A Language-Focused Needs Analysis for

ESL-SpeakingNulsing Students in
Class and Clinic
Richard Cameron
The Uniuersily of Illinois at Chicago
ABSTRACT Because clinical experience is essential for nursing education, even students with
modest-to-lowproficiency in English as a second language @L) receive training and provide
care in clinics. Yet modest-to-low language proficiency could prove hazardous for the students
or their patients. Therefore, these nursing students would benefit from special classes in EL.
Such classes require prior needs analyses that precisely articulate academic and clinical lan-
guage needs. These needs statements serve as suggestions for course content. Reported here
are the results o f an extensive needs analysis for ESL-speaking graduate nursing students. The
approach to needs definition derives from Stufflebeamet al. (1985). The analysis focuses on
skills required for school, clinical practice, and interaction with a multicultural, socially strati-
fied patient population. Resulting needs statements are organized in terms of (1) Speech Pro-
duction Accuracy, (2) Academic Performance, (3) Clinical Performance, (4) Dialect (Culturag
Variation, and (5) lnferencing Skills.
~~~ ~

IntroducEion wisdom of placing non-nativespeaking (NNS)

Graduatelevel training of nursing students typ
ically consists of academic course work fol-
lowed by on-site practice in those clinical
settings most relevant to the nurses area of
specialization. For some international stu-
dents, the rigors of the nursing classroom are
increased by the need to understand and per-
form in English, a language which they may
speak or write non-natively at a relatively low
level of proficiency. In clinical settings, the
consequences of such low proficiency may af-
fect not only the students professional future
but also the well-being of patients, patients
families and friends, and the reputation of the
clinic. Owing to the frequency of communica-
tive conflict between care providers and pa-
tients (Cameron and Williams 1997; Fisher
1995;Freeman 1987;Gozzi, Morris, and Korsch
1969; Herselman 1996; McTear and King 1991;
Prince 1985; Shuy 1983;Weijts, Houtkoop, and
Mullen 1993; West 1985), one may doubt the
Richard Cameron (Ph.D.. University of Pennsylvania) is
Assistant Professor of Linguistics a t the University of
Illinois at Chicago.
nurses with modest levels of linguistic c o m p e
tence in clinical contexts. Yet, given the need
for clinical experience, this is precisely what
occurs in many graduate schools of nursing.
Therefore, these students may benefit from
auxiliary classes in language.
Classes in English as a Second Language
(FSL) that are designed for nursing students in
these circumstances must rely on needs analy-
ses that articulate not only academic and clin-
ical communication skills but also potentially
problematic aspects of the dialects spoken by
a diverse patient population. Nunan (1989,
40) would term these the real-world tasks of
school and clinic. Although numerous publi-
cations exist on how to carry out needs analy-
ses (Holiday 1995; Munby 1978; Richterich
and Chancerel 1977), there are very few stud-
ies that publish the results of these analyses in
ways that may directly serve course designers
who lack time and resources to carry out their
own needs analyses. (See Candlin, Bruton,
Leather, and Woods (1981) for o n e e x c e p
tion.) To my knowledge, there are currently
no published studies that provide the results

Foreign Language Annals, 31,No. 2 , 1998

 FOREIGN LANGUAGE A N N A L S S U M M E R 1998

of needs analyses for ESLspeaking graduate nonnative medical personnel in general. Fi-
nursing students. nally, implicit in the process of needs analysis
In the research presented here, I provide r e is the problematic issue of need definition, a
sulk of a n extensive needs analysis for inter- concern initially explored by Widdowson
national graduate nursing students who study (1981). Richterich (1983, 2) observed that
in the University of Pennsylvania (henceforth "the very concept of language needs has
Penn). The clinics in which these nurses d o never been clearly defined and remains at
their internships serve the predominantly best ambiguous." Brown (1995, 38) and
urban, multi-ethnic, and socially stratified Berwick (1989) seek to resolve this issue by
population of Philadelphia and surrounding adopting the approach to need definition of
environs. From this needs analysis, two ESL Stufflebeam, McCormick, Brinkerhoff, and
classes' have been developed and taught Nelson (1985, 6-7). As 1 will show, this a p
through the English Language ProgramsZin proach not only provides a rigorous f r a m e
conjunction with the Graduate School of work for needs definition but also suggests
Nursing at Penn. research methods for gathering information
A needs analysis is defined succinctly by from the learners and their instructors in the
Brown (1995,36) as relevant institutional contexts.
The remainder of the article will contain (1)
...the systematic collection and analysis of all a description of the target student group; (2)
subjective and objective information neces- definitions of need in line with Stufflebeam et
sary to define and validate defensible cur- al. (1985); and (3) a description of how data
riculum purposes that satisfy the language on needs was gathered. Finally, I provide the
learning requirements of students within the resulting needs statements. These statements
context of particular institutions that influ- are classified in terms of (1) Speech Produc-
ence the learning and teaching situation. tion Accuracy, (2) Academic Performance,
(3) Clinical Performance, (4) Dialect (Cul-
From Brown's definition w e may derive three tural) Variation, and (5) Inferencing Skills.
points. First, a needs analysis targets language These categories, though listed separately, are
use within a particular institutional context. not mutually exclusive sets. Speech accuracy
This context provides a focus in terms of set- is necessary when performing interactive clin-
ting and participant roles. Second, the results ical tasks that require inferencing skills in
of a needs analysis d o not constitute a syl- order to understand the intentions of patients
labus yet may serve as input to one.3 For in- or coworkers who speak vernacular dialects.
stance, o n e result of the analysis reported Inferences of coherence and anaphor resolu-
here is the need for explicit instruction in id- tion are essential elements in the academic
ioms or metaphors of the self, pain, emotion, skill of critical reading.
loss, recovery, healing, and connections to
others. Where such elements of the needs Who Are the Students?
analysis are provided, they are intended as The students targeted for this particular
learnercentered suggestions for instructional needs analysis are incoming graduate stu-
content. A useful needs analysis may actually dents in the nursepractitioner programs in the
provide many more suggestions for instruc- School of Nursing at Penn. The majority are fe-
tion than any given course, constrained by male, with bachelor's degrees in nursing from
time and other resources, could incorporate. their home countries. Though the students
Hence, the analysis may b e selectively con- come from many different countries, those
sulted in accordance with local constraints. In with language needs have typically been from
addition, the needs statements provided here Taiwan, Japan, Thailand, and Jordan. Hence,
may serve materials developers, syllabus d e the language backgrounds include Chinese,
signers, and other language educators for Japanese, Thai, and Arabic.

