2024 Volume 7 Issue 2 Pages 12-20
Objective
To clarify the changes in the same nursing students’ interests in and reasons for learning English, attitudes toward people from other countries, willingness, motivation, and need for studying English as a goal as they progress to a higher year of study.
Methods
We conducted a prospective study with undergraduate nursing students at a medical university in Tokyo using an online self-administered questionnaire. The McNemer test and Wilcoxon signed-rank tests were used for analyses.
Results
A total of 80 students completed the questionnaire in two different years (2018–2019). Regarding self-evaluated English level, 75% of the students answered that they could speak “a few words” or “can only greet others.” The top three highest scores for basic interest in and reasons for learning English were “traveling abroad” and “traveling to English-speaking countries,” followed by interest in “English-language music, movies, and dramas” in both years. Among the 16 items, four items decreased significantly: “It is fun to study English,” “I am interested in English-language newspapers, magazines, and online articles,” “I would like to attend classes taught in English,” and “I am interested in technical books written in English.” Attitudes toward communicating with people from other countries and willingness and motivation to study English did not change significantly. The learning needs total score, specifically the preparing for professional work subtotal score, decreased significantly. The most frequent need to study English as a goal was for traveling, followed by listening to general English, and having daily conversations in both years.
Conclusion
Undergraduate nursing students’ interest and need to study English decreased significantly, while their willingness to study English and positive attitudes toward people from other countries remained stable. It is necessary to develop an effective English curriculum to enable students to set a goal and maintain their interest and need to study English.
As a result of globalization and migration, many countries are increasingly culturally diverse. However, the percentage of foreigners in Japan in 2019 was just over 2%, which was much lower than that of other countries in the Organization for Economic Co-operation and Development (OEDC, 2022). Therefore, Japanese medical facilities are not well adapted to hospitalizing non-Japanese people.
A study on international students who visited Japanese hospitals reported that their most difficult challenge was communicating with staff and that they preferred medical staff who could communicate with them in English (Soneta et al., 2021). According to a previous study, nurses’ most necessary training for managing non-Japanese patients was “English daily conversation,” followed by coping with different cultural customs (Kambayashi et al., 2020). Therefore, it is necessary for nurses to attain proficiency in English at a daily conversational level to enhance communication with non-Japanese patients and, consequently, provide better care for them.
As globalization progresses, it is crucial for Japan to improve its English ability, which is considered to be the international common language. Therefore, it is necessary to aim for top-class English proficiency in Asia (Ministry of Education Culture Sports Science and Technology, 2014). However, Japan may be still ranked lower than its Asian neighbor countries, such as China and South Korea, in English skills (EF English Proficiency Index, 2022). Although Japanese students are encouraged to learn different cultures through short- and long-term overseas studies, only a limited number of nursing students join overseas study programs, mostly owing to low confidence in their English abilities (Hua & Kondo, 2022).
In a past study, we conducted a cross-sectional study with nursing students at a university in Tokyo and reported that factors related to the willingness to get involved with non-Japanese people included high self-evaluated English ability, a greater number of opportunities to talk with non-Japanese people, and a greater number of overseas travel experiences (Isoda & Kondo, 2022). In this study, participation in overseas training programs and self-evaluated English ability were related to a motivation to learn English. Even though more students in higher years of study participated in overseas training programs, higher years of study were associated with negative attitudes toward non-Japanese people and a lower motivation to learn English (Isoda & Kondo, 2022). However, the cited study compared different students in different years of study. The change over time for the same students was unclear. Therefore, the purpose of this study was to clarify the changes in the same nursing students’ interests in and reasons for learning English, attitudes toward people from other countries, willingness, motivation, and need for studying English as a goal as they progress to a higher year of study.
1. Design
This was a prospective study that used an online self-administered questionnaire, which was conducted at a medical university located in Tokyo metropolitan area.
