understood the territory of medicine. Third, the interviewed nurses encountered many difficulties in the areas of listening, speaking, and reading while learning medical discourse. Although the nurses were guided by their preceptors, there were occasions when clarifications were needed and the nurses were afraid to ask questions due to the preceptors' attitudes. The nurses' accounts revealed a common situation in Taiwan's hospitals; that is, new nursing graduates have worries and fears about asking for help from experienced nurses (Liu et al., 2010; Yeh et al., 2017). These are not just simple language issues, as nurses' deficient knowledge in specialist language used in the shift report context is likely to lead to compromised nursing care and jeopardise patient safety. This finding is supported by international literature which emphasises failures in communication as leading causes of patient harm (Streitenberger et al., 2006; Scott et al., 2017). The main function of shifting reports is to
to two weeks, you know who to ask. (Wendy) In the following case, due to the negative experience of being blamed by her seniors, Karen pretended to understand a message given to her by a nurse on a previous shift, which put her in an even more difficult and dangerous situation. I experienced difficulties in understanding medical terms in the shift report context. But I did not ask the nurse on the previous shift because she was very impatient and unfriendly. Then, when I walked into one of my patients' rooms, I was shocked-he was on a ventilator. I had no idea how to care for him. (Karen) Examples like this, where the receiver misinterpreted information given by the sender, are not unusual. According to a 2015 report by CRICO Strategies, a division of the Risk Management Foundation of the Harvard Medical Institutions, communication failures in hospitals in the US accounted for 30% of medical malpractice, with a consequence of $1.7 billion lost and 44% of 7149 malpractice cases involving highseverity injuries and death, from 2009 to 2013. This may have been avoided if communication between medical professionals and their patients was clearer. In this study, Karen's improper strategy for dealing with language difficulties may have resulted in underestimating the severity of the patient's illness and even jeopardising his or her life. In the following example, Sally's experience also raises concerns about patient safety. She put pressure and expectations on herself—that she should be equipped with both nursing knowledge and linguistic competence to fulfil her job demands. She worried that her preceptor may question her patient care ability if she asked the wrong questions and did not understand medical terms, as she believed that deficient English capacities resulted in an impression of the inability to provide safe patient care. One of the common ways to deal with language difficulty is to pretend—pretend you understand medical jargon…If you ask for clarification, it is likely that they [senior nurses] may think you lack language knowledge, so how can you do nursing care activities? (Sally)
6. Discussions and implications The findings of this study resonate with previous studies and contribute to the knowledge base. Three themes that emerged from the study include (1) learning in practice, (2) identity construction through engaging in nursing, and (3) difficulties in medical discourse being a potential threat to patient safety. First, although the interviewed nurses were from different wards and hospitals, they went through a very similar training process when they were freshly graduated nurses. Preceptorship was the training method through which new graduates learned how to be nurses. Their preceptors demonstrated how to read medical charts and do nursing tasks, explained the steps, and evaluated their performances. Overall, the evidence from this research indicated that preceptorship is helpful in developing new graduates' competence—they learned and accumulated nursing and language knowledge and skills. However, a deep understanding about nursing and specialist language began to develop when nurses learned those on their own through participation and engagement in communication, interactions, socialising, and performing patient care activities. This relates to Wenger's (1998) community of practice, which argues that individuals learn from participating in social practice and develop a situational understanding and expertise in relation to the community with which they connect themselves. What the nurses learned was not simply language knowledge and nursing skills, but the way(s) to be professional nurses and integrate into the healthcare community. This kind of learning, 5
Nurse Education Today 85 (2020) 104301
Y.-L. Lu
participating in many aspects of the workplace and of nursing practice underpinned by medical discourse. Concerning the dominant role of medical discourse in Taiwanese hospitals (and elsewhere) and the patient safety issue raised by nurses' English difficulties, particular attention must be given to the process of acquisition so that new graduate nurses can acquire the required language and nursing knowledge and skills and integrate themselves into the healthcare community.
deliver and receive correct patient information. If anything goes wrong, shifting reports could be a time of particular high risk, leading to information gaps and interruptions in continuity of care (Streitenberger et al., 2006). In this study, due to the uneasy relationship that existed between senior and novice nurses, the understanding of shifting reports was compromised. This kind of disharmony, according to Tzeng and Chou (2016), is one of the common sources of stress for new graduates, resulting in compromised nursing care and feelings of frustration. Nurses' worries and fears and their inappropriate strategies to deal with language difficulties could be in part attributed to the mechanism for training new graduates in Taiwan, AKA preceptorship, which is sponsored through a government programme, the ‘Two-Year Post Graduate Training Programme for Nurses’ from 2007 (Yin, 2013). Although it is supported by international literature as being an effective way for developing a new graduate nurse's confidence and competence and of increasing job satisfaction (Heffernan et al., 2009; Kaviani and Stillwell, 2000; Haggerty et al., 2013; Yin, 2013), preceptorship, in actual implementation in Taiwan's hospitals, is associated with problems such as high workloads, a lack of clarity about the preceptor's role, and staff shortages (Yin, 2013). In the current study, a lack of teaching enthusiasm and unfriendly attitudes were pointed out as problems. For this, three suggestions are provided. First, a policy of having primary and secondary preceptors should be established so that, when encountering problems, nurses have different sources to go to for clarification. Second, unlike preceptorship focusing on developing new nurses' clinical skills in a limited period of time, as espoused by Taiwan's hospitals, mentorship, in which a long-term friendship-like relationship is established by a voluntary mentor and a voluntary mentee and in which the mentor supports and nurtures rather than teaches and evaluates (as in preceptorship) the professional and personal growth of the mentee (Yonge et al., 2007), may be a possible solution. As indicated by Cope et al. (2000), clinical practice is not only a technical context but also a social setting. Support and reassurance are needed when nurses are new to the workplace. In this voluntary and trusting relationship with its emotional bonds, mentees are more likely to share their uncertainty and worries. Third, senior nurse leaders should create a supportive learning environment in which nurses feel safe asking questions and actively participate in the shift report process; they should also select capable potential preceptors who have enthusiasm towards teaching and prepare them well for their roles.
