Clinical Simulation in Nursing (2017) 13, 524-530

www.elsevier.com/locate/ecsn

Featured Article

Fostering Academic Success among English as an

Additional Language Nursing Students Using
Standardized Patients
Krista King, MN, RNa,*, Caroline Porr, PhD, RNb, Alice Gaudine, PhD, RNc
a
Lecturer, School of Nursing, Memorial University of Newfoundland, St John’s, NL, Canada A1B 3V6
b
Associate Professor, School of Nursing, Memorial University of Newfoundland, St John’s, NL, Canada A1B 3V6
c
Dean and Professor, School of Nursing, Memorial University of Newfoundland, St John’s, NL, Canada A1B 3V6

KEYWORDS
simulation;
standardized patients;
EAL nursing students;
visible minorities;
health care disparities;
community of practice;
attitudes
Abstract: To reduce health care disparities among minority groups, it is imperative that nursing
schools increase their enrollment and retention of English as an additional language (EAL) nursing stu-
dents. However, EAL nursing students struggle academically. The aim of this study was to explore the
perceived effectiveness of standardized patients (SPs) as a means to achieve academic success among
EAL nursing students. Using focus group methodology, 35 EAL nursing students shared their percep-
tions of SPs as a teachingelearning tool. Analysis generated seven core concepts: (a) psychological
safety, (b) comfort communication, (c) psychomotor skill development, (d) language acquisition, (e)
change in attitudes, (f) debrief, debrief, debrief, and (g) learning takes time. SP simulation creates a
supportive community of practice that enables EAL nursing students to experience a sense of
psychological safety as they acquire new learning in cognitive, psychomotor, and affective domains.
Additionally, EAL nursing students are able to enhance their English proficiency as they
communicate with patients and families. Engaging in debriefing and repeat practice sessions are
instrumental to EAL nursing student learning. A strategic transformation in the delivery of EAL
nursing education is needed. If EAL nursing students are to attain positive learning outcomes, they
need to be immersed in a supportive and contextually-rich learning environment fostered by SP simu-
lation that encourages them to strive for mastery.

Cite this article:

King, K., Porr, C., & Gaudine, A. (2017, October). Fostering academic success among english as an addi-
tional language nursing students using standardized patients. Clinical Simulation in Nursing, 13(10),
524-530. http://dx.doi.org/10.1016/j.ecns.2017.06.001.
Ó 2017 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier
Inc. All rights reserved.

There is an unprecedented growth in ethnocultural and
linguistic diversity within United States and Canada
(Statistics Canada, 2017; U.S. Census Bureau, 2015);
* Corresponding author: krista.king@mun.ca (K. King).
accompanying this growth is a marked increase in health
care disparities among minority groups. The Institute of
Medicine (2003) recommends increasing the diversity of
health care professionals to address these disparities.
Expanding student enrollment into schools of nursing
by recruiting applicants from diverse backgrounds is

1876-1399/$ - see front matter Ó 2017 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ecns.2017.06.001
EAL Nursing Students 525