2. Setting
At the studied university, freshmen were allocated to different English classes based on their Test of English as a Foreign Language Institutional Testing Program scores. They took compulsory English classes with four credits: reading and writing classes given by Japanese teachers and oral communication classes given by native English-speaking teachers. Sophomores and juniors took a compulsory English reading class for one credit in their spring semester but had no compulsory English classes in their fall semester. Seniors did not have any compulsory English classes. Six total credits were available for compulsory English classes (15 90-minute lectures per credit) during the four-year program. Two elective classes, “Practicum of English for Nursing” and “Learning Medical English,” were open to students from sophomores to seniors. The former was available during the spring semester and the latter during the fall semester. In addition, the Health Sciences Leadership Program to become a world-level leader in the medical and/or medical fields was available, and only a few nursing students with high-level English took it.
3. Participants
All undergraduate nursing students from first to third year in 2018 (N=165) and the same students from second to fourth year in 2019 enrolled at the university were targeted, and those who completed the questionnaire in both years were included in this study.
4. Data collection
The researchers asked students to participate using a PowerPoint presentation to describe the study and distributing a flyer that provided an explanation about the aim and methods of the study with a QR code, and an URL for the Google Form questionnaire. The questionnaire was written in Japanese. The study period was from July to October, in both 2018 and 2019.
5. Definition of key terms
Motivation was defined as an incentive to achieve and strong will to do something; thus, motivation to study English represents the “reason” students study English (Isoda & Kondo, 2022). We categorized motivation based on Ichikawa’s (2014) two-factor learning motivation model: the importance and utility of the study contents. Both were evaluated from high to low. If the importance of the content is high, it is regarded as “content-involved motivation.” If the utility of the content is high but its importance is low, motivation is regarded as reward-based, rather than practical use. This means that the person studies to obtain rewards, such as English course credits.
Learning needs were defined as learning methods and contents that, based on individuals’ characteristics, are perceived as necessary to achieve an educational purpose and/or goals. We defined student nurses’ needs related to English language ability in the form of 14 “goals” for students to achieve by their time of graduation (Isoda & Kondo, 2022).
Attitudes toward communicating with people from other countries refer to how actively students interact with non-Japanese people. We included this item because nurses who experience difficulties communicating with patients from other countries may lose their motivation to attempt communication (Isoda & Kondo, 2022).
We defined willingness as the “strength” of will to study English. Interest in and reasons for learning English relates to students’ voluntary and/or base reasons to study English, rather than a goal they need to achieve by the time of graduation. Fifteen items were selected because they could be related to students’ motivation and the need to study English, regardless of experiences or studies during university (Isoda & Kondo, 2022).
6. Survey contents
The survey collected data on students’ characteristics, basic interest in English, reasons for learning English, attitude toward communicating with people from other countries, willingness, motivations, and learning needs regarding studying English as a goal.
Students’ characteristics included year of study, English level, frequency of opportunities to interact with people from other countries, and participation in the university’s overseas study programs or any international events outside the university in Japan. English language skills were measured as a four-level self-evaluation: native-speaker level, daily conversation level, can speak a few words, and can only greet others.
The 16 items regarding students’ basic interest in and reasons for learning English, such as “I am interested in traveling abroad,” and “I would like to travel to English-speaking countries,” were surveyed using a four-point scale (1 = “strongly disagree” ~ 4 = “strongly agree”).
Attitude toward communicating with people from other countries was surveyed through the statement “I actively interact with people from other countries” using the same four-point scale (1 = “strongly disagree” ~ 4 = “strongly agree”).
Willingness to study English was assessed by asking students how much they would like to study English. The participants responded on a four-point scale (1 = “strongly disagree” ~ 4 = “strongly agree”).
Students chose one of the seven motivations to study English based on Ichikawa’s (2014) two-factor learning motivation model. If students selected studying English is fun (fulfillment), acquiring knowledge and culture (discipline), or for professional and daily life (practical use), it was regarded as “content-involved motivation.” If students selected conforming with peers (relationship), getting good scores on exams (pride and competitive spirit) (self-esteem), passing exams or acquiring credits (rewards), it was regarded as “content-separate motivation.”