Declaration of competing interest The author declares no potential conflicts of interest with respect to the research, authorship, and/or publication of this report. Acknowledgements The completion of this research was largely due to the participants, and I am grateful for their assistance with the data collection. In addition, considerable help was received from one anonymous coder, who is also gratefully acknowledged. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. References Allen, S., Chapman, Y., O’Connor, M., Francis, K., 2007. The importance of language for nursing: does it convey commonality of meaning and is it important to do so? Aust. J. Adv. Nurs. 24 (4), 47–51. Bosher, S., Stocker, J., 2015. Nurses’ narratives on workplace English in Taiwan: improving patient care and enhancing professionalism. Engl. Specif. Purp. 38, 109–120. https://doi.org/10.1016/j.esp.2015.02.001. Chang, C.-S., Su, Y.-C., 2014. Discussion on the development of medicine in Taiwan before Japanese Colonial period. Journal of China Medicine 2, 309–320. https://doi. org/10.3966/101764462014122502017. Chang, F.-F., 2010. The five steps of qualitative data analysis: climbing up a ladder of abstraction. Journal of Elementary Education 35, 87–120. https://doi.org/10.7036/ JEE.201004.0087. Cope, P., Cuthbertson, P., Stoddart, B., 2000. Situated learning in the practice placement. J. Adv. Nurs. 31 (4), 850–856. https://doi.org/10.1046/j.1365-2648.2000.01343.x. CRICO Strategies, 2015. Malpractice Risk in Communication Failures, 2015 Annual Benchmarking Report. The Risk Management Foundation of the Harvard Medical Institutions, Inc., Boston, MA. Dennen, V.P., Burner, K.J., 2008. The cognitive apprenticeship model in educational practice. In: Spector, J.M., Merrill, M.D., Merrienboer, J.V., Driscoll, M.P. (Eds.), Handbook of Research on Educational Communications and Technology. Taylor & Francis Group, New York, NY, pp. 425–439. Fagermoen, M.S., 1997. Professional identity: values embedded in meaningful nursing practice. J. Adv. Nurs. 25, 434–441. https://doi.org/10.1046/j.1365-2648.1997. 1997025434.x. Fusch, P.I., Ness, L.R., 2015. Are we there yet? Data saturation in qualitative research. The Qualitative Report 20 (9), 1408–1416. Gender Equality Committee of the Executive Yuan (2018). Healthcare professionals' education and working environment. Retrieved from: https://www.gender.ey.gov. tw/GecDB/Common/FileDownload.ashx?sn=b521rJsGfCVeL8%2b8Yw9Igg%3d %3d&ext=.pdf Goh, Y.-S. (2010). Bilingual education policy in Singapore: Evolution and new opportunities. Journal of Taiwanese Languages and Literature, 5(2), 1–10. Retrieved from https://s3.amazonaws.com/academia.edu.documents/33371716/14.%E5%90%B3% E8%8B%B1%E6%88%90-%E8%AC%9B%E7%BE%A9.pdf?response-contentdisposition=inline%3B%20filename%3DBilingual_education_policy_in_Singapore. pdf&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Credential= AKIAIWOWYYGZ2Y53UL3A%2F20190821%2Fus-east-1%2Fs3%2Faws4_request&XAmz-Date=20190821T065003Z&X-Amz-Expires=3600&X-Amz-SignedHeaders= host&X-Amz-Signature= 7fd0e741230b42982d729cd4280c045e9f8a44eca249ee2379bfb909006fef0c Goodman, B., 2019. Psychology and Sociology in Nursing, 3rd edition. Sage, London, UK. Gunnarsson, B.-L., 2009. Professional Discourse. Continuum, London, UK. Haggerty, C., Holloway, K., Wilson, D., 2013. How to grow our own: an evaluation of preceptorship in New Zealand graduate nurse programmes. Contemp. Nurse 43 (2), 162–171. https://doi.org/10.5172/conu.2013.43.2.162. Heffernan, C., Heffernan, E., Brosnan, M., Brown, G., 2009. Evaluating a preceptorship programme in South West Ireland: perceptions of preceptors and undergraduate students. J. Nurs. Manag. 17 (5), 539–549. https://doi.org/10.1111/j.1365-2834. 2008.00935.x. Ho, H.-H., Liu, P.-F., Hu, H.-C., Huang, S.-F., Chen, H.-L., 2010. Role transition and working adaption in new nursing graduates: a qualitative study. J. Nurs. 57 (6), 31–41. Hyland, K., 2009. Teaching and Researching Writing. Harlow. Pearson, UK.
7. Conclusions This study explored how nurses learned English medical discourse in hospital contexts and how their professional identities were constructed in relation to medical discourse, an area that had not previously been thoroughly reported. Although the research findings offer insights and increase awareness of learning through participation and constructing identity, they may not be generalisable, as the chosen research site, the role of medical discourse, and the learning approach contributed to the nurses' unique perspectives on medical discourse and identity in this study. This paper provides support for the idea that learning occurs in practice. Nurses acquired their understanding and knowledge of English medical discourse and nursing by engaging and being involved in nursing practice, communication, interactions, and relationships. This means that medical discourse does not exist in and of itself and cannot be separated from the practice that gives meaning to it. By properly responding to doctors' questions, demonstrating their knowledge of medical discourse, providing quality nursing care, and helping patients recover from illness, nurses' professional roles are proclaimed to both insiders and outsiders of the healthcare community. Therefore, rather than saying that nurses develop professional identities through aligning their language use with other experienced members or through showing their language knowledge in internal professional events, it is more precise to say that nurses' identities are forged by engaging and 6
Nurse Education Today 85 (2020) 104301
Y.-L. Lu
20159762. Price, S.L., 2009. Becoming a nurse: a meta-study of early professional socialisation and career choice in nursing. J. Adv. Nurs. 65, 11–19. https://doi.org/10.1111/j.13652648.2008.04839.x. Scott, A.M., Li, J., Oyewole-Eletu, S., Nguyen, H.Q., Gass, B., Hirschman, K.B., ... Williams, M.V., 2017. Understanding facilitators and barriers to care transitions: Insights from Project ACHIEVE site visits. The Joint Commission Journal on Quality and Patient Safety 43 (9), 433–447. https://doi.org/10.1016/j.jcjq.2017.02.012. Streitenberger, K., Breen-Reid, K., Harris, C. (2006). Handoffs in care—Can we make them safer? Quality & Risk Management, 53, 1185–1195. https://doi.org/10.1016/j. pcl.2006.09.010 Tonkiss, F., 2012. Discourse analysis. In: Seale, C. (Ed.), Researching Society and Culture. Sage Publications, London, UK, pp. 405–424. Tzeng, S.-C., Chou, C.-C., 2016. The learning experiences of new graduated nurses. Veterans General Hospital Nursing 33 (2), 183–192. Wenger, E., 1998. Communities of Practice: Learning, Meaning, and Identity. Cambridge University Press, New York, NY. Wenger, E., 2009. Foreword. In: Andrée, M. (Ed.), Communities of Practice in Health and Social Care (pp. vii–ix). Sussex. Wiley-Blackwell, UK. Wilce, J.M., 2009. Medical discourse. The Annual Review of Anthropology 38, 199–215. https://doi.org/10.1146/annurev-anthro-091908-164450. Yang, C.-L., 2011. Internationalised medical care services increase need of health care providers to improve English communication skills. J. Nurs. 58 (1), 97–101. Yang, M.-N., Su, S.-M., 2003. A study of Taiwanese nursing students’ and in-service nurses’ English needs. Journal of Chang Gung Institute of Technology 2, 269–284. Yeh, M.-T., Yu, Y.-M., Chen, S.-Y., Sun, M.-H., 2017. A program to improve the retention rates of new nursing staff in a hospital. New Taipei Journal of Nursing 19 (1), 47–57. Yin, Y.-C., 2013. The two-year post graduate training program for nurses’: implementation status and personal perspectives. J. Nurs. 60 (3), 11–16. https://doi.org/10. 6224/JN.60.3.11. Yonge, O., Billay, D., Myrick, F., Luhangu, F., 2007. Preceptorship and mentorship: not merely a matter of semantics. Int. J. Nurs. Educ. Scholarsh. 4 (1), 19.