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 FOREIGN LANGUAGE A i V N ~ - S L I M M E R1998

From September 1991 to September 1992 we on the needs of these nursing students in
evaluated 16 incoming students using various ways that match all four approaches. In prac-
institutional versions of the SPEAK test made tice, I find that at different stages in the
available by the Educational Testing Services.l process of needs assessment, different a p
The SPEAK test evaluates speaking proficiency proaches to needs elicitation and definition
in four areas: pronunciation, fluency, grammar,may b e most appropriate. One may begin
and comprehensibility. Scores may range from with the approaches of democracy and analy-
0 to 300. The highest score obtained by one stu-sis, which provide an initial set of identified
dent was 300 (out of 300), the lowest was 100. needs, and then move to the approaches of
The average score was 200; however, students discrepancy and diagnosis.
from Taiwan or Thailand tended to average 50 The democratic and analytic definitions of
points below this group average. A SPEAK need presuppose a research strategy of con-
score of 150 is quite low and indicates that thesultation with nursing educators, onsite pre-
speech of the test taker may be disfluent? oc- ceptors who supervise the students in their
casionally unintelligible, and limited in terms clinical experiences, and the students them-
of vocabulary and grammatical control. Stu- selves. Needs derived from a democratic per-
dents with scores of 270 or higher on the spective are those which are articulated "by a
SPEAK test were either exempted from further majority of some reference group"(Stuff1e-
language instruction or referred to private tu- beam et al. 1985,6). In this case, the reference
tors for assistance with their writing. Studentsgroups are the educators, the preceptors, and
with lower scores were placed in the general the students. Within the analytic approach,
program of ESL offered through the English one conceives of needs as those elements of
Language Programs at Penn. Some of the stu- competent academic or professional perfor-
dents, however, felt that the classes of generalmance that are not yet sufficiently controlled
instruction did not sufficiently target such speby the students; however, task-based experi-
ences, either in class or in a clinical setting,
cific tasks as scientific research writing, inter-
acting with ill children, debating ethical issues
are scheduled for the students and will p r o
of teen pregnancy with assertive native speak- vide them with opportunities for learning.
ers, inferring clinically relevant information By consulting the various reference groups,
from the speech of socially diverse patients, orone may better identify certain needs that the
recognizing patterns of speech that indicate professional program will address and others
that a patient is in denial. Hence, in response to
that will be overlooked. For instance, one may
these students and to requests from the School assume that technical vocabulary should be
of Nursing, we began to develop a program of an item of instruction in a language class for
language instruction in the English Language nurses. Nonetheless, for this particular group
Programs that addressed both the academic of nurses, the university nursing program p r o
and workplace communication problems of vides this instruction in the contexts of class
these students. In order to do so,a needs analy-and clinic. In contrast, some aspects of pro-
sis was required. fessional training neglect certain needs s p e
cific to the NNS students. For example,
Defining Need although students are exposed to the mean-
Stufflebeam, McCormick, Brinkerhoff, and ings of technical vocabulary, they will not r e
Nelson (1985,6-7) provide a succinct and crit- ceive explicit instruction in how to predict
ical discussion of four common approaches stress patterns within technical vocabulary,
to needs definition: discrepancy, democracy, how to derive verbs from nouns, how to
analysis, and diagnosis. On the assumption check their understanding of local abbrevia-
that any definition of need at once facilitates tions in clinical settings,Gor how to paraphrase
research while also limiting the type of infor- technical vocabulary in vernacular terms un-
mation obtained, I attempted to gather data derstandable to patients of differing ages and

205
 FOREIGN LANGUAGE A"-UMMER 1998

backgrounds. Another example involves diag- ences in language production and under-
nostic interviewing skills. Even though stu- standing between second- and native-lan-
dents will receive instruction in strategies for guage speakers but also crucial differences
diagnostic interviewing, they will not receive between novice and expert language users in
explicit form-focused instruction on the gram- those contexts relevant to these nursing stu-
mar of questions, the discourse functions of dents. By way of illustration, consider the fol-
certain sentence types, or the intonation con- lowing example of an apparently insufficient
tours of questions containing options. And it response by a NNS nurse. This is one of many
may be the case that even though a particular instances where this particular student nurse
skill is part of the professional curriculum, was unable to provide background informa-
such as case presentations in class and clinic, tion, in narrative form, about a patient's life. In
educators and students may feel that students line (3) the preceptor attempts to elicit gen-
would benefit from extra practice. Finally, eral background material on the patient's s~
when consulting such reference groups, the cia1 situation over a period of approximately
needs analyst may ask the very important ten years. The student nurse's response in line
question of just what the students d o and what (4) is simply uninformative.
they need to d o in order to be competent per-
formers in class and in clinic. The answers Transcript #I:
that one receives may serve as guides for sub- Insufficient Narrative/DescriptiveResponse
sequent onsite observations during which the Preceptor: (1) OK, alright. And h e came from
researcher may either confirm the opinions of the orphanage to ...live and
those consulted or revise the actual scope and work where?
content of these opinions. (2) On his own? Has h e been on
Working within the discrepancy approach his own?
to needs assessment, one identifies as needs (3) Or...what's his life been like
those observed differences between the ac- since then?
tual performance of students and their desired Nurse: (4) mm. He's uh like a. He spend
performance. For the purposes of this needs time with his girlfriend.
analysis, I define desired performance as
being a combination of three interdependent Examples of insufficient responses by stu-
elements: dent nurses, as in Transcript #1, illustrate the
fine line between linguistic competence (i.e.,
(1) Comprehensible use of speech or writing being able to provide a n interpretive descrip
that is grammatically acceptable to the tion or narration) and professional compe-
audience. This is to be complemented by tence (i.e., knowing that one is supposed to
the student's comprehension of those who provide a n interpretation of the quality of a
speak or write to her. patient's social life). Similar limitations on
(2) Interactive use of language guided by gathering, reporting, and using social informa-
knowledge of culturally relative rules of tion about patients have also been reported
speaking (Wolfson 1989,37,14@161) so as for novice native speakers in medical training
to avoid the unintentional alienation of (Boshuizen and Schmidt 1992; Pomerantz,
others or stigmatization of self. Mastriano, and Halfond 1987; Soyland 1994).
(3) Strategic use of language informed by pro- Whatever the case, based o n examples such
fessional expertise and institutionally as Transcript #1, one may infer the need for
required task agendas (Drew and Heritage practice in interpretive narration and descrip
1992,22). tion of the social lives of patients.