For their learning needs with regard to studying English, students were surveyed about the above-mentioned 14 goals for graduation, which were categorized into three domains: preparation for professional work, clinical practice, and daily use (Isoda & Kondo, 2022). Preparing for professional work included “writing general English,” “writing research papers,” “studying abroad,” “taking English-proficiency examinations,” “professional activities,” and “taking English examinations.” Clinical practice included “managing patients from other countries,” “understanding medical and nursing terms,” “interacting with colleagues from other countries,” and “reading theses and technical books.” Daily use included “traveling,” “listening to general English,” “having daily conversations,” and “reading general English.” Participants responded regarding their English learning need for each item using a four-point scale (1 = “strongly disagree” to 4 = “strongly agree”). Cronbach’s alpha for the total score was 0.912 in 2018 and 0.924 in 2019. Cronbach’s alpha for each domain was 0.870, 0.815, and 0.850 in 2018 and 0.878, 0.837, and 0.923 in 2019, respectively.
7. Sample size and power
We used G*Power 3.1.9.7 (Heimrich Heine Universitat Dusseldolf, 2007) to conduct a post-hoc power analysis. With an alpha error of 0.05 and a power of 0.8 in a Wilcoxon signed-rank test (matched pairs) in two tails, 80 participants were considered an adequate number to be able to detect an effect size of d=0.33.
8. Analysis
SPSS version 28 was used for all the analyses. An alpha level of 0.05 was set for significance for all analyses. The McNemer test was used to analyze the change in dichotomous variables, such as participation in international events and having motivation from 2018 to 2019. The Wilcoxon signed-rank test was used to analyze the changes in all other ordinal variables. Changes in learning needs were analyzed through the total score (14 items) and each domain sub-score: prepare for professional work (six items), clinical practice (four items), and daily use (four items). Since it is difficult to see a small change in the median, we used the mean ±SD and median for each ordinal variable’s descriptive statistics.
9. Ethics
This study was approved by the Medical Ethics Committee of the Tokyo Medical and Dental University (No. M2018-080). We informed prospective participants orally and in writing of the aim of the survey and that their responses would remain confidential. They were required to report their student ID numbers to connect their previous years’ responses. They were informed that participation was voluntary, although answering all questions on the form was required, that they would not incur any demerits for refusing to participate, and that students’ answers would not affect their grades. The Google Form was set to be unable to locate IP or email addresses, and study numbers were assigned when the data were analyzed. The Google Form included a consent form on which the students checked a check box to indicate their agreement to participate.
1. Participants’ characteristics
Participants’ basic characteristics are presented in Table 1. In 2018, 116 students (70.3%) participated in the survey. Among them, 80 students completed the questionnaire in 2019 (response rate: 48.5% of all 165 students and 69.0% of the 116 students who participated in 2018). Among students who participated in the survey in 2018 (N=116), those who completed the survey in 2019 (n=80) had significantly higher self-evaluated English levels, had higher interest in technical books in English and a job in which English was used, and more felt studying English is fun and that English is necessary for clinical practice than those who did not complete the survey in 2019 (n=36).
Because all questions were required in Google Form, there were no missing data. In 2019, 34 participants (42.5%) were in the second year, 21 (26.3%) were in the third year, and 25 (31.3%) were in the fourth year. Regarding self-evaluated English level, 75% of the students answered that they could speak “a few words” or “can only greet others,” which was not significantly different from 2018 (Table 1).
| Table 1 Participants' characteristics (N=80) | |||
| 2018 | 2019 | P | |
| n (%) | |||
| Self-evaluated English-language skill | |||
| Native speaker level | 1 (1.3) | 1 (1.3) | 0.827† |
| Conversational | 19 (23.8) | 19 (23.8) | |
| A few words | 41 (51.2) | 42 (52.5) | |
| Can only greet others | 19 (23.8) | 18 (22.5) | |
| Number of trips abroad | |||
| Never | 16 (20.0) | 7 (8.8) | <0.001† |
| Once | 20 (25.0) | 18 (22.5) | |
| Twice | 14 (17.5) | 21 (26.3) | |
| Three or more times | 30 (37.5) | 34 (42.5) | |
| Frequency of opportunities to converse with people from other countries | |||
| Not at all | 16 (20.0) | 9 (11.3) | 0.051† |
| Once every few years | 8 (10.0) | 6 (7.5) | |
| Once in a year | 16 (20.0) | 20 (25.0) | |
| Once every few months | 21 (23.8) | 19 (23.8) | |
| A few times a month | 19 (23.8) | 26 (32.5) | |
| Participated in study abroad programs at school | 8 (10.0) | 14 (17.5) | 0.031‡ |
| Participated in international events outside of school | 14 (17.5) | 12 (15.0) | 0.791‡ |
| †Wilcoxon signed-rank test; ‡McNemar test | |||
The total number of trips abroad increased significantly (z=-3.680, p<0.001), with 42.5% of students having travelled three or more times. Still, 8.8% of students had never been abroad in 2019. Although the frequency of opportunities to converse with people from other countries increased slightly, it was not significant at an alpha level of 0.05 (z=-1.951, p=0.051). The number of students who had participated in university study-abroad programs increased significantly (p=0.031), but was still only 17.5% (Table 1).