Hyland, K., 2010. Community and individuality: performing identity in applied linguistics. Writ. Commun. 27 (2), 159–188. https://doi.org/10.1177/0741088309357846. Hyland, K., 2011. Projecting and academic identity in some reflective genres. Ibérica 21, 9–30. Hyland, K., Tse, P., 2012. ‘She has received many honours’: identity construction in article bio statements. J. Engl. Acad. Purp. 11, 155–165. https://doi.org/10.1016/j.jeap. 2012.01.001. Kaviani, N., Stillwell, Y., 2000. An evaluation study of clinical preceptorship. Nurse Educ. Today 20, 218–226. https://doi.org/10.1054/nedt.1999.0386. Khomeiran, R.T., Yekta, Z.P., Kiger, A.M., Ahmadi, F., 2006. Professional competence: factors described by nurses as influencing their development. Int. Nurs. Rev. 53 (1), 66–72. https://doi.org/10.1111/j.1466-7657.2006.00432.x. Lave, J., 1996. Teaching as learning. in practice. Mind, Culture & Activity 3 (3), 149–164. https://doi.org/10.1207/s15327884mca0303_2. Lin, A., 2008. Modernity, postmodernity, and the future of “identity”: Implications for educators. In: Lin, A. (Ed.), Problematising Identity: Everyday Struggles in Language, Culture, and Education. Lawrence Erlbaum, Mahwah, NJ, pp. 199–219. Little, M., Jordens, C.F.C., Sayers, E.J., 2003. Discourse communities and the discourse of experience. Health 7, 73–86. https://doi.org/10.1177/1363459303007001619. Liu, S.-L., Wang, M.-H., Liu, H.-H., 2010. An investigation of job stressors in newly employed nurses. Veterans General Hospital Nursing 27 (3), 276–284. Lu, Y.-L., 2016. Experiences in the workplace community and the influence of community experiences on ENP courses for nursing professionals. Nurse Educ. Today 40, 39–44. https://doi.org/10.1016/j.nedt.2016.01.025. Marañón, A.A., Pera, M.P.I., 2015. Theory and practice in the construction of professional identity in nursing students: a qualitative study. Nurse Educ. Today 35, 859–863. https://doi.org/10.1016/j.nedt.2015.03.014. McLaughlin, E., Parkinson, J., 2018. ‘We learn as we go’: how acquisition of a technical vocabulary is supported during vocational training. Engl. Specif. Purp. 50, 14–27. https://doi.org/10.1016/j.esp.2017.11.003. Pratt, M.G., Rockmann, K.W., Kaufmann, J.B., 2006. Constructing professional identity: the role of work and identity learning cycles in the customisation of identity among medical residents. Acad. Manag. 49 (2), 235–262. https://doi.org/10.2307/
7
Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/locate/nedt
How do nurses acquire English medical discourse ability in nursing practice? Exploring nurses' medical discourse learning journeys and related identity construction
T
Yi-Ling Lu Language Centre, National United University, 1 Lienda, Miaoli 36003, Taiwan, ROC
A R T I C LE I N FO
A B S T R A C T
Keywords: English medical discourse Nursing professionals Hospitals Professional identity
Background: In Taiwan's hospitals, English medical discourse underpins nursing and medical practice. Much patient care work is done through language work, by both text and talk. This means that when nurses start their nursing careers in the hospital context, where English medical discourse is shared to produce knowledge and engage in practice, knowledge of medical discourse and the ability to use it are prerequisites. In the process of learning and using such specialist language, the formation of professional identities is assumed. Objectives: This study aimed to explore nurses' learning journeys relating to medical discourse and the development of their professional identities. Methods: This research adopted a qualitative approach, using data from 10 nurses working in different hospitals in Taiwan. Results: The findings revealed that English medical discourse was employed in Taiwan's hospitals not only for fulfilling professional purposes but also for socialising nurses into the healthcare community. Nurses acquired it through interactions, small talk, relationships, discussions, and nursing tasks. Their professional identities were formed through engaging in meaningful nursing practice based on English medical discourse. However, in the learning process, they encountered difficulties in the areas of listening, speaking, and reading, which raised concerns about patient safety. Conclusion: Sufficient support is needed to ease nurses' difficulties in learning. We propose having primary and secondary preceptors, establishing a mentorship policy, and creating a learning environment that is supportive of nurses' learning experiences.
1. Introduction English medical discourse serves as an indispensable tool in both written and spoken discourse among healthcare personnel in Taiwan's clinical practice. Although the Chinese equivalents of medical discourse do exist, nurses and doctors code-switch into English whenever medical terms are mentioned. This phenomenon is distinctive. Unlike Singapore, where the population speaks different mother tongues and where English thus functions as a lingua franca in the workplace (Goh, 2010), the majority of healthcare professionals speak the official language, Chinese, in Taiwan's hospitals. According to statistics from the Gender Equality Committee of the Executive Yuan (2018), the percentage of in-practice foreign nurses who may resort to English to communicate in Taiwan is less than 1%. In such a context, the reason why English medical discourse is dominant is worth exploring. English's privileged place in the hospital context dates back to the
colonial period from 1895 to 1945, when the Japanese government introduced Western medical education to Taiwan, establishing formal institutions and offering medical instruction in order to improve the sanitary environment and maintain political stability (Chang and Su, 2014). From there, the privileged place of medical English in Taiwan's healthcare education was established. Western medical education and its influence were not terminated with the end of the Japanese government's reign; instead, they have been continuously developed and advanced. Today, Taiwan's medical care, compared to nearby countries such as Japan and Singapore, although being less expensive, is of a high quality (Yang, 2011). English medical discourse is widely used to circulate information in medicine and nursing. Therefore, when nurses enter a healthcare community, where English medical discourse is shared to produce knowledge and engage in nursing practice, they must possess medical discourse ability to fulfil their job demands (Bosher and Stocker, 2015; Yang and Su, 2003). In the process of learning and using
E-mail address: [email protected]. https://doi.org/10.1016/j.nedt.2019.104301 Received 17 April 2019; Received in revised form 16 September 2019; Accepted 18 November 2019 0260-6917/ © 2019 Elsevier Ltd. All rights reserved.