Closely related is the diagnostic view in
The discrepancy view results in error analy- which need definition results from reflection
sis construed broadly to cover not only differ- on "something whose absence or deficiency

206
 FOREIGN LANGUAGE A"ALS--SUMMER 1998

proves harmful" (Stufflebeam et al. 1985, 7). generated during the first stage, a few points
Consider, for instance, the confusion of /n/ were noteworthy. First, many of the needs of
and /1/ for some Chinese learners of English. the NNS students were identical to those of the
Working within the discrepancy approach to native speakers. For instance, all students ini-
need definition, the inability of a learner to tially experienced difficulty with the amount
distinguish between such words as "no" and of reading, with reading critically, and with
"low" simply suggests a need to address the producing writing that met professional stan-
contrast of /n/ and /l/. Within the diagnostic dards. All students required experience inter-
approach to need definition, however, an in- acting with a variety of patients and, in
ability to distinguish /n/ and /I/ takes on particular, with ill patients who were either r e
added significance because it may lead to luctant to or unable to extend themselves in
such potentially hazardous mispronuncia- coopemtive conversation. Second, from inter-
tions as "no blood pressure" when the intent views with the four division chairs and from at-
was that of "low blood pressure." Therefore, tending the workshop for nursing supervisors,
by considering a particular need from a com- I was able to derive four general maxims of
bination of discrepancy and diagnostic view- nursing behavior that served as guideposts for
points, one may also develop an approximate needs identification in clinical settings. Briefly,
ranking of needs. Such ranking will prove these are:
useful for the eventual selection of course ma-
terials and for the sequencing of learning ex- (1) Be safe.
periences required for syllabus design. (2) Be timely in gathering information and
providing treatment.
How Was Data on Needs Gathered? (3) Be able to say what you know and don't
In keeping with the plan to obtain data on know and how you came to know what
needs from multiple perspectives, 1 worked you do know.
through two general stages of data gathering. (4) Be able to justify what you know and what
Initially, I conducted interviews with four di- you do in both scientific and ethical
vision chairpersons in the School of Nursing. terms.
The four divisions included Adult Health and
Illness, Family/Community Health, Nurse In general, supervisors reported that students
Midwifery, and Psychiatric Mental Health. In had problems with gathering relevant infor-
addition I attended a workshop for clinical mation in a timely fashion, with being able to
preceptors, met with students, and con- identify what they know and don't know, and
ducted library research. The interviews and with being able to justify their knowledge and
workshop provided perceptions of need actions when questioned. From a language
from educators, clinical preceptors, and stu- based perspective, one may ask how these
dents. The general goal of this stage was to four maxims are accomplished through
gather information on the content, sequenc- speech or writing.
ing, and requirements of the different acade- The second stage of the research consisted
mic programs within the graduate nursing of ethnographic observations and tape record-
program as well as information on criteria ings in four different clinical sites where stu-
and strategies for evaluating both academic dents either were currently placed or could be
and clinical performance. Demographic in- placed. These included a community-based
formation on the students, including infor- HMO clinic, a psychiatric unit of a major met-
mation on the social/academic networks of ropolitan hospital, a neurotrauma unit of an-
the students while in school, was also sought. other major hospital, and a gynecological and
Finally, I asked for information about the birthing clinic in a smaller metropolitan hospi-
clinical sites where the students were placed. tal. The fundamental goal was to gather data
Although a great deal of information was on language use in contexts of tertiary care,

207
 FOREIGN LANGUAGE ANNm-SUMMER
primary care, and outpatient care because
these were identified, in the first stage, as the
contexts in which the NNS graduate students
would eventually have their clinical experi-
ences.
Observations and recordings may serve a
number of purposes in needs assessment.
First, they permit empirical testing and revi-
sion of needs hypotheses generated from in-
terviews. Second, they provide opportunities
to observe aspects of spoken interaction, ei-
ther for native or nonnative speakers, which
escape the intuition and reflection of educa-
tors or students. Third, recordings may serve
as sources for (a) listening activities that repli-
cate the noise level common to clinics, (b)
discussion of difficult interactions between
patients and care providers, or (c) actual sam-
ples of vernacular speech not found in any
FSL textbook.
The observations in the gynecological and
neurotrauma sites were carried out by Felicia
Lincoln-Porter and Lynn Buchheit respec-
tively. Both are trained ESL instructors with ex-
perience in health care. In addition to training
in ethnographic research methods at the Uni-
versity of Pennsylvania, Lincoln-Porter re-
ceived midwifery training for home birthing
through the Hospital of Russellville,Arkansas.
Buchheit is a Registered Nurse (RN). 1 did the
observations and recordings in the psychiatric
unit and community health clinic in accor-
dance with my training as a sociolinguist and
ESL instructor. After completing the observa-
tions and recordings, I closely analyzed the
tapes and field notes in order to refine and
add to the needs statements. As a conse-
quence of these observations, five basic c a t e
gories of communicative behavior related to
clinical performance were derived. These in-
clude the abilities to get information; to trans-
mit information; to translate information from
one medium to another or from one audience
to another, to utilize different channels of
communication; and to interact socially as
well as professionally in the clinical site. As
Goffman (1961) showed, the intermingling of
social and professional roles is the norm
among participants in a clinical setting.
208
1998
Based on the combination of information
from the two stages of research, five general
categories of need emerged. Some of these
needs statements were also subsequently r e
vised during initial instruction of the two
courses. The statements are reported here in
outline form. Some statements are accompa-
nied by data that illustrate the need. Sen-
tences or words spoken by students, their
supervisors, or patients are italicized and en-
closed within quotation marks. Where tran-
scription of spoken language is apparent, as in
Transcripts #1 and #2, no quotation marks are
used. Commentary, where added, occurs in
paragraph form.
Needs Statements
[ 1. Speech Production Accuracy 1
Accuracy refers to linguistic encoding and
discourse interaction. The primary categories
are pronunciation, vocabulary, grammar (syn-
tax and morphology), and discourse.
Pronunciation
Phonemic contrasts. The unit of instruction
is the phoneme, e.g.:
Feeling vs. feeding/I level vs. label/I
pain vs. ban
Low Blood Pressure vs. NoBlood fissure
Technical-professional words, names, num-
bers (15 vs. 50, ten hundred vs. one thou-
sand), words of frequency (time vs. term),
and letters, acronyms, or abbreviations. The
unit of instruction is the phonological word.
Phrasal intonation, wordstress, unstressed
syllables, and regular reductions found in
rapid speech, e.g.:
Respiratory us. respiratory/I All previous
five died. vs. ~ l l p r e efay
s die.