2. Basic interest in and reasons for learning English
The top three highest scores for basic interest in and reasons for learning English were “traveling abroad” and “traveling to English-speaking countries,” followed by interest in “English-language music, movies, and dramas” in both years. Among the 16 items, four items decreased significantly: “It is fun to study English” (z=-2.372, p=0.018), “I am interested in English-language newspapers, magazines, and online articles” (z=-2.622, p=0.009), “I would like to attend classes taught in English” (z=-2.536, p=0.011), and “I am interested in technical books written in English” (z=-2.871, p=0.004). Almost all the items’ average scores decreased, although they were not statistically significant.
| Table 2 Basic interest in and reasons for learning English (N=80) | |||
| Items | 2018 | 2019 | p |
| Median (Mean±SD)† | |||
| 1. I am interested in traveling abroad | 4 (3.71±0.6) | 4 (3.65±0.7) | 0.486 |
| 2. I would like to travel to English-speaking countries | 4 (3.51±0.7) | 4 (3.40±0.8) | 0.317 |
| 3. I am interested in English-language music, movies, and dramas | 4 (3.36±0.8) | 3 (3.21±0.9) | 0.149 |
| 4. English is needed in clinical practice | 3 (3.21±0.7) | 3 (3.15±0.7) | 0.369 |
| 5. University nursing students need to study English | 3 (3.25±0.7) | 3 (3.14±0.8) | 0.168 |
| 6. I am interested in being able to converse in English | 3 (3.18±0.9) | 3 (3.08±0.9) | 0.172 |
| 7. It is fun to study English | 3 (2.98±0.9) | 3 (2.76±0.9) | 0.018 |
| 8. I have difficulty taking classes taught in English | 2.5 (2.53±1.1) | 3 (2.60±1.0) | 0.574 |
| 9. I study English to obtain credits | 3 (2.75±0.9) | 3 (2.65±1.0) | 0.300 |
| 10. I would like to study English to conform with other students | 3 (2.64±0.9) | 3 (2.49±0.8) | 0.073 |
| 11. I am interested in English-language newspapers, magazines, and online articles | 3 (2.76±0.9) | 2 (2.51±1.0) | 0.009 |
| 12. I would like to attend classes taught in English | 3 (2.69±1.1) | 2 (2.40±1.0) | 0.011 |
| 13. I am interested in a job in which English is used | 3 (2.61±0.9) | 2.5 (2.49±1.0) | 0.271 |
| 14. I am interested in technical books written in English | 2 (2.36±0.9) | 2 (2.08±0.9) | 0.004 |
| 15. I did not think I would need to study English in university | 1 (1.69±0.9) | 2 (1.91±1.0) | 0.091 |
| 16. I would like to take a free elective subject where I read about different culture and have discussions with international students in English. | 2 (2.21±1.0) | 2 (2.17±0.9) | 0.702 |
| † 1 = “strongly disagree,” 2 = “disagree,” 3 = “agree,” and 4 = “strongly agree” | |||
| Wilcoxon signed-rank test; Bold indicates significance at p<0.05 | |||
3. Attitude toward communicating with people from other countries, willingness, and motivation to study English
Attitudes toward communicating with people from other countries, willingness, and motivation to study English did not change significantly (Tables 3 and 4). The most frequent motivation to study English was learning English for professional and daily life, followed by acquiring credits (Table 4).