Nurse Education Today 85 (2020) 104301
Y.-L. Lu
Second, medical discourse, which appears incomprehensible to outsiders, is employed by healthcare personnel to delineate their membership. They share knowledge, ideas, habits, and norms in using medical discourse and demonstrate their competence, specialisation, and knowledge through the expert discourse (Little et al., 2003). Third, medical discourse symbolises a form of expert knowledge. Individuals speaking in medical discourse are deemed to have professional knowledge so that they are considered authoritative. For example, in Taiwan, doctors usually use medical discourse in English to communicate with nurses (and their patients) to reinforce their authority (Bosher and Stocker, 2015).
medical discourse, nurses may develop beliefs regarding medical discourse in relation to their professional identities. This assumption is based on Wenger's (1998) seminal concept of community of practice, the significance of which centres on learning from participating in practice. Here, practice is doing ‘but not just doing in and of itself. It is doing in a historical and social context that gives structure and meaning to what we do’ (1998, p. 47). Learning propels practice. Everything individuals learn in order to fit themselves into a particular community—for instance, learning to talk, engage, and interact—gives rise to and shapes practice, and lays the foundation for developing competence in relation to the community. Identity is thus formed through the learning process. What inspired the current study is that if learning, as assumed by Wenger, takes place in a social context, where established members negotiate meaning to achieve a mutual understanding and to participate in a joint enterprise, nurses' learning of medical discourse in hospitals, where healthcare professionals interact, discuss, and cooperate with one another to promote patient well-being, may share this character and help construct professional identities. Therefore, this paper explores nurses' learning journeys related to medical discourse and the development of their professional identities.
3. Study aim The literature review helped me to understand that expert language used by a particular group defines membership and has authority and power; it excludes those who lack such knowledge. However, the previous studies also raised more questions, prompting the current study, where I look at the broader and more comprehensive picture of the relationships among learning, language, and identity. A particular interest in this study is the ‘process’ rather than the ‘product’; that is, how does learning take place in hospitals and how is professional identity forged through language use? These research questions are related to others worthy of exploration, such as how does medical discourse function in a hospital? How do nurses perceive the relationship between knowledge of medical discourse and clinical competence? Do nurses feel under pressure to use medical discourse when they are involved in the healthcare community? This study was intended to answer these questions.
2. Background According to Hyland (2009, 2010, 2011), language is able to represent one's identity. Speaking or writing in particular ways announces people's connection with and membership in certain communities, so that they become, as Lave (1996, p. 157) stated, ‘kinds of persons’. By using the community discourse that members belonging to the same communities use, individuals are recognised as insiders in a community, as ‘we position ourselves in relation to others using these discourses and in turn are positioned by these same discourses’ (Hyland and Tse, 2012, p. 156). In a hospital context, medical discourse, which refers to descriptions of a disease, medication, therapy, and relevant expressions in the medical domain (Wilce, 2009), is a paradigm for defining memberships and distinguishing the self from others. The members in a healthcare community share knowledge, norms, and habits in relation to the use of medical discourse, including in oral as well as written communication. This means that socialisation into this community requires mastery of knowledge about and attitudes towards the use of professional language (Gunnarsson, 2009). In the case of Taiwan, according to their official websites, 21 out of 23 nursing junior colleges and all 11 universities of science and technology in northern Taiwan's technical and vocational education system have developed professional English courses for their students, in the hope of equipping their students with professional English ability to meet both the entry requirements and demanding linguistic realities awaiting them. Lu (2016) introduced how English medical discourse was used in the context of shifting reports in Taiwan's hospitals and how nurses code-switched into English rather than using Chinese medical terminology. Nurses learned this shared and accepted way of speaking from their seniors, and they did this in order to be seen as professional in the eyes of others. The current study built upon the existing evidence base and further explored how medical discourse helped construct nurses' professional identities. The assertion of Allen et al. (2007) lends support to the basic assumption concerning identity in this study. For them, medical discourse identifies and consolidates nurses' membership in the healthcare community. Only those with professional knowledge within the community understand this specialist language, as meaning and understanding are shared among them, with the consequent exclusion of others not belonging to the community. In addition, Tonkiss (2012, p. 408) remarked that medical discourse has three functions: it ‘marks out a field’, ‘confers membership’, and ‘bestows authority’. As to the first function, medical discourse is devoted to the domain of healthcare professionalism and is used to address issues in the healthcare field.
4. Methodology 4.1. Methods This study employed a qualitative approach to fulfil the research aims. Nurses' views result from their interactions within their practice and within the context in which they are involved; therefore, a potential approach to fulfil the research aims was to question nurses and talk interactively with them in order to understand and comprehend the meanings they created for their world. Semi-structured interviews with 10 nursing professionals from 5 large-scale hospitals in Taiwan were conducted by the researcher in the hospitals, where the participants were working, over the 6-month period from October 2017 to March 2018. 4.2. Participants The inclusion sampling criteria for selecting participants were that they must have at least 2 years of clinical experience working in 1 of 3 main clinical departments—namely, the Department of Internal Medicine, the Department of Surgery, and the Specialist Centre (a common way of classifying speciality in a hospital)—at District Teaching Hospitals with more than 600 beds in Taiwan. 10 voluntary nurses were recruited from 5 hospitals in northern Taiwan. Nurses from large-scale hospitals were purposefully selected because these hospitals may have similar language needs related to nursing practice. In addition, selecting nurses from different hospitals helped reduce bias when reporting the perspectives of nurses who were involved in a particular context. Table 1 provides basic information on the participants. 4.3. Data analysis The process of data analysis followed Chang's (2010) five steps for analysing qualitative data, which are (1) transcribing, (2) conceptualising (coding), (3) propositionalising, (4) graphing, and (5) 2
Nurse Education Today 85 (2020) 104301
Y.-L. Lu
Table 1 Profiles of interviewees. Hospital A hospital B hospital
C hospital D hospital E hospital
a
Name a
Wendy Justina Karena Sallya Amya Chua Abbya Bensona Maya Jennya
Position
Ward/attribute
Work experience
Lead nurse Registered nurse Registered nurse Nursing practitioner Registered nurse Registered nurse Registered nurse Registered nurse Registered nurse Lead nurse
Medical ward/internal medicine Psychiatry ward/specialist centre General surgery ward/surgery Emergency room/specialist centre Neurosurgery ward/surgery Colon-rectal surgery ward/surgery Operation room/specialist centre Cardiology ward/internal medicine Medical intensive care unit/specialist Paediatrics ward/internal medicine
3.5 years 2.1 years 3 years 3.8 years 2.11 years 3.7 years 4.4 years 3.11 years 2.10 years 2.9 years
Pseudonym.
development of professional identity in relation to medical discourse.
theorising. The recorded interview data were transcribed verbatim in the first step. In the second step, codes were assigned to the collected pieces of data. The developed codes were ranked by forming a tiered system. The codes and transcriptions were read repeatedly until no new data and codes appeared. Another coder who was not involved in the study was invited to read the transcriptions and verify the developed codes. The third step involved identifying themes emerging from the data set. A schematic diagram was drawn to test out the themes to see whether they were appropriate for describing the research findings. The last step concerned finding evidence to revise (or support) the existing theories.
5.1. Learning in practice The participants learned English medical discourse mainly from engaging in nursing with the guidance of their preceptors when they were novices (AKA preceptorship). Their learning journeys began with observation. They observed how their preceptors read the nursing Kardex and patients' progress notes written in English medical discourse, extracted information, used jargon to shift reports, and performed patient care activities. In accordance with previous arguments (Marañón and Pera, 2015; Price, 2009), the preceptors were crucial figures in shaping the participants' professional identities. 8 out of 10 nurses indicated that their preceptors were their nursing models and believed that the image of professional nurses should resemble that of their preceptors, who were competent in performing nursing tasks and in using medical discourse in intercommunication.