Both respimtoryand Allpwes fay die. were
said by the same student nurse. Research into
native speaker perception of nonnative speech
suggests that suprasegmental aspects of p r o
duction, such as word stress, result in greater
 FOREIGN LANGUAGE A N N U - S U M M E R 1998

comprehension problems than segmental Technical items and nontechnical para-

mispronunciation (Anderson-Hsieh, Johnson,
and Koehler 1992). An illustration of how mis-
placed stress may contribute to momentary
communication breakdown is illustrated in
the following transcribed interaction between
a nonnativespeaking graduate nurse and a
patient in a psychiatric unit. The particular
problem resides in the misplaced stress of
sentence in line (3), which the patient cre-
atively reanalyzes as ten cents. Although the
interaction did proceed here, this nurse did
not gather the specific information she sought
as a consequence of the breakdown.
phrases, e.g.:
Do you still have suicidal thoughts? vs. Do
you still have suicidal ideation?
IdiomdMetaphors of self (inner and outer),
pain, emotion, loss, recovery, healing, con-
nections to others, e.g.:
To fall out, to be at the end of my rope, to
feel adrift, to feel tied down, to go nuts.
Descriptive terms for the physical appear-
ance of patients. See Cassell (1985) for a
similar need in native speakers.

Transcript #2: Phrasal (two or three word verbs), e.g.:

Misplaced Stress and Miscommunication To bring up, to hold on, to come down with,
to turn up with, or to break out in. For British
Nurse: (1) Yes....OK, very good. Could you examples, see Parkinson (1991).
please write a sentence for me?
Patient: (2) Write what? Word formation:
Nurse: (3) Sentence..sentence. verb/noun/adjective/adverb and gaps in a
Patient: (4) sentence. paradigm, e.g.:
Nurse: (5) Yes. Verb: to live / noun: life, liveliness / adj: live,
Patient: (6) sentence? alive / adv: lively
Nurse: (7) mmhhrnm The donor doesnt need to be alive. vs. The
Patient: (8) Write the word? donor dont need to be life.

Nurse: (9) Yea

Patient: (10) Ten cents. (Patient here writes
these two words on a notepad.)
Nurse: (11) Yes... and read it.
Patient: (12) Ten cents.
Nurse: (13) Oh, ten cents.. OK, I know.
Maybe.. I have the problem
with my accents.
a Reading aloud from in-take interview forms,
from instructions on how to self-inject
insulin shots, from instructions on when
and how to take other medications.
Vocabulary
Accuracy of word choice, e.g.:
Stomach, belly, tummy, abdomen, gut //
mature vs. welldone
Appropriateness of term, e.g.:
Do you have any medical conditions? vs.
Doyou have any diseases?
G m m m a r Syntactic/Morphological
Question asking, e.g.:
Yes-No, WH (who, what, when), Elliptical,
Tag, Intonation, Information vs. Confirma-
tion, questions that contain embedded eval-
uation (How many of these cramps would
you say you get in a row??, and questions
containing options (Didyou feel bener aker
taking the medicine or did you just start feel-
ing better anyway?)
WH- and Itcleft vs. noncleft sentences, e.g.:
(WHCleft) WhatI want you to try and do
is drink lots o f water. * vs.
(It-Cleft) It is water, and lots of it, that I
want you to drink. vs.
I want you to try and drink lots
of water.

209
 FOREIGN LANGUAGE AALS--SUMMER 1998

Cleft sentences involve the fronting of infor- found in the speech of nurses in a neurotrauma
mation for purposes of focus o r contrast unit.
(Leech and Svartvik 1975, 180). See Prince
(1978) for a discussion of the different dis- Transcript#4:
course functions associated with these differ- Dialogue Introducers
ences in form.
BE LIKE xx
Hypothesis vs. fact, e.g.: But like hes like, Well, do whatever you
This shot doesnt hurt as much as other think you can do, like if you ride your bike.
ones might. vs.
I was like, Can I ride my bike?
That shot could not have hurt as much as
other ones might. SAYS, kx
And as 1 was taking his signs then, he says,
Tense and aspect, e.g.: I wanna go out and smoke a cigarette.
1 havent seen him since h e went to T.Clinic.
vs. I dont see him since he goes to T: GOES / GO, kx
Clinic.
And he goes, Well, I see everybody out
I a m here for four years. vs. I was here for there smoking cigarettes.
four years. vs.1 have been here for four years.
0 Accurate pronoun usage.

A lack of past tense marking, common in
the speech of the students, can require inter-
active resolution of time reference when the
interlocutor is willing or capable of doing so.
Consider Transcript #3, which follows.
Transcript # 3
(0=Lack ofpast tense marking)
Nurse = Non-native speaker; Patient = Native
speaker
From a n inclass oral report by a native
speaker of Chinese:
We want to how much time if we transfer
CW to another hospital because she is criti-
cal condirion. If we transferhim, we need to
waste much time. Maybe we, you know,
maybe she died during the transfer time.
(Question = Is GW a she or a he?)
Discourse

Nurse: (1) Uh. Do0 you uh.. what should I Coherenthfficient recountings, narra-
Say? tions, and/or description (see Transcript #1
(2) Do0 you like uh..give money to for illustration).
them or? a. Narratives from first- or third-person
Patient : (3) I dont give em nothing. viewpoints
(4) They better send me some b. Descriptions of self and of others
money.
(5) They 27 years old. (laughter) Strategic interweaving of full and elliptical
Nurse: (6) Nooooo. I mean in the past. questions with confirmation checks.
Patient : (7) Oh, yeah. I did.
Nurse: (8) Not now. Interactive repair, comprehension checks,
and paraphrase.
a Reported speech.
Prescriptive textbook treatments of reported
speech d o not address such very common ver-
nacular strategies as discussed by Ferrara and
Bell (1995). Consider these various strategies

210
 FOREIGN LANGUAGE ANNALSSUMMER 1998
I 11. Academic Performance 1
Reading Strategies
Overview reading: Skimming and question-
asking as prereading strategies.
Information reading: Seeking answers to
specific questions.
Critical reading: Questioning structure of
argument, definition of problem, validity of
evidence, and proposed problem solutions.
Identifying unexpressed implications o r
unanswered questions. Making predictions
based on evidence presented.
Writing
Skills.
a. Avoiding plagiarism by knowing what
plagiarism is, by selective notetaking
and paraphrase, and by synthesis involv-
ing citations and attributions.
b. Problem statements as statements of con-
trast or conflict (Ibut B as in Olsen
and Huckin 1983,88)
(A) It would be fair to say that ICU nurses are
typically under high stress,some of which is
caused by their feelings of powerlessness.
Whether they are under more stress than
non-ICU nurses remains an open question.
(but) However,
(B) stress and burnout are critical problems in
hospital settings and thoughtful investiga-
tion of the contributing factors is needed.