considered a key strategy (Institute of Medicine, 2003); recommendations for enhancement. A focus group study
however, there are several obstacles that must be overcome. entails conducting a series of discussions on a particular
EAL nursing students, for example, experience a greater topic of interest (Krueger & Casey, 2009).
struggle for academic success than their native English
speaking counterparts (Miguel & Rogan, 2011).
Between 1967 and 1995, Study Setting and Sample
the pass rate on the NCLEX-
Key Points RN was 21% lower for
 Standardized patient On obtaining institutional review board approval, recruit-
Mexican-American nursing ment commenced. Thirty-five undergraduate EAL nursing
simulation fosters a students who spoke English
supportive and contex- students from a Canadian nursing university in a foreign
as an additional language country where Arabic is the official language volunteered to
tually rich community than native English-
of practice for nursing participate. Participants were enrolled in a Bachelor of
speaking nursing students Nursing (BN) program (includes post-diploma option).
student learning. (Bosher & Bowles, 2008).
 Standardized patient Participants had recently taken part in a nursing course
English language deficiency that had integrated SPs as a teachingelearning tool.
simulation affects posi- is making comprehension of
tive attitudinal change. Participants were enrolled in a foundational nursing course,
nursing terminology and ab- a family nursing course, a health assessment nursing course,
 Diversity in nursing stract concepts challenging
may reduce health and/or a mental health nursing course. The exact duration or
(Donnelly, McKiel & frequency each participant utilized SPs is unknown.
care disparities among Hwang, 2009; Olson, 2012).
minority groups. According to the Cummins
Model of Language Acquisi- Data Collection and Analysis
tion, contextually rich
learning environments that provide learners with facial
Participants took part in one of six focus group sessions that
cues, gestures or concrete objects of reference, enhance
lasted approximately 75 minutes. On receiving consent,
learning (Cummins, 2003). Standardized patient (SP) simula-
focus group discussions were audiotaped and later tran-
tion can create a rich context for learners and promote the like-
scribed verbatim. During the focus group sessions, partic-
lihood of academic success among EAL nursing students.
ipants responded to open-ended questions designed to elicit
A SP is ‘‘a person trained to portray a patient in realistic
EAL nursing students’ perceptions of SPs as a teachinge
and repeatable ways’’ (Lewis et al., 2017, para 2). Imple-
learning tool. Transcribed data were analyzed using the
menting SP simulation into undergraduate nursing curricula
analytical framework of key concepts (Krueger & Casey,
may create the contextually rich learning environment that
2009) to identify core ideas pertaining to EAL nursing stu-
EAL nursing students require in order to excel. If, ulti-
dents’ perceptions of SPs as a teachingelearning tool and
mately, there is a substantial increase in enrollment, reten-
recommendations for enhancement.
tion, and success of EAL nursing students, the health care
system will be better poised to deliver culturally competent
nursing care. However, little is known about the teaching
Results
effectiveness of SPs among undergraduate nursing students
and even less is known about the impact of SPs on the
The 35 participants (female ¼ 30, male ¼ 5) spoke a variety
learning of EAL nursing students (Becker, Rose, Berg,
of native languages including Arabic, Tagalog, Malayalam,
Park, & Shatzer, 2006; Kurz, Mahoney, Martin-Plank, &
Bengali, Afrikaans, and so forth. The majority (60%) spoke
Lidicker, 2009). The purpose of this research study was
Arabic as their native language and had been speaking
to explore EAL nursing students’ perceptions of SPs as a
English for more than 10 years. Seven concepts emerged
teachingelearning tool. It was anticipated that there would
that reflected EAL nursing students’ perceptions of SPs as a
be an opportunity to glean insight into strategies that may
teachingelearning tool: (a) psychological safety, (b) com-
enhance the effectiveness and integration of SP simulation
fort communication, (c) psychomotor skill development, (d)
in nursing curricula.
language acquisition, (e) change in attitudes, (f) debrief,
debrief, debrief, and (g) learning takes time.

Methodology
This qualitative, exploratory study utilized focus group
methodology guided by Morgan (1995, 1997) and Krueger
and Casey (2009) to ascertain EAL nursing students’ per-
ceptions of SPs as a teachingelearning tool and
Psychological Safety
Participants experienced an immense sense of psycholog-
ical safety as they interacted with the SPs. The SPs
prepared them for the unknown, accepted them as learners,