4.4. Researcher identity Before working as an English language instructor, I was a nurse in a district hospital in Taiwan. Because I was involved in nursing for some years, I came to understand the use of medical jargon and also used it a lot to facilitate nursing tasks in my career. During the interview process, I defined my role as an active participant, producing knowledge with people whose stories were to be studied. Due to my nursing background, nurses were more open and direct, and were willing to share their stories and experiences with me. They even used medical jargon many times in the interviews. Important to mention here is the issue of a ‘personal lens’ (Fusch and Ness, 2015, p. 1411). In order to avoid exerting an influence on the integrity of the data collected, I clarified the meanings of the medical jargon in the interview encounter, as I did not wish for my subjective assumptions about these medical terms to influence the data's integrity. Therefore, this study truthfully reflected what the nurses said, although to some degree my own subjectivity and judgment were unavoidable.
I imitated my preceptor's way of doing nursing duties, for example, checking the nursing Kardex first, shifting reports and making the plans for shifts. She was my model at the time. A professional nurse should be good at English medical discourse, just like her. (Sally) Preceptorship, according to nurses, was useful when they were new to nursing, as this kind of learning provided opportunities to experience and see tacit elements that may be difficult to explicate in a lecture and that are able to lead to improved practice (Khomeiran et al., 2006). However, it was when they were actually involved in the internal communication events, in the relationships with their colleagues and patients, and in the engagement in nursing care on their own, that a better idea of what nursing was about and how to effectively use medical discourse was clearly developed. This is what Wenger (1998, p. 100) called ‘legitimate peripheral participation’, a process by which newcomers learn how to be a part of the community.
4.5. Ethics The study was conducted in accordance with the regulations of and with the approval of the Institutional Review Board Committee of the Central Regional Research Ethics Centre (CRREC-106-073) and the study hospitals. A consent form clearly explaining the purpose of the study and the manner and process of data collection was given to the nurses before the interviews. Each participant was orally informed again in accessible language and was assured that their participation was voluntary and that they could withdraw from this study at any time without any reason. The confidentiality and anonymity of the participants were protected. This was achieved by not mentioning their names (pseudonyms were used throughout the study) and by not reporting findings related to individuals.
Preceptorship is useful at the beginning stage. You familiarise yourself in routine work and learn medical discourse. The more you learn from it the more ease you feel when you start to care for patients independently. But the real challenge begins after you start to work on your own. You meet difficulties, you make mistakes, you look for help, and you solve the problems. All of these are about learning and make you a professional nurse. (Justin) This finding indicates that participants learned language and nursing, including knowledge and skills, through participating in the sociocultural process (Dennen and Burner, 2008), where they interacted with established members of the healthcare community and engaged in practice under their support and guidance. The finding also echoes McLaughlin and Parkinson's (2018) study, in which the process of learning specialist language of carpentry in a practical environment was studied. ‘We learn as we go’, said one of the interviewees in their study,
5. Research findings While the nurses interviewed came from different wards and hospitals, they were similar in their recognition of the assimilation process, particular language practices in the healthcare community, and the 3
Nurse Education Today 85 (2020) 104301
Y.-L. Lu
to doctors, they particularly demonstrate their professionalism and knowledge. Doctors, based on the nurses' accounts, are more willing to have a direct discussion and share medical knowledge with nurses.
succinctly illustrating how learning took place in contextual practice; that is, through communication and participation in a real-world situation. Similarly, through repeated practice and guided participation, the participants in this study accumulated experience and developed competence from the periphery to full participation. Patients' conditions are constantly changing, and knowledge and skills in nursing are continuously advancing so that nurses' learning is an ongoing process. Even though the nurses interviewed were viewed as senior members of the community, they still stressed the importance of constant learning to their nursing career—they learned new English medical terms, they learned to read research papers written in specialist language, they learned how to operate new medical machines, they learned new medical concepts from foreign doctors in clinical placements in their wards, and they even learned how to get along with newcomers to medicine and nursing. As one of the participants indicated,
Particularly, when discussing your patients' conditions with doctors, you must be knowledgeable enough to let them respect you. I mean, you need to understand the very professional terms doctors are using. Otherwise, you may give doctors an impression that you are a nurse who simply knows how to do routine work. (Benson) To this point, the above evidences English medical discourse use in internal professional contexts and events; however, there are occasions in which jargon is not solely for professional purposes, but for the purpose of social integration into the workplace. Jokes, stories, complaints, and small talk are important parts of the workplace discourse and help create both relations and a pleasant working atmosphere. In interactions alike, nurses indicated that their Chinese is still mixed with a large amount of English medical discourse, which they use unconsciously because that is the accepted and shared way of communication. This finding illustrates that the act of speaking in English does not always imply the necessity of speaking in English. However, the social and professional aspects are often bound up with each other and hard to separate. As Cope et al. (2000) indicated, social inclusion increases familiarisation and eases the process of professional acceptance, and vice versa.
Knowledge in relation to heart diseases is changing and advancing. So, you need to be equipped with English language ability in order to keep abreast of medical research and treatments. I read a lot because I want to learn the latest knowledge in medicine so that I can keep up with advancing nursing practice. (Benson) 5.2. Identity construction through engaging in nursing All of the participants acknowledged the importance of English medical discourse in the hospital context. Its importance is related to professional identity, which forms through practice, interactions, and relationships based on nurses' roles. Medical discourse is embedded in nursing practice through both spoken and written discourse. In their daily engagement in practice, nurses read patients' progress notes and doctor orders, discussed their patients' conditions with their colleagues, participated in morning meetings, provided quality nursing care, operated life support machines, observed and comforted their patients, gave clinical instructions, and shifted reports. All of these practices in which English medical discourse is partially involved are meaningful to nurses and actualise their values—to help patients recover from illness and to promote patients' well-being. Through engaging in these meaningful nursing activities, nurses see and value their professional identities. In addition, nurses experience their competence in these nursing practices—they know how to talk, what to talk, how to interact with people inside (or outside) of the community, how to act, and how to use the shared resources in the community. Such positive feelings are important in realising their professionalism and solidifying their membership (i.e. being seen as insiders) in the healthcare community. Everything we do in the process of caring for patients is related to English medical discourse. For example, before doing any nursing interventions, we check doctors' orders written in medical discourse. Shifting reports, one of the very important activities among nurses, is also done through medical discourse. So, we learn medical discourse through doing in nursing. (Amy)
5.3. Difficulties in medical discourse being a potential threat to patient safety The process of learning how to navigate English medical discourse is challenging according to all of the nurses interviewed. Nurses' difficulties include not understanding senior nurses' English in the shift report context, not being familiar with the sentence patterns in doctor's writing, not comprehending patients' documents, and having problems with using medical terms in discussions with other experienced members. These findings relate to the observations of Tzeng and Chou (2016) and Ho et al. (2010) that nursing practices exert institutional pressure on nurses and urge them to develop the ability to use medical discourse and meet the demands of nursing jobs. However, when asked if using Chinese equivalents of medical terms instead of English would be safer and easier in nursing practice, although they came from different wards and hospitals, their answers were identical: A firm ‘no’. Nurses in this study aspired to improve their English proficiency, as it was an indication of their professionalism and competence. They understood clearly that at both the local and international levels, English plays a dominant role and associated it with quality nursing care and the latest knowledge in the healthcare field. As one nurse said, I don't think using Chinese equivalents in English medical discourse would improve nursing practice. I mean, it [English medical discourse] is a workplace language and creates a link between nurses and internationalisation…yes, it is difficult, but it is something you have to learn and overcome. (Chu)
My role as a nurse makes me feel professional. I care for patients who depend on my professional knowledge and skills to maintain their basic needs and even to support their lives. Whenever my patients recover from illness, I feel professional in myself and I can see the value of work…I think this positive feeling is very important because you know you have the ability. (May)
Nurses' difficulties in English medical discourse lead to an important issue: patient safety. Although the preceptorship approach to learning exists, it was revealed that preceptoring cannot completely fulfil learner needs. 5 out of 10 nurses were strategic regarding how to ask, when to ask, and who to ask when they were new to nursing. They had experiences of being blamed by their preceptors, which stopped them from asking further questions for clarification.