(Keane, Ducette, and Adler 1985,232)
Conventions.
a. Formatting of research papers according
to the American Psychological Associa-
tion or the American Medical Association.
b. Rhetorical organization of experimental
research papers vs. other types of profes-
sional writing as found in professional
nursing journals.
Test-taking (Nugent and Vitale 1993).
a. Multiple choice vs. multiple-multiple
choice.
b. Short answers.
c. Questions requiring knowledge, applica-
tion, or analysis.
21 1
d. Preparing.
e. Allotting time to questions during test-
taking.
Visual aids.
a. lnterpreting graphs, charts, into words.
b. Translating words into graphs, charts,
illustrations.
Speaking
lnteraction in class discussion and debate.
a. Asking and answering questions, inter-
rupting, holding the floor, challenging,
disagreeing, asking for repetition or clari-
fication.
Oral presentation skills.
Listening
Notetaking from lectures.
ldentifying numbers and letters.
Predicting content from organizational cues.
Critical lbinking and Moral Reasoning
(Bandman and Bandman 1988; Thompson
and Thompson 1985)
Claims and proofs.
Argument strategies and types.
Use of criteria to evaluate options of action.
Parallels to and incorporation of bioethics
within critical thinking.
I nI. Clinical PerformanceI
Getting Information
Medical interview and assessment.
a. Getting a history from a patient or a
patients family.
b. Physical examination and simple com-
mands required to do this: Cross your
legs, bend your elbow, touch your finger
to your nose, follow the light.
c. Strategies for directing an interview
towards topics that are suggested by the
interviewhnteraction.
d. Strategies of befnending prior to or while
proceeding through bureaucratic tasks via
strategic roledistancing. (Goffman 1961;
Heritage and Sojonen 1994,23)
 FOREIGN LANGUAGE AALS--SUiUiUER 1998
For example, during one interaction with
an elderly male patient in the Community
HMO Health Clinic, the n u w practitioner said
sympathetically, after sending him to get yet
another EKG, I put you through this all the
time, dont I?
e. Strategies for renewing an interview in
the face of patient resistance. In short,
strategies for topic control.
Illustration of topic renewal and brief role
distancing may be found also in the speech of
the nonnative psychiatric nurse previously
cited. In Transcript #5, the somewhat reticent
patient, who has provided a painful account of
his past, decides that he has had enough talk-
ing about it. By guiding him temporarily to the
more enjoyable topic of reading in line (6), the
nurse at once departs from her agenda while
not straying into topics that are too far re-
moved from that agenda. By so doing, she ex-
hibits a measure of topic control, an aspect of
conversational interaction that has been iden-
tified as particularly problematic for NNS c a r e
providers (Erickson and Rittenberg 1987).
Transcript # 5:
Topic Departure and Renewal
Patient: (1) mmhm. OK. Enough about me.
I tired of talking about it.
(laughter)
Nurse: (2) (laughter)
Patient: (3) Im tired of talkin.
Nurse: (4) You tired to talk.
Patient: (5) mmhm.
Nurse: (6) Do you like to read?
Patient: (7) I love to read.
Nurse: (8) Ohh.
Patient: (9) Thats my one enjoyment 1
dont tired of.
Nurse: (10) mhmhm. How bout speaking?
(=I
Patient: (1 1) Im not in-Im not in love with
speaking.
Nurse: (12) Do you have a good relation
ship with your roommate?
Patient: (13) Um ...-
Nurse: (14) Have you had any chance to
talk-
212
Patient: (15) -Hes alright.
Nurse: (16) -them?
Patient: (17) We not into barin souls, but we
get along.
Asking questions.
a. Openended versus yes-no.
b.Asking the right questions in a timely
fashion.
c. Asking one question at a time so that
patients have the opportunity to answer.
See West (1984, 83) for the hazards of
posing a string of questions. For an illus
tration, see the batch of questions posed
by the Preceptor in Transcript 4.
d. Knowing what is taboo forself and others
and being able to overcome self- or cul-
turally imposed taboos to get necessary
information.
Providing and recognizing feedback in the
interview.
a. Nonverbal and verbal cues of under-
standing and misunderstanding.
b. Being able to paraphrase and reflect back
in order to check understanding for self or
for others (i.e., patients, colleagues).
This is particularly important when speak-
ing to patients with tubes in their mouths, pa-
tients under medication, traumatized patients,
or those who have neurological conditions af-
fecting speech. This is also important when a
patients misunderstanding of a question b e
comes apparent through their response. For
instance, during o n e observation, a nurse
asked a patient Ireyou sexually acfiue?The
patient replied, No.I dont moue much. Hu-
morous moments like this require the ability
to redirect the interaction back to the initial
question and to reformulate the question in
different terms.
c. Strategic use of humor, empathy, and ex-
pressions of confident authority and the
ability to linguistically encode these strate
gies.
Getting information from children vs.
adults, from family instead of the patient,
from mentally retarded individuals.
This may be seen as part of a larger issue,
 FOREIGN LANGUAGE A N N U - S U M M E R 1998

relevant to writing and speaking, which in- friend at work on Thursday if the phone at
volves audience analysis and the ability to tai- work has been fixed by then. The chain con-
lor messages to the audience. Consider the sists here of the patient, the attending physi-
appropriate audience for the term "booboo" cian, the nursepractitioner, the social worker,
as opposed to "bruise" or "contusion." the mother's friend, and the mother.

Listening to and guessing the intended m e Writing in the clinic in locally expected
sages of softspoken patients or fellow c a r e ways: SOAP charts,3forms, notes, etc.
providers against a noisy background of a. Biomedical information.
public announcements, other competing b. Social information in nontechnical
voices, heart monitor machines, floor pol- language that depicts, represents, and
ishers, crying children, or outbursts of the describes patients in ways that are
bereaved or the joyous. In short, listening in understandable (Cassell 1985).
contexts of prevalent white noise.
Communicating what one knows and who
Transmitting Information one is.
Educating patients or their families through This involves both the communication of
speech and visual aids. information and of a professional demeanor.
With respect to information, this includes
Communicating bad news and options to being able to identify the limits of what one
patients and families (Maynard 1991). knows and the level of confidence one has in
what one knows. In short, one is required to
Communicating good news to patients and articulate the scope and limits of one's knowl-
families. edge. With respect to professional demeanor,
this involves the ability to communicate a r e
Skills for presenting cases to preceptors and assuring confidence in one's ability to help
physicians versus inclass presentation. even in moments of uncertainty.
a. Presenting facts and action plans based
on the facts as known. Translating Information
b. Challenging representations and inter- Take "medicalese" and translate into lan-
pretations of facts. guage appropriate for nonspecialists who
c. Justifymg representations and interpreta- read at a sixthgrade level or less.
tions of facts. Translate charted information into prose
d. Defining roles in treatment teams. and viceversa.
e. Negotiating differences of opinion. Translate nonspecialist language into accu-
f. Responding to an interruption, answering, rate and reasoned specialist language.
and then resuming the flow of discourse. Communicate the same information to a
range of different audiences for whom the
Setting up a chain of reported speech or same information will mean different things.
acting within that chain.