| Table 3 Attitude for studying English and people from other countries | |||
| Items | 2018 | 2019 | p |
| Median (Mean±SD) | |||
| I actively interact with people from other countries | 3 (2.59±0.9) | 3 (2.63±0.9) | 0.636 |
| I have a willingness to study English | 3 (2.76±0.9) | 3 (2.76 ±0.9) | 0.892 |
| 1 = “strongly disagree,” 2 = “disagree,” 3 = “agree,” and 4 = “strongly agree” | |||
| Wilcoxon signed-rank test | |||
| Table 4. Reason to study English (Motivation) N=80 | ||||
| Classification | Reason to study English | 2018 | 2019 | p |
| n (%) | ||||
| Fulfillment | 1. Studying English is fun | 6 (7.5) | 3 (3.8) | 0.375 |
| Discipline | 2. To acquire knowledge and culture | 18 (22.5) | 16 (20.0) | 0.832 |
| Practical use | 3. For professional and daily life | 37 (46.3) | 38 (47.5) | 1.000 |
| Relationships | 4. To conform with peers | 0 (0) | 0 (0) | x |
| Self-esteem | 5. To get good scores on exams | 0 (0) | 0 (0) | x |
| Rewards | 6. To pass examinations | 1 (1.3) | 0 (0) | 1.000 |
| 7. To acquire credits | 18 (22.5) | 23 (28.7) | 0.388 | |
| Content-involved motivation（1～3） | 61 (76.3) | 57 (71.3) | 0.388 | |
| McNemar test | ||||
4. Learning needs for studying English as a goal
The total score for learning needs decreased significantly (z=-2.640, p=0.008) (Table 5). The median total score for preparing for the professional domain decreased significantly from 16 to 13 (z=-2.774, p=0.006). The median total score of the clinical practice domain decreased significantly from 14 to 13 (z=-1.798, p=0.072), whereas that of the daily use domain did not change and remained at 16 (z=-1.505, p=0.132).
The most frequent need to study English as a goal was traveling, followed by listening to general English, and having daily conversations in both years. The top four items were all for daily use and the lowest five items were all for professional preparation.
| Table 5. Learning needs (English-language-related goals to achieve by graduation) N=80 | |||||
| 2018 | 2019 | p | |||
| Median (Mean±SD)† | |||||
| Total score | 45 (43.7±7.8) | 41 (41.5±8.9) | 0.008 | ||
| Sub-score | Daily use | 16 (14.7±1.9) | 16 (14.3±2.4) | 0.132 | |
| Clinical practice | 14 (13.5±2.5) | 13 (12.9±2.6) | 0.072 | ||
| Prepare for professional | 16 (15.5±4.4) | 13 (14.2±5.1) | 0.006 | ||
| 1 | D | Traveling | 4 (3.75±0.5) | 4 (3.64±0.6) | |
| 2 | D | Listening to general English | 4 (3.69±0.6) | 4 (3.63±0.6) | |
| 3 | D | Having daily conversations | 4 (3.66±0.6) | 4 (3.61±0.7) | |
| 4 | D | Reading general English | 4 (3.61±0.6) | 4 (3.46±0.7) | |
| 5 | C | Managing patients from other countries | 4 (3.59±0.7) | 4 (3.51±0.7) | |
| 6 | C | Understanding medical and nursing terms | 4 (3.43±0.7) | 3 (3.33±0.7) | |
| 7 | C | Interacting with colleagues from other countries | 4 (3.48±0.8) | 3 (3.31±0.8) | |
| 8 | P | Writing general English | 3 (3.31±0.8) | 3 (3.10±0.8) | |
| 9 | C | Reading theses and technical books | 3 (2.98±0.8) | 3 (2.79±0.9) | |
| 10 | P | Studying abroad | 3 (2.68±1.1) | 2.5 (2.46±1.1) | |
| 11 | P | Writing research papers | 3 (2.60±1.0) | 2 (2.30±1.0) | |
| 12 | P | Taking English-proficiency examinations | 2 (2.50±1.0) | 2 (2.21±1.2) | |
| 13 | P | Professional activities | 2 (2.34±1.1) | 2 (2.24±1.1) | |
| 14 | P | Taking English examinations | 2 (2.10±0.9) | 2 (1.93±1.1) | |
| D: Daily use; C: Clinical practice; P: Prepare for professional | |||||
| †1 = “strongly disagree,” 2 = “disagree,” 3 = “agree,” and 4 = “strongly agree.” | |||||
| Wilcoxon signed-rank test | |||||
This study found that undergraduate nursing students’ interest in and need to study English significantly decreased over one year. However, willingness to study English and positive attitudes toward people from other countries were maintained within the same period.