Based on the accounts of the participants, English medical terms employed by doctors, which are more specialised and belong to the medical domain, created institutional pressure for nurses, even though they called themselves ‘old hands’. When nurses have a good understanding of these terms and demonstrate the ability to properly respond
Whenever I asked similar questions again, she [the preceptor] was unhappy. I knew it…I could tell from her facial expressions. I instead asked someone who was more willing to teach. I mean, after being here for one 4
Nurse Education Today 85 (2020) 104301
Y.-L. Lu
according to Wenger (2009), has a close relationship with the development of practice: ‘…the actual practice cannot be fully learned in the classroom. Health and social care delivery remains a practice located in relationships, in interactions and in the improvisation inherent in situated intelligence’ (p. vii). Nurses' ongoing process of learning has advanced nursing care and carved out the professionalism of nursing, developing the unique caring role alongside the curing role of doctors (Goodman, 2019), and contributing to the legitimate status of the healthcare community. In this research, through continuous learning from peripherality to full participation, the nurse participants developed their own knowledge, competences, repertoires, and styles, all of which exert influences on the community, making nursing practice what it is today. Second, I wish to emphasise that English medical discourse exists in many aspects in nursing practice through both spoken and written communication, upholding and solidifying the healthcare community. Through engagement and participation in meaningful nursing practice underpinned by professional English, nurses developed a deep understanding about their roles and valued themselves as professional nurses (Fagermoen, 1997). As Wenger (1998, p. 151) said, ‘who we are lies in the way we live day to day’ and ‘identity is defied… not merely because it is reified in a social discourse of the self and social categories, but also because it is produced as a lived experience of participation in specific communities.’ In this study, nurses' professional identities were formed when nursing values were actualised through meaningful practice: nursing interventions, actions, interactions, communication, and relationships with their colleagues and patients, all of which, for nurses, improved thier patients' well-bing. This may explain why nurses valued the importance of English ablity as it is related to their professionalism. What is important to mention here is ‘competence’ in identity construction. Wenger emphasised that it is not the case that when one joins a particular community and knows how to act in the community, identity simply forms. The generation of identity requires some kind of competence (Cope et al., 2000). In the current study, to the nurse participants, to be recognised as a competent nurse in the eyes of doctors and their fellow colleagues was important because it was closely related to their professional images. They felt that they were competitive insiders in the community when they had the ability to discuss medical issues with doctors, when they understood medical jargon that their fellow nurses did not understand, and when their patients recovered their health. This finding is in line with Lin's (2008, p. 218) argument that ‘people have a psychological need to construct for themselves identities that are positive and empowering’ and that they want to perceive themselves as ‘having competencies that are valued and valuable in… some reference groups significant to them.’ Besides, the result also corresponds to the finding of Pratt et al. (2006) study in which a group of medical students' professional identities were explored. Competence, according to them, is one of the important factors. The participants reported that when developing the ability to deal with their work and the responsibilities of the medical community, they knew better about their identity as doctors and better understood the territory of medicine. Third, the interviewed nurses encountered many difficulties in the areas of listening, speaking, and reading while learning medical discourse. Although the nurses were guided by their preceptors, there were occasions when clarifications were needed and the nurses were afraid to ask questions due to the preceptors' attitudes. The nurses' accounts revealed a common situation in Taiwan's hospitals; that is, new nursing graduates have worries and fears about asking for help from experienced nurses (Liu et al., 2010; Yeh et al., 2017). These are not just simple language issues, as nurses' deficient knowledge in specialist language used in the shift report context is likely to lead to compromised nursing care and jeopardise patient safety. This finding is supported by international literature which emphasises failures in communication as leading causes of patient harm (Streitenberger et al., 2006; Scott et al., 2017). The main function of shifting reports is to
to two weeks, you know who to ask. (Wendy) In the following case, due to the negative experience of being blamed by her seniors, Karen pretended to understand a message given to her by a nurse on a previous shift, which put her in an even more difficult and dangerous situation. I experienced difficulties in understanding medical terms in the shift report context. But I did not ask the nurse on the previous shift because she was very impatient and unfriendly. Then, when I walked into one of my patients' rooms, I was shocked-he was on a ventilator. I had no idea how to care for him. (Karen) Examples like this, where the receiver misinterpreted information given by the sender, are not unusual. According to a 2015 report by CRICO Strategies, a division of the Risk Management Foundation of the Harvard Medical Institutions, communication failures in hospitals in the US accounted for 30% of medical malpractice, with a consequence of $1.7 billion lost and 44% of 7149 malpractice cases involving highseverity injuries and death, from 2009 to 2013. This may have been avoided if communication between medical professionals and their patients was clearer. In this study, Karen's improper strategy for dealing with language difficulties may have resulted in underestimating the severity of the patient's illness and even jeopardising his or her life. In the following example, Sally's experience also raises concerns about patient safety. She put pressure and expectations on herself—that she should be equipped with both nursing knowledge and linguistic competence to fulfil her job demands. She worried that her preceptor may question her patient care ability if she asked the wrong questions and did not understand medical terms, as she believed that deficient English capacities resulted in an impression of the inability to provide safe patient care. One of the common ways to deal with language difficulty is to pretend—pretend you understand medical jargon…If you ask for clarification, it is likely that they [senior nurses] may think you lack language knowledge, so how can you do nursing care activities? (Sally)
6. Discussions and implications The findings of this study resonate with previous studies and contribute to the knowledge base. Three themes that emerged from the study include (1) learning in practice, (2) identity construction through engaging in nursing, and (3) difficulties in medical discourse being a potential threat to patient safety. First, although the interviewed nurses were from different wards and hospitals, they went through a very similar training process when they were freshly graduated nurses. Preceptorship was the training method through which new graduates learned how to be nurses. Their preceptors demonstrated how to read medical charts and do nursing tasks, explained the steps, and evaluated their performances. Overall, the evidence from this research indicated that preceptorship is helpful in developing new graduates' competence—they learned and accumulated nursing and language knowledge and skills. However, a deep understanding about nursing and specialist language began to develop when nurses learned those on their own through participation and engagement in communication, interactions, socialising, and performing patient care activities. This relates to Wenger's (1998) community of practice, which argues that individuals learn from participating in social practice and develop a situational understanding and expertise in relation to the community with which they connect themselves. What the nurses learned was not simply language knowledge and nursing skills, but the way(s) to be professional nurses and integrate into the healthcare community. This kind of learning, 5
Nurse Education Today 85 (2020) 104301
Y.-L. Lu
participating in many aspects of the workplace and of nursing practice underpinned by medical discourse. Concerning the dominant role of medical discourse in Taiwanese hospitals (and elsewhere) and the patient safety issue raised by nurses' English difficulties, particular attention must be given to the process of acquisition so that new graduate nurses can acquire the required language and nursing knowledge and skills and integrate themselves into the healthcare community.