pp 524-530  Clinical Simulation in Nursing  Volume 13  Issue 10

EAL Nursing Students
and created a risk-free learning environment. Prior to SP
learning experiences, many participants feared the unfa-
miliar realities of nursing education. They were unsure of
what to expect when they went to their first clinical
experience. One participant shared, ‘‘When you have dealt
with the SPs you know what’s gonna be expected from you,
like the way you introduce yourself . it like trains [you] to
go into the hospital setting.’’ Participants perceived that real
patients were less enthusiastic than SPs to have nursing
students directly involved with their nursing care. One
participant shared, ‘‘A real patient would kind of get
annoyed . I think they have somewhere inside their head
that she’s a student nurse and she’s working on me and [she
is] not as good as the real nurse.’’ The SP learning
environment was perceived to be risk free. Participants
believed it was ‘‘safe to [make] mistakes’’ when caring for
SPs. They did not fear causing harm to patients and families.
Rather, they could focus on improving their practice so they
could become ‘‘better nurses.’’ One participant said, ‘‘It .
was um easier for me because you know that it’s a learning
tool. You’re not afraid to do something wrong. You can
always learn from your mistakes.’’
Comfort Communication
Comfort communication is the essence of quality nursing
care. After completing the SP learning experiences, partic-
ipants verbalized significant improvement in their ability to
engage in ‘‘comfort’’ communication with patients and
families in the clinical setting. One participant stated,
‘‘Therapeutic relationships [are] very difficult to apply in
the real world . It’s not easy to do comfort conversation
. the SPs [make] you feel like it’s easier for you . [when]
you reach the clinical setting.’’
SP simulation not only affords nursing students with the
opportunity to practice developing therapeutic relationships
but also validates the importance of establishing these
essential relationships with patients and families. One
participant stated, ‘‘If you touch [their] hands, if you just
put your hand on their shoulder, it means something to
them. A lot of time, really we are forgetting those things.’’
Participants indicated it was more meaningful to develop
therapeutic relationships with SPs than classmates. A
‘‘serious’’ rather than ‘‘casual’’ environment was fostered
when learning with SPs. One participant explained this
difference in interaction:
Without the standardized patients we might not have
been able to perfect those skills because when you’re
practicing with your friends it is a very friendly
casual manner and you giggle a lot. But [with] a
standardized patient you are very serious and you’re
very professional, the same exact way you would be
in real life nursing situation, in a hospital.
pp 524-530  Clinical Simulation in Nursing  Volume 13  Issue 10
526
Psychomotor Skill Development
Prior to SP learning experiences, some post-diploma students
could not competently perform a health assessment and were
at times required to duplicate the health assessment docu-
mentation of other nurses in the clinical setting. The honesty
with which these participants spoke of their struggle to
perform a head-to-toe assessment was admirable:
Before [I did not] know how to do it . I’ll read the
theory but when I want to do it like [in] practical, I do
not know [how]. That’s why some . nurses they copy
[the health assessment] . In the hospital, [the nurses]
copy, paste; copy paste; copy, paste; copy, paste.
Following simulation completion, participants’ believed
they could competently perform a through health assess-
ment. They no longer needed to duplicate the documenta-
tion of other nurses:
I am different . [After working with the SPs], I am
doing, I am taking my stethoscope, I am assessing
the, the lungs sound[s], I’m assessing the heart sound
[s] [and] I am assessing the abdomen . I am not
copying anymore.
Language Acquisition
SP simulation improved participants’ ability to effectively
communicate in English with patients and families more so
than with other modalities of simulation:
The SPs . help you to put the right words in the right
sentence. [When] they say something to you . and you
have no idea how to reply to it you can just ask them for
clarification, you can ask them to repeat what they are
saying and they can help you. If you are working with a
mannequin they can’t say anything to you.
Participants learned how to relay complex medical
information to patients and families in a simplified manner.
One participant stated, ‘‘The standardized patients
improved our communication . in [theory], we learn a
lot but when we go to the actual patients we . have to