For example, imagine the following situa- Different Channels of Communication
tion. An attending physician on Monday asks Telephone vs. facetoface. During observa-
the nursepractitioner to contact the clinical tions in a community-based HMO clinic, the
social worker on Wednesday to speak with the nursepractitioners used the telephone to con-
mother of a patient who says he has been at- tact government agencies, pharmacies to call
tending school but the physician is uncertain. in prescriptions, medical suppliers, or patients
The physician, who won't return until Friday, who needed clarification of instructions for
wants the answer by Friday. The mother has self-medication. In all cases, portions of the
no telephone but can be contacted through a conversations required explicit spelling aloud

213
 FOREIGN LANGUAGE ANNALSSUMMER 1998

and letter identification as in b as in boy. This ical encounters in particular and cross-cultural
is a particularly useful strategy for the second communication and miscommunication in
language speaker and one found in such early general (Erzinger 1991; Galanti 1991;Kochman
and still useful textbooks as Morley (1972). For 1981; Kleinman 1988; Paniagua 1994; Raney
instance, one nursepractitioner on the phone 1992; Wolfson 1989, 14G161; Woolfson, Hood,
to a pharmacy said, Imcalling a prescription Secker-Walker, and Macaulay 1995;Zola 1966).
please..urn for Cenoveva Soto. S - 0 - T - 0..C -
E - N - 0 - V - E - V -A is the first name.

Social Interaction with Different

Indiuiduals in the Clinical Setting
Greetings and leavetaking.
Small talk and complimenting (Thatsweater
is so preftyr),telling jokes or narratives of per-
sonal experience.
lnsincere and sincere invitations or requests
or sincere apologies (Im sorry) and less
severe apologies (Thatstoo bad).
Terms of address and other aspects of polite
ness and deference.
Recognizing and deflecting cranky behav-
ior and insults.
Culturally specific nonverbal behaviors and
the idioms that may accompany them, as d i s
cussed in such textbooks as Adams (1987).
IV. Dialect(Cultural)
~- Variation I
. .
Introduction to the Nature of Dialect
Variation in American English
This may be either regional or social (gen-
der, class, race and ethnicity, age-related
terms). See Wolfram (1991) for useful descrip
tions, e.g.:
The bees with me there at night. // I done
run out that.
Training in DifferencesBetween Biomedical
and Vernacular Vocabulary for the Body
and Bodily Functions
Such vocabulary may differ in unexpected
and unnoticed ways across dialects. See the
work of Nations, Camino, and Walker (1985)
on such ethnomedical complaints as high
blood, sugar, floatin eardrum, or loss
of nature. Practice in the Inference o f Releuant Social
Information that Requires Knowledge of
Introduction to Cultural Differencesin
Styles o f Communication
This is most significant as it pertains to med-
Practice in Deriving Inferences h m Both
Written and Spoken English
By inference, I mean a conclusion about a
set of facts or observations in which the con-
clusion itself is not explicitly represented
among the facts o r the observations (Singer
1994). Inferences may be drawn with respect
to a speaker/writers communicative intention
or to features unintentionally communicated
by the manner and content of speech, such as
emotional state, mental status, or degree of
competence (Goffman 1963, 13; Cassell 1985,
196-207; Lechtenberg 1991, 3). Other infer-
ences to consider are those identified by Bou-
ton (1994) a s problematic for second
language learners. These may include irony,
indirect or understated criticism, or the se-
quential occurrence of actions or events as
depicted through speech. See Carrel1 (1984 )
for illustrations of other difficulties associated
with inferences.
Practice in Explaining Utterance Meaning
as a Function of Who I s Speaking in a
Giuen Context
For instance, consider the differing possible
interpretations of the phrase of I am hungry
when spoken by a fiveyear-old at 10 p.m., s p a
ken by you at 12 noon, or spoken by a football
player on the sidelines to the coach. This is im-
portant to consider when gathering informa-
tion about a patient from family members or
other interested parties.
Local Culture
For instance, what does it mean if a patient
indicates a preference for tuna sold by Purina

214
 FOREIGN LANGUAGE A"ALS4UMMER 19%
versus tuna sold by Bumble Bee? When may
bruises be reasonably explained as football
injuries and when not? For a discussion of the
potential consequences of not having knowl-
edge of local culture for medical profession-
als, see Gumperz (1982).
Conclusion
I have provided here a list and discussion of
language needs relevant to NNS graduate-
level nursing students who study in a major r e
search university and practice in clinical sites
that serve a predominantly urban, multieth-
nic, and socially stratified population. Despite
a wealth of publications on the methods of
needs analysis, very few if any "studies" pro-
vide results of these analyses. Such results
may be particularly useful for course design-
ers who lack the time and resources to carry
out their own analyses. The needs statements
provided here are intended as suggestions for
instructional content. As stated previously, a
needs analysis may actually provide many
more suggestions for instruction than any
given course, constrained by time and other
resources, could incorporate. Hence, this
needs analysis may be selectively consulted
by course or materials designers in accor-
dance with local constraints. Some of the
needs identified here may also apply to con-
texts of instruction for other medical person-
nel. For instance, although this work was
developed prior to the publication of Cegala,
Socha McGee, and McNeilis (1996, 12-19) on
the perception of "communication compe-
tence" in doctors and patients, there is con-
siderable similarity.
In his insightful introduction to a collec-
tion of needs analyses, Richterich (1983, 4)
reviewed arguments which "taken to the ex-
treme, might mean denying the very possibil-
ity of identifying needs." I have argued here
that the four approaches to needs definition
found in the work of Stufflebeam, Mc-
Cormick, Brinkerhoff, and Nelson (1985,6-7)
provide a framework that makes it possible
to define and identify needs. Moreover, these
definitions suggest methods for data gather-
ing. Working within this framework, five
215
major categories of needs statements
emerged. These have included (1) Speech
Production Accuracy, (2) Academic Per-
formance, (3) Clinical Performance, (4)
Dialect (Cultural) Variation, and ( 5 ) In-
ferencing Skills. These five categories of
need, are a working set for educators of NNS
nurses who work in diverse contexts.