deliver and receive correct patient information. If anything goes wrong, shifting reports could be a time of particular high risk, leading to information gaps and interruptions in continuity of care (Streitenberger et al., 2006). In this study, due to the uneasy relationship that existed between senior and novice nurses, the understanding of shifting reports was compromised. This kind of disharmony, according to Tzeng and Chou (2016), is one of the common sources of stress for new graduates, resulting in compromised nursing care and feelings of frustration. Nurses' worries and fears and their inappropriate strategies to deal with language difficulties could be in part attributed to the mechanism for training new graduates in Taiwan, AKA preceptorship, which is sponsored through a government programme, the ‘Two-Year Post Graduate Training Programme for Nurses’ from 2007 (Yin, 2013). Although it is supported by international literature as being an effective way for developing a new graduate nurse's confidence and competence and of increasing job satisfaction (Heffernan et al., 2009; Kaviani and Stillwell, 2000; Haggerty et al., 2013; Yin, 2013), preceptorship, in actual implementation in Taiwan's hospitals, is associated with problems such as high workloads, a lack of clarity about the preceptor's role, and staff shortages (Yin, 2013). In the current study, a lack of teaching enthusiasm and unfriendly attitudes were pointed out as problems. For this, three suggestions are provided. First, a policy of having primary and secondary preceptors should be established so that, when encountering problems, nurses have different sources to go to for clarification. Second, unlike preceptorship focusing on developing new nurses' clinical skills in a limited period of time, as espoused by Taiwan's hospitals, mentorship, in which a long-term friendship-like relationship is established by a voluntary mentor and a voluntary mentee and in which the mentor supports and nurtures rather than teaches and evaluates (as in preceptorship) the professional and personal growth of the mentee (Yonge et al., 2007), may be a possible solution. As indicated by Cope et al. (2000), clinical practice is not only a technical context but also a social setting. Support and reassurance are needed when nurses are new to the workplace. In this voluntary and trusting relationship with its emotional bonds, mentees are more likely to share their uncertainty and worries. Third, senior nurse leaders should create a supportive learning environment in which nurses feel safe asking questions and actively participate in the shift report process; they should also select capable potential preceptors who have enthusiasm towards teaching and prepare them well for their roles.
Declaration of competing interest The author declares no potential conflicts of interest with respect to the research, authorship, and/or publication of this report. Acknowledgements The completion of this research was largely due to the participants, and I am grateful for their assistance with the data collection. In addition, considerable help was received from one anonymous coder, who is also gratefully acknowledged. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. References Allen, S., Chapman, Y., O’Connor, M., Francis, K., 2007. The importance of language for nursing: does it convey commonality of meaning and is it important to do so? Aust. J. Adv. Nurs. 24 (4), 47–51. Bosher, S., Stocker, J., 2015. Nurses’ narratives on workplace English in Taiwan: improving patient care and enhancing professionalism. Engl. Specif. Purp. 38, 109–120. https://doi.org/10.1016/j.esp.2015.02.001. Chang, C.-S., Su, Y.-C., 2014. Discussion on the development of medicine in Taiwan before Japanese Colonial period. Journal of China Medicine 2, 309–320. https://doi. org/10.3966/101764462014122502017. Chang, F.-F., 2010. The five steps of qualitative data analysis: climbing up a ladder of abstraction. Journal of Elementary Education 35, 87–120. https://doi.org/10.7036/ JEE.201004.0087. Cope, P., Cuthbertson, P., Stoddart, B., 2000. Situated learning in the practice placement. J. Adv. Nurs. 31 (4), 850–856. https://doi.org/10.1046/j.1365-2648.2000.01343.x. CRICO Strategies, 2015. Malpractice Risk in Communication Failures, 2015 Annual Benchmarking Report. The Risk Management Foundation of the Harvard Medical Institutions, Inc., Boston, MA. Dennen, V.P., Burner, K.J., 2008. The cognitive apprenticeship model in educational practice. In: Spector, J.M., Merrill, M.D., Merrienboer, J.V., Driscoll, M.P. (Eds.), Handbook of Research on Educational Communications and Technology. Taylor & Francis Group, New York, NY, pp. 425–439. Fagermoen, M.S., 1997. Professional identity: values embedded in meaningful nursing practice. J. Adv. Nurs. 25, 434–441. https://doi.org/10.1046/j.1365-2648.1997. 1997025434.x. Fusch, P.I., Ness, L.R., 2015. Are we there yet? Data saturation in qualitative research. The Qualitative Report 20 (9), 1408–1416. Gender Equality Committee of the Executive Yuan (2018). Healthcare professionals' education and working environment. Retrieved from: https://www.gender.ey.gov. tw/GecDB/Common/FileDownload.ashx?sn=b521rJsGfCVeL8%2b8Yw9Igg%3d %3d&ext=.pdf Goh, Y.-S. (2010). Bilingual education policy in Singapore: Evolution and new opportunities. Journal of Taiwanese Languages and Literature, 5(2), 1–10. Retrieved from https://s3.amazonaws.com/academia.edu.documents/33371716/14.%E5%90%B3% E8%8B%B1%E6%88%90-%E8%AC%9B%E7%BE%A9.pdf?response-contentdisposition=inline%3B%20filename%3DBilingual_education_policy_in_Singapore. pdf&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Credential= AKIAIWOWYYGZ2Y53UL3A%2F20190821%2Fus-east-1%2Fs3%2Faws4_request&XAmz-Date=20190821T065003Z&X-Amz-Expires=3600&X-Amz-SignedHeaders= host&X-Amz-Signature= 7fd0e741230b42982d729cd4280c045e9f8a44eca249ee2379bfb909006fef0c Goodman, B., 2019. Psychology and Sociology in Nursing, 3rd edition. Sage, London, UK. Gunnarsson, B.-L., 2009. Professional Discourse. Continuum, London, UK. Haggerty, C., Holloway, K., Wilson, D., 2013. How to grow our own: an evaluation of preceptorship in New Zealand graduate nurse programmes. Contemp. Nurse 43 (2), 162–171. https://doi.org/10.5172/conu.2013.43.2.162. Heffernan, C., Heffernan, E., Brosnan, M., Brown, G., 2009. Evaluating a preceptorship programme in South West Ireland: perceptions of preceptors and undergraduate students. J. Nurs. Manag. 17 (5), 539–549. https://doi.org/10.1111/j.1365-2834. 2008.00935.x. Ho, H.-H., Liu, P.-F., Hu, H.-C., Huang, S.-F., Chen, H.-L., 2010. Role transition and working adaption in new nursing graduates: a qualitative study. J. Nurs. 57 (6), 31–41. Hyland, K., 2009. Teaching and Researching Writing. Harlow. Pearson, UK.