change our words . you have to tell them in a simple
way.’’ Participants also became more aware of cultural
idioms such as ‘‘feeling blue’’ that had once caused them
difficulty when communicating with patients and families
in the clinical setting.
Change in Attitudes
SP learning experiences affected significant attitudinal
change among participants. Participants developed new
EAL Nursing Students
practice framework convictions, overcame stereotypical
views about patients with mental health illnesses, acquired
positive attitudes about older adults, and adapted to new
cultural norms regarding gender segregation.
Post-diploma participants adopted a new practice frame-
work espousing family-centered nursing care. They real-
ized that the profession of nursing is about much more than
the timely completion of nursing tasks and that the family
should be at the center of nursing care. One participant
stated, ‘‘It helped us to see how important the family is.’’ A
participant shared her new practice framework conviction
with the group:
[I now] treat the patient equal to their family. Both of
them they need my attention; both of them, they need
my care. I [am] always reminding myself that I have
to talk to the family.
Participants who engaged in learning with SPs who
portrayed various mental health illnesses such as schizo-
phrenia were able to overcome stereotypical views about
patients with mental health illnesses. Prior to the learning
experiences, many participants were unsure of ‘‘what to
expect’’ and they were fearful they may be harmed in the
clinical setting by patients with mental health illnesses. One
participant shared, ‘‘I was afraid in a way that I did not
want to turn my back to someone without noticing what
they’re doing because, you know, something bad could
happen.’’ Upon completion of the SP learning experiences,
participants were no longer concerned about going to
clinical for their mental health nursing course and they no
longer feared for their personal safety.
Prior to SP learning experiences, some participants
believed that older adults were unproductive and that
declining health and quality of life was a natural conse-
quence of aging.
This notion is evident in the following quote:
I thought like most elderly people ah they cannot like,
they cannot [live] normal life . Because in our
country elder people like, most likely, they have a
cane, a chair outside by the street and they just sit and
look at people going here and going there. [They
have] nothing to do . [They are] not healthy to walk.
SP simulation enabled participants to experience a pos-
itive attitudinal change toward older adults. They realized
that older adults can lead healthy and productive lives. One
participant stated, ‘‘I [was] shocked . when he talked to me
about his life . he eat[s] vegetables, he watch[es] his diet .
And he told me he like ah walks four to five kilometers.’’
Female participants were able to adapt to new cultural
norms pertaining to gender segregation. Despite deep-
rooted cultural beliefs that male and female residents
should have limited interaction in the community, female
nurses are being expected to provide nursing care to male
pp 524-530  Clinical Simulation in Nursing  Volume 13  Issue 10
527
patients in the clinical setting. Female participants’ stated
that interacting with male SPs prior to commencing their
clinical course enabled them to feel at ease when caring for
male patients:
I was shy the first time . He came in for [a]
respiratory assessment and you have to do hands on
like percussion and auscultation so . I was kinda
like shy in the beginning. Then I just went with the
flow, like you get used to it. That’s why now, I’m
doing [a specific clinical nursing course] [in a] a male
trauma unit [and] I do not have any problem doing [a]
health assessment. [Now] I feel good.
Debrief, Debrief, Debrief
All participants viewed debriefing as an essential compo-
nent of SP simulation:
It is actually very helpful for us to hear . a patient
tell us how they think, how they felt, about our
intervention. Was it good, was it bad, did we need to
change something to make it better for a real patient.
During reflective debriefing sessions, participants were
able to glean insight into their nursing practice; they were
able to identify areas of their practice that were skillful and
others that were in need of improvement:
So, I learned something from her feedback . during
. communication with the family, [it] is not always
necessary to only communicate in conversation and
talk with them. There is [other] ways which we [can]
connect with the family like emotional support or [a]
hug . the mom was really sad . I just hug[ged] her
and she really trust[ed] me after that.
Participants emphasized the need to debrief immedi-
ately after an SP learning experience.