ACKNOWLEDGMENTS
I wish to thank Kristine Billmyer, Director of
the English Language Programs, and also the
School of Nursing, both at the University of
Pennsylvania, for their support during this re-
search. Felicia Lincoln-Porter, Lynn Buchheit,
and Nancy Overholt made important contri-
butions during the research process. Elliot
Judd gave crucial editorial advice. 1 thank all
of these talented folks. Finally, 1 thank the two
reviewers who gave very useful, constructive,
and insightful critiques.
NOTES
IThe first course was developed to address aca-
demic needs, whereas the second focused on lan-
guage use in clinical sites attended by a diverse
patient population. The classes were first taught
during the academic year of 19931994 and again
during 1994-1995. Each class met twice a week for
ten weeks for class periods of one hour and thirty
minutes. This was supplemented by weekly indi-
vidual tutoring.
The English Language Programs is the name
of the program at Penn that provides ESL classes.
For more information, see their Web Site: www.
sas.upenn.edu/elp
'See Richards (1990, 1-34) for an instructive
overview of needs analyses and of the position of
a needs analysis with respect to syllabus and cur-
riculum design.
The full title of the SPEAK Test is the Speaking
Proficiency English Assessment Kit. It is designed
by Educational Testing Services (En) and is simi-
lar in content and format to the Test of Spoken
English also designed by ETS. In recent years, ETS
has revised the SPEAK test. Therefore, the SPEAK
tests and rating systems used for these students
were those available before 1994.
The term "disfluent" is the opposite of "fluent."
 FOREIGN LANGUAGE A"ALS--SUMMER 1998
This is a technical term of assessment for speech
that is marked by such frequent pauses and sen-
tence fragments that the speech may b e unintelli-
gible.
In all clinical sites, different areas of the clinic,
types of paperwork, or medical tests may b e r e
ferred to through one form of abbreviation or an-
other. Acronyms such as EKG are common. A new
nurse will need to find out what the abbreviations
mean in order to function within that clinic. B e
cause s o m e abbreviations may only b e used
within one particular clinic, I refer to them as local.
' One reviewer of this research noted that the
following transcript from this student contained
many more problems than simply pronouns. This
is true. The various other problems are addressed
elsewhere in the article.
A multiplemultiple choice question is a type of
multiple choice question wherein a student must
select not one answer, but two or three. This type
of test question is designed to test reasoning skills
relevant to differential diagnosis.
The SOAP Chart is a very common method for
organizing the write-up of progress notes o n pa-
tients. 'S" refers to subjective information derived
from asking the patient for hidher current com-
plaint and past history. "0"refers to the putatively
objective results derived from a physical examina-
tion or laboratory studies of blood or stool sam-
ples. "A" refers to the care provider's assessment
and diagnosis. "P" refers to the treatment plan that
follows from the diagnosis.
REFERENCES
Adams, Thomas. 1987. Body English: A Study ot
Gestures. Glenview, IL: Scott, Foresman a n d
Company.
Anderson-Hsieh, Janet, Ruth Johnson, a n d Ken-
neth Koehler. 1992. "The Relationship between
Native Speaker Judgments of Nonnative Pronun-
ciation a n d Deviance in Segmentals, Prosody
and Syllable Structure." Language Learning 42:
529555.
Bandman, Elsie, and Bertram Bandman. 1988. Crit-
ical Thinking in Nursing. Norwalk, CT: Appleton
and Lange.
Berwick, Richard. 1989. "Needs Assessment in Lan-
guage Programming: From Theory to Practice,"
4062, in Robert K. Johnson, ed., TheSecond Lan-
216
guage Curriculum. cambridge: Cambridge Uni-
versity Press.
Boshuizen, Henny, and Henk Schmidt. 1992. "On
the Role of Biomedical Knowledge in Clinical
Reasoning by Experts, Intermediates and
Novices." Cognitive Science 16: 153184.
Bouton, Lawrence. 1994. "Conversational Implica-
ture in a Second Language: Learned Slowly
When Not Deliberately Taught." Journal of Rag-
matics 22: 157-167.
Brown, James Dean. 1995. The Elements of Lan-
guage Cuniculum: A Systematic Approach to Re
gram Development. Boston: Heinle & Heinle.
Cameron, Richard, a n d Jessica Williams. 1997.
"Sentence to Ten Cents: A Case Study of Rele-
vance and Communicative Success in Nonna-
tive-Native Speaker Interactions in a Medical
Setting." Applied Linguistics 18: 4154l5.
Candlin, Christopher, Clive Bruton, Jonathan
Leather, and Edward Woods. 1981. "Designing
Modular Materials for Communicative Language
Learning: An Example: Doctor-Patient Cornmu-
nication Skills," 10.5133, in Larry Selinker, Elaine
Tarone, and Victor Hanzeli, eds., English forAca-
demic and Technical Purposes. Rowley, MA:
Newbury House Publishers.
Carrell, Patricia. 1984. "Inferencing in EL:Presup
positions and Implications of Factives and Im-
plicative Predicates." Language Learning 34: 1-21.
Cassell, Eric. 1985. Talking with Patients: Volume I :
The Theory of Doctor-Patient Communication.
Cambridge, MA: MIT Press.
Cegala, Donald, Deborah Socha McGee, and Kelly
McNeilis. 1996. "Components of Patients' and
Doctors' Perceptions of Communication Com-
petence during a Primary Care Medical Inter-
view." Health Communication 8: 1-27.
Drew, Paul, and John Heritage. 1992. "Analyzing
Talk at Work: An Introduction," 3-65 in Paul
Drew and John Heritage, eds., Talk at Work: In-
teraction in Institutional Settings. Cambridge:
Cambridge University Press.
Erickson, Frederick, and William Rittenberg. 1987.
"Topic Control a n d Person Control: A Thorny
Problem for Foreign Physicians in Interaction
with American Patients." Discourse Processes 10:
40141 5.
Erzinger, Sharry. 1991. "Communication between
Spanish-Speaking Patients and their Doctors in
 FOREIGN LANGUAGE A N N A L S S U M M E R 1998
Medical Encounters." Culture,Medicine, and Psy-
chiatry 15: 91-110.
Ferrara, Kathleen, and Barbara Bell. 1995. "Soci-
olinguistic Variation and Discourse Function of
Constructed Dialogue Introducers: The Case of
BE + LIKE." American Speech 70: 265-290.
Fisher, Sue. 1995. Nursing Wounds: Nurse Practi-
tioners, Doctors, Women Patients, and the Nege
tiation of Meaning. New Brunswick, NJ: Rutgers
University Press.
Freeman, Sarah. 1987. "Introduction: Verbal Com-
munication in Medical Encounters: An Overview
of Recent Work." Text 7: 317.