We reported that higher years of study were associated with negative attitudes toward non-Japanese people and lower motivation to learn English in different individual students (Isoda & Kondo, 2022), but attitude and motivation did not change over one year for the same students. This does not mean that their attitudes became negative as the school year progressed but, instead, that lower-year students had more positive attitudes compared to senior students. International education, including English, before university (e.g., elementary school to high school) could be improving (Terasawa, 2022) while that in nursing programs at the university may remain ineffective because learning needs, especially professional and clinical practice domains, significantly decreased in one year.
In this prospective study, students’ interest in and reasons for learning English decreased, especially their feeling that studying English was fun and their interest in English-language newspapers, magazines, and online articles, which could lead to decreased learning needs. In Japan, English proficiency is not required to graduate from a nursing program, and the national nursing licensure examination is entirely in Japanese, and no English proficiency test is included. Further, hospitals do not usually require English for nurses to be employed. Less than 2% of students went to graduate programs in Japan, and only 0.1% of students went to study abroad immediately after graduating from an undergraduate program (Japan Association of Nursing Programs in Universities and The Japan Society of Private Colleges and Universities of Nursing, 2018). Therefore, undergraduate students’ need to study English, especially in preparation for professional work, could not be maintained through to the time of graduation.
According to the Tokyo Intercultural Portal Site (2018), the most common issues experienced by foreigners living in Tokyo were medical-related. Their preferred language for receiving information was easy-to-understand Japanese, followed by English, rather than their machine translated native language. It is noteworthy that the majority of respondents were from Asian countries. Therefore, improving English education is necessary, not only for studying or working abroad, but also for taking care of non-Japanese patients.
Higher self-evaluated English language levels were associated with positive attitudes toward people from other countries (Isoda & Kondo, 2022). In this prospective study, the self-evaluated English-language level or attitude toward people from other countries did not improve. It would be necessary for students to improve self-evaluated English language levels to improve positive attitudes toward people from other countries.
This study was conducted at a medical university in an urban area where students’ English levels and the number of foreign residents were relatively high. In addition, students with higher self-evaluated English levels and higher interest in English were more likely to participate, limiting the study’s generalizability to all nursing students in Japan. A larger nationwide study is necessary to understand changes in nursing students’ motivation and need to study English, as they progress through university, to develop an effective nursing English curriculum.
In order to maintain English learning needs, it is necessary to have a class where students can have fun using materials that they are interested in, and where they can develop interest in situations in which English is used, so that they feel that English is necessary in clinical practice and professional work.
Undergraduate nursing students’ interest and need to study English decreased significantly, while their willingness to study English and positive attitudes toward people from other countries remained stable over one year. Developing an effective nursing English curriculum is necessary so that Japanese nursing students can set a goal and continuously maintain their interest and need to study English.
There is no conflict of interest to be disclose.
This study was conducted as a graduation thesis in Nursing Science, School of Health Care Science at Tokyo Medical and Dental University in 2019. This study was conducted using International Nursing Development’s field cost of the university. A part of this study was reported at the 6th Annual Meeting of Japanese Society for International Nursing 2022.09.18.
Akiko Kondo and Mai Noguchi equally contributed for conceptualization and design; data curation, formal analysis, and interpretation of data; drafting the work, revising the work, critically reviewed and approved the final manuscript.
All authors listed meet the authorship criteria according to the latest guidelines of the International Committee of Medical Journal Editors, and all authors are in agreement with the manuscript.