One participant said, ‘‘I enjoyed having the opportunity
to receive feedback immediately from the standardized
patients themselves.’’ While the majority of debriefing
sessions took place immediately after an SP learning
experience, there were a few occasions when debriefing
was delayed. Participants who were unable to debrief
immediately experienced a high level of uncertainty
regarding the quality of their nursing care. The lack of
immediate feedback from simulation facilitators halted
engagement in SP learning experiences:
It gets hard for the instructor to give attention to all of
us equally . sometimes we just stand there not like,
not knowing what to do when the instructor’s viewing
someone else . [with] the standardized patient you
have to wait until the teacher comes, you have to wait
for your turn . like you just get stuck.
EAL Nursing Students
Learning Takes Time
The time allocated to SP learning experiences was
perceived to be insufficient. Participants desired to have
‘‘more time’’ engaging with the SPs. A participant shared:
We ran out of time . we were on a tight timeframe.
One patient [had] so many things going on . [we]
lost track of time and then the [instructors] come in
and [told us], ‘‘ok, your time is up.’’ It [was] time to
debrief and . [we] were not even half way through
all the questions that [we had] to ask.
Some participants were unable to incorporate the
constructive feedback they had received during their
debriefing session into practice due to a lack of time.
Instead of being encouraged to engage in repeat practice
after the debriefing session, some participants were
informed that the SP learning experiences had come to an
end. One participant emphatically stated that a single SP
learning experience ‘‘is not enough.’’
Participants verbalized the desire to practice a nursing
skill until they ‘‘got it right.’’ They eluded that repeat
practice would enable them to progress toward achieving
mastery of the nursing care embedded within a simulation.
One participant stated, ‘‘Like, [when] you do it a lot, it’s
gonna be in your memory. You will not forget it when you
go [to] the hospital.’’
Discussion
There has been some urgency among nurse educators to
improve the quality of undergraduate nursing education,
and toward this end, many have begun to integrate
innovative teachingelearning strategies such as SP simu-
lation into nursing curricula. EAL nursing students who
engage in SP simulation can achieve many positive learning
outcomes. Although the findings of this study are based on
the perceptions and experiences of EAL nursing students,
the implications may have far-reaching application for
nursing curricula and pedagogy.
Rich Opportunity for Learning
The positive learning outcomes reported by EAL nursing
students entail cognitive, psychomotor, and affective do-
mains of learning. Learning in the cognitive domain
includes acquisition of new knowledge and development
of intellectual abilities (Anderson et al., 2001). Empirical
support for the claim that SP simulation enhances knowl-
edge acquisition is ambiguous. Becker et al. (2006)
concluded, for example, that there was no significant in-
crease in knowledge of depression management between
the group of students who used SPs and those who received
pp 524-530  Clinical Simulation in Nursing  Volume 13  Issue 10
528
traditional education. Whereas, Dearmon et al. (2013)
found that there was a significant increase in basic nursing
care knowledge among nursing students who engaged in SP
simulation. It is noteworthy that in the Becker et al. (2006)
study, participants only had the opportunity to interview an
SP on one occasion for a period of 30 minutes and that in
the Dearmon et al. (2013) study, participants had the oppor-
tunity to interact with an SP over a two-day period.
The EAL nursing students did not specifically indicate
that their knowledge level had increased. However, knowl-
edge acquisition extends beyond the ability of students to
merely recall information; rather, it may also be demon-
strated when students can analyze, evaluate information,
and/or create new understanding (Anderson et al., 2001).
EAL nursing students described numerous situations
wherein they were able to critique their nursing care and
then integrate those changes to improve the quality of their
nursing care during simulated SP learning experiences.
Learning in the psychomotor domain includes the
development of new skills (Anderson et al., 2001). The
ability of SPs to improve therapeutic communication skills
among undergraduate nursing students is well substantiated
in the literature (Doolen, Giddings, Johnson, Guizado de
Nathan, & O’Badia, 2014; Webster, 2013). EAL nursing
students reported an improvement in both their relational
skills and ‘‘hands-on’’ nursing skills.