Galanti, Geri-Ann. 1991. Caring forPatients fromDif-
ferent Cultures: Case Studies from American Hos-
pitals. Philadelphia: University of Pennsylvania
Press.
Goffman, Erving. 1961. "Role Distance," 85152, in
Erving Goffman, Encounters: Two Studies in the
Sociology of Interaction. Indianapolis, IN: The
Bobbs-Memll Company.
-. 1963. Behavior in Public Places. London:
Collier-Macmillan Ltd.
Gozzi, Ethel, Mane Morris, and Barbara Korsch.
1969. "Gaps in Doctor-Patient Communication:
Implications for Nursing Practice." American
Journal of Nursing 69: 529533.
Gumperz, John. 1982. "Fact and Inference in Court-
room Testimony," 163-195, in John Gumperz,
ed., Language and Social Identify. Cambridge:
Cambridge University Press.
Heritage, John, and Marja-Leena Sojonen. 1994.
"Constituting and Maintaining Activities across
Sequences: And-Prefacing as a Feature of Ques-
tion Design." Language in Society 23: 1-19.
Herselman, Stephn6. 1996. "Some Problems in
Health Communication in a Multicultural Clini-
cal Setting: A South African Experience." Health
Communication 8: 153170.
Holliday, Adrian. 1995. "Assessing Language Needs
within an Institutional Context: An Ethnographic
Approach." Englkh forspecilicfirposes14: 115126.
Keane, Anne, Joseph Ducette, and Diane Adler.
1985. "Stress in the ICU and Non-ICU Nurses."
Nursing Research 34: 231-236.
Kleinman, Arthur. 1988. 7he Illness Narratives: Sub
fering, Healing, and the Human Condition. New
York: HarperCollins.
Kochman, Thomas. 1981. Black and Mite Styles in
217
Conflict.Chicago: The University of Chicago Press.
Lechtenberg, Richard. 1991. Synopsis OfNeurology.
Philadelphia: Lea & Febiger.
Leech, Geoffrey, and Jan Svartvik. 1975. A Com-
municative Grammar of English. London: Long-
man Group Limited.
Maynard, D o u g l a s 1991. "Bearing Bad News in
Clinical Settings," 143172, in Brenda Dervin, ed.,
Progress in Communication Sciences: Vol. 10.
Norwood, NJ: Ablex.
McTear, Michael, and Florence King. 1991. "Mis-
communication in Clinical Contexts: Speech
Therapy Interview," 195-214, in Nikolas C o u p
land, Howard Giles, and John Wiemann, eds.,
"Miscommunication and Problematic Talk. New-
bury Park, CA: Sage Publications.
Morley, Joan. 1972.Improving Aural Comprehension.
Ann Arbor The University of Michigan Press.
Munby, John. 1978. Communicative Syllabus De-
sign: A Sociolinguistic Model for Defining the Con-
tent of firp0se;SpecificLanguage Programmes.
Cambridge: Cambridge University Press.
Nations, Marilyn, Linda Camino, and Frederic
Walker. 1985. "'Hidden' Popular Illnesses in Pri-
mary Care: Residents' Recognition and Clinical
Implications." Culture, Medicine, and Psychiatry
9: 223240.
Nugent, Patricia, and Barbara Vitale. 1993. Test Suc-
cess: Test Taking Techniques for Beginning Nurs-
ing Students. Philadelphia: F.A. Davis Company.
Nunan, David. 1989. Designing Tasks for the Com-
municative Classroom. Cambridge: Cambridge
University Press.
Olsen, Leslie, and Thomas Huckin. 1983. Principles
of Communication for Science and Technology.
New York: McGraw-Hill.
Paniagua, Freddy. 1994. Assessing and Treating Cul-
turally Diverse Clients: A Practical Guide. Thou-
sand Oaks, CA: Sage Publications.
Parkinson, Joy. 1991.A Manual of English for the Over-
seas Doctor. Edinburgh: Churchill Livingstone.
Pomerantz, Anita, Barbara Mastriano, and Murray
Halfond. 1987. "Student Clinicians' Difficulties
while Conducting the Summary Diagnostic In-
terview." Texf 7: 1936.
Prince, Cynthia. 1985. Hablando Con El Doctor:
Communication Problems Between Doctors and
Their Spanish-Speaking Patients. Unpublished
Ph.D. Dissertation: Stanford University.
 FOREIGN LANGUAGE ANNALSSUMMER 1998

Prince, Ellen. 1978. "A Comparison of WHClefts and Woolfson, Peter, Virginia Hood, Roger Secker-
PseudoClefts in Discourse." Language 54: 883-906. Walker, a n d Ann Macaulay. 1995. "Mohawk
Raney, Susan. 1992. "Learning a New Script: An Ex- English in the Medical Interview." Medical An-
ploration of Sociolinguistic Competence." A p thropology Quarterly 9: 503-509.
plied knguistics 13: 25-50. Zola, Irving. 1966. "Culture and Symptoms: An
Richards, Jack. 1990. The Language Teaching Ma- Analysis of Patients Presenting Problems." Arner-
hix. Cambridge: Cambridge University Press. ican Sociological Review 3: 615-630.
Richterich, RenC. 1983. "Introduction," 11-13, in
RenC Richterich, ed., Case Studies in Identifying
Language Needs. Oxford: Pergamon Press.
Richterich, RenC, and Jean-Louis Chancerel. 1977.
Identifying the Needs o fAdults Learning a Foreign
Language. Oxford: Pergamon Press.
Shuy, Roger. 1983. "Three Types of Interference to
a n Effective Exchange of Information in the
Medical Interview," 189-202, in Sue Fisher and
Alexandra Todd, eds., The Social Oqanization of
Doctor-Patient Communication.Washington, DC:
Center for Applied Linguistics.
Singer, Murray. 1994. "Discourse Inference Pro-
cesses," 479-515, in Morton Ann Gemsbacher,
ed., Handbook of Psycholinguistics. New York:
Academic Press.
Soyland, A. J. 1994. "Functions of the Psychiatric
Case-Summary." Text 14: 113-140.
Stufflebeam, Daniel, Charles McCormick, Robert
Brinkerhoff, and Cheryl Nelson. 1985. Conduct-
ing Educational Needs Assessments. Boston:
Kluwer-Nijhoff Publishing.
Thompson, Joyce, and Henry Thompson. 1985.
Bioethical Decision Making for Nurses. Norwalk,
CT:Appletonenturyrofts.
Weijts, Wies, Hanneke Houtkoop, a n d Patricia
Mullen. 1993. "Talking Delicacy: Speaking about
Sexuality During