7. Conclusions This study explored how nurses learned English medical discourse in hospital contexts and how their professional identities were constructed in relation to medical discourse, an area that had not previously been thoroughly reported. Although the research findings offer insights and increase awareness of learning through participation and constructing identity, they may not be generalisable, as the chosen research site, the role of medical discourse, and the learning approach contributed to the nurses' unique perspectives on medical discourse and identity in this study. This paper provides support for the idea that learning occurs in practice. Nurses acquired their understanding and knowledge of English medical discourse and nursing by engaging and being involved in nursing practice, communication, interactions, and relationships. This means that medical discourse does not exist in and of itself and cannot be separated from the practice that gives meaning to it. By properly responding to doctors' questions, demonstrating their knowledge of medical discourse, providing quality nursing care, and helping patients recover from illness, nurses' professional roles are proclaimed to both insiders and outsiders of the healthcare community. Therefore, rather than saying that nurses develop professional identities through aligning their language use with other experienced members or through showing their language knowledge in internal professional events, it is more precise to say that nurses' identities are forged by engaging and 6
Nurse Education Today 85 (2020) 104301
Y.-L. Lu
20159762. Price, S.L., 2009. Becoming a nurse: a meta-study of early professional socialisation and career choice in nursing. J. Adv. Nurs. 65, 11–19. https://doi.org/10.1111/j.13652648.2008.04839.x. Scott, A.M., Li, J., Oyewole-Eletu, S., Nguyen, H.Q., Gass, B., Hirschman, K.B., ... Williams, M.V., 2017. Understanding facilitators and barriers to care transitions: Insights from Project ACHIEVE site visits. The Joint Commission Journal on Quality and Patient Safety 43 (9), 433–447. https://doi.org/10.1016/j.jcjq.2017.02.012. Streitenberger, K., Breen-Reid, K., Harris, C. (2006). Handoffs in care—Can we make them safer? Quality & Risk Management, 53, 1185–1195. https://doi.org/10.1016/j. pcl.2006.09.010 Tonkiss, F., 2012. Discourse analysis. In: Seale, C. (Ed.), Researching Society and Culture. Sage Publications, London, UK, pp. 405–424. Tzeng, S.-C., Chou, C.-C., 2016. The learning experiences of new graduated nurses. Veterans General Hospital Nursing 33 (2), 183–192. Wenger, E., 1998. Communities of Practice: Learning, Meaning, and Identity. Cambridge University Press, New York, NY. Wenger, E., 2009. Foreword. In: Andrée, M. (Ed.), Communities of Practice in Health and Social Care (pp. vii–ix). Sussex. Wiley-Blackwell, UK. Wilce, J.M., 2009. Medical discourse. The Annual Review of Anthropology 38, 199–215. https://doi.org/10.1146/annurev-anthro-091908-164450. Yang, C.-L., 2011. Internationalised medical care services increase need of health care providers to improve English communication skills. J. Nurs. 58 (1), 97–101. Yang, M.-N., Su, S.-M., 2003. A study of Taiwanese nursing students’ and in-service nurses’ English needs. Journal of Chang Gung Institute of Technology 2, 269–284. Yeh, M.-T., Yu, Y.-M., Chen, S.-Y., Sun, M.-H., 2017. A program to improve the retention rates of new nursing staff in a hospital. New Taipei Journal of Nursing 19 (1), 47–57. Yin, Y.-C., 2013. The two-year post graduate training program for nurses’: implementation status and personal perspectives. J. Nurs. 60 (3), 11–16. https://doi.org/10. 6224/JN.60.3.11. Yonge, O., Billay, D., Myrick, F., Luhangu, F., 2007. Preceptorship and mentorship: not merely a matter of semantics. Int. J. Nurs. Educ. Scholarsh. 4 (1), 19.
Hyland, K., 2010. Community and individuality: performing identity in applied linguistics. Writ. Commun. 27 (2), 159–188. https://doi.org/10.1177/0741088309357846. Hyland, K., 2011. Projecting and academic identity in some reflective genres. Ibérica 21, 9–30. Hyland, K., Tse, P., 2012. ‘She has received many honours’: identity construction in article bio statements. J. Engl. Acad. Purp. 11, 155–165. https://doi.org/10.1016/j.jeap. 2012.01.001. Kaviani, N., Stillwell, Y., 2000. An evaluation study of clinical preceptorship. Nurse Educ. Today 20, 218–226. https://doi.org/10.1054/nedt.1999.0386. Khomeiran, R.T., Yekta, Z.P., Kiger, A.M., Ahmadi, F., 2006. Professional competence: factors described by nurses as influencing their development. Int. Nurs. Rev. 53 (1), 66–72. https://doi.org/10.1111/j.1466-7657.2006.00432.x. Lave, J., 1996. Teaching as learning. in practice. Mind, Culture & Activity 3 (3), 149–164. https://doi.org/10.1207/s15327884mca0303_2. Lin, A., 2008. Modernity, postmodernity, and the future of “identity”: Implications for educators. In: Lin, A. (Ed.), Problematising Identity: Everyday Struggles in Language, Culture, and Education. Lawrence Erlbaum, Mahwah, NJ, pp. 199–219. Little, M., Jordens, C.F.C., Sayers, E.J., 2003. Discourse communities and the discourse of experience. Health 7, 73–86. https://doi.org/10.1177/1363459303007001619. Liu, S.-L., Wang, M.-H., Liu, H.-H., 2010. An investigation of job stressors in newly employed nurses. Veterans General Hospital Nursing 27 (3), 276–284. Lu, Y.-L., 2016. Experiences in the workplace community and the influence of community experiences on ENP courses for nursing professionals. Nurse Educ. Today 40, 39–44. https://doi.org/10.1016/j.nedt.2016.01.025. Marañón, A.A., Pera, M.P.I., 2015. Theory and practice in the construction of professional identity in nursing students: a qualitative study. Nurse Educ. Today 35, 859–863. https://doi.org/10.1016/j.nedt.2015.03.014. McLaughlin, E., Parkinson, J., 2018. ‘We learn as we go’: how acquisition of a technical vocabulary is supported during vocational training. Engl. Specif. Purp. 50, 14–27. https://doi.org/10.1016/j.esp.2017.11.003. Pratt, M.G., Rockmann, K.W., Kaufmann, J.B., 2006. Constructing professional identity: the role of work and identity learning cycles in the customisation of identity among medical residents. Acad. Manag. 49 (2), 235–262. https://doi.org/10.2307/
7