Learning in the affective domain involves developing
new values, attitudes, and beliefs (Oerman & Gaberson,
2006). SP simulation changed the longstanding beliefs
and attitudes of many EAL nursing students. SP simulation
enabled EAL nursing students to develop new practice
framework convictions, overcome stereotypical views
about patients with mental health illnesses, acquire positive
attitudes toward older adults, and adapt to new cultural
norms regarding gender segregation.
Supportive Community of Practice
The clinical learning environment enables students to engage
in real-world practice and to join a community of practice
(CoP). A CoP is, ‘‘a group of people who share a concern
or passion for something they do and learn how to do it better
as they interact regularly’’ (Lave & Wenger, 1991, para.3).
Some nursing students have reported feeling unwelcome in
the clinical setting and that the clinical setting was a hostile
learning environment (Bradbury-Jones, Sambrook, &
Irvine, 2007; Castledine, 2002). The nursing students who
took part in our study believed they were not valued members
of the health care team. Some believed that their contribution
as a student nurse was undervalued and unappreciated by pa-
tients. In contrast, SP learning experiences were viewed as
‘‘relaxing,’’ ‘‘comfortable,’’ ‘‘open,’’ and ‘‘accepting.’’
They perceived that SPs prepared them to enter the hospital
for their first clinical experience, they felt their nursing
EAL Nursing Students
care was valued by SPs, and they felt they could make errors
without jeopardizing the health and well-being of real pa-
tients and families. SP simulation fosters a supportive CoP
that enables EAL nursing students to experience a sense of
psychological safety as they acquire new learning in cogni-
tive, psychomotor, and affective domains. There has been
overwhelming support for simulated learning to foster a sup-
portive CoP (Robinson-Smith, Bradley, & Meakim, 2009)
with the potential to enhance student learning (Levett-
Jones & Lathlean, 2008), to influence development of a pro-
fessional role concept (Levett-Jones & Lathlean, 2008), and
to encourage professional progression and retention within
nursing education programs (Bowden, 2008).
Debriefing: An Essential Component of Simu-
lation Education
Debriefing is an essential component of simulation educa-
tion and in fact where the learning occurs (Decker et al.,
2013; Neil & Wotton, 2011). During a debriefing session,
participants are encouraged to reflect on their performance;
they are encouraged to think critically in relation to pro-
cess, outcomes, and application of knowledge and skills
(Neil & Wotton, 2011). After participating in a debriefing
session, students are encouraged to engage in repeat prac-
tice until they are able to demonstrate consistent success.
The debriefing session that follows an SP learning
experience is unique in comparison with the debriefing
session that follows other simulation modalities. Simula-
tions that make use of high-fidelity human patient simula-
tors use only the simulation facilitator and, or, the learners
to provide feedback to participants. During an SP debrief-
ing session, nursing students are able to gain feedback
about their nursing care from a ‘‘patient’’ perspective.
Conclusion
A strategic transformation in the delivery of EAL nursing
curricula is necessary. EAL nursing students can achieve
positive learning outcomes when immersed in a supportive
and contextually rich CoP that encourages them to strive for
mastery. The implementation of innovative teachingelearning
strategies, such as SP simulation, can promote success among
EAL nursing students. EAL nursing students are greatly
needed in the health care system; diversity in nursing may
reduce health care disparities among minority groups.
References
Anderson, L. W., Krathwohl, D. R., Airasian, P. W., Cruikshank, K. A.,
Mayer, R. E., Pintrich, P. R., & Wittrock, M. C. (2001). A taxonomy
pp 524-530  Clinical Simulation in Nursing  Volume 13  Issue 10
529
for learning, teaching, and assessing: A revision of Bloom’s taxonomy
of educational objectives. New York, NY: Longman.
Becker, K. L., Rose, L. E., Berg, J. B., Park, H., & Shatzer, J. H. (2006).
The teaching effectiveness of standardized patients. Journal of Nursing
Education, 45(4), 103-111.
Bosher, S., & Bowles, M. (2008). The effects of linguistic modification on
ESL nursing students’ comprehension of nursing course test items.
Nursing Perspectives, 29(3), 165-172, Retrieved from http://www.ncbi.
nlm.nih.gov/pubmed/18575241.
Bowden, J. (2008). Why do nursing students who consider leaving
stay on their courses? Nurse Researcher, 15(3), 45-58. http:
//dx.doi.org/10.7748/nr2008.04.15.3.45.c6456.
Bradbury-Jones, C., Sambrook, S., & Irvine, F. (2007). The meaning of
empowerment for nursing students: A critical incident study. Journal of
Advanced Nursing, 59(4), 342-351. http://dx.doi.org/10.1111/0j.1365-
2648.2007.04331.x.
Castledine, G. (2002). Students must be treated better in clinical areas. British
Journal of Nursing, 11(18), 1222, Retrieved from http://web.b.ebscohost.
com.qe2a-proxy.mun.ca/ehost/pdfviewer/pdfviewer?vid¼2&sid¼efaf2200e
6eaa-4533-8d52-e68fd6ba6844%40sessionmgr114&hid¼123.
Statistics Canada. (2017). Study: A look at immigration, ethnocultural di-
versity and languages in Canada up to 2036, 2011 to 2036. Retrieved
from http://www.statcan.gc.ca/daily-quotidien/170125/dq170125b-eng.
htm.
Cummins, J. (2003). Education research in bilingual education. Retrieved
from www.iteachilearn.com./cummins/educationalresearch.html.
Dearmon, V., Graves, R. J., Hayden, S., Mulekar, M. S., Lawrence, S. M.,
Jones, L., & Farmer, J. E. (2013). Effectiveness of simulation-based
orientation of baccalaureate nursing students preparing for their first
clinical experience. Journal of Nursing Education, 52(1), 29-38. http:
//dx.doi.org/10.3928/01484834-20121212-02.
Decker, S., Fey, M., Sideras, S., Caballero, S., Rockstraw, L., Boese, T., &
Borum, J. C. (2013). Standards of best practice: Simulation standard VI:
The debriefing process. Clinical Simulation in Nursing, 9(6S), s27-s29.
http://dx.doi.org/10.1016/j.ecns.2013.04.008.
Donnelly, T. T., McKiel, E., & Hwang, J. (2009). Factors influencing the perfor-
mance of English as an additional language nursing students: Instructors’
perspectives. Nursing Inquiry, 16(3), 201-211. http://dx.doi.org/10.11
11/j.1440-1800.2009.00453.x.
Doolen, J., Giddings, M., Johnson, M., Guizado de Nathan, G., &
O’Badia, L. (2014). An evaluation of mental health simulation with
standardized patients. International Journal of Nursing Education
Scholarship, 11(1), 1-8. http://dx.doi.org/10.1515/ijnes-2013-0075.
Institute of Medicine. (2003). Unequal treatment: Confronting racial and
ethnic disparities in health care. Washington, DC: The National Acad-
emies Press.
Krueger, R. A., & Casey, M. A. (2009). Focus groups: A practical guide
for applied research (4th ed.). Thousand Oaks, CA: Sage.
Kurz, J. M., Mahoney, K., Martin-Plank, L., & Lidicker, J. (2009).
Objective structured clinical examination and advanced practice
nursing students. Journal of Professional Nursing, 25(3), 186-191.
http://dx.doi.org/10.1016/j.profnurs.2009.01.005.
Lave, J., & Wenger, E. (1991). Situated learning: Legitimate
peripheral participation. Cambridge, MA: Cambridge University
Press.
Levett-Jones, T., & Lathlean, J. (2008). Belongingness: A prerequisite for
nursing students’ clinical learning. Nurse Education in Practice, 8(2),
103-111. http://dx.doi.org/10.1016/j.nepr.2007.04.003.
Lewis, K. L., Bohnert, C. A., Gammon, W. L., H€olzer, H., Lyman, L.,
Smith, C., Thompson, T. M., Wallace, A., & Galiva-McConvey, G.
(2017). The association of standardized patient educators (ASPE) stan-
dards of best practice (SOBP). Advances in Simulation, 2(10), 1-8. http:
//dx.doi.org/10.1186/s41077-017-0043-4.
Miguel, C. S., & Rogan, F. (2011). Clinical expectations: What facilitators
expect from ESL students on clinical placement. Nurse Education in
Practice, 12, 115-119. http://dx.doi.org/10.1016/j.nepr.2011.10.008.
 EAL Nursing Students
Morgan, D. L. (1997). Focus groups as qualitative research. Thousand
Oaks, CA: Sage.
Morgan, D. L. (1995). Why things (sometimes) go wrong in focus groups.
Qualitative Health Research, 5(4), 516-523. http://dx.doi.org/10.1177/
104973239500500441.
Neil, M. A., & Wotton, K. (2011). High-fidelity simulation in nursing ed-
ucation: A literature review. Clinical Simulation in Nursing, 7(5), e161-
e168. http://dx.doi.org/10.1016/j.ecns.2011.02.001.
Oerman, M. H., & Gaberson, K. (2006). Evaluation and testing in nursing
education (2nd ed.). New York, NY: Springer.
Olson, M. A. (2012). English-as-a-second language (ESL) nursing student
success: A critical review of the literature. Journal of Cultural Diversity,
pp 524-530  Clinical Simulation in Nursing  Volume 13  Issue 10
530
19, 26-32, Retrieved from http://web.a.ebscohost.com.qe2a-proxy.mun.
ca/ehost/pdfviewer/pdfviewer?vid=1&sid=6fbecd3e-32d4-4a3d-b667-3
41a56cd89d6%40sessionmgr4009.
Robinson-Smith, G., Bradley, P. K., & Meakim, C. (2009). Evaluating the
use of standardized patients in undergraduate psychiatric nursing expe-
riences. Clinical Simulation in Nursing, 5(6), e203-e211.
U.S. Census Bureau. (2015). New census bureau report analyzes U.S. pop-
ulation projections. Retrieved from http://www.census.gov/newsroom/
press-releases/2015/cb15-tps16.html.
Webster, D. (2013). Promoting therapeutic communication and patient-
centered care using standardized patients. Journal of Nursing Education,
52(11), 645-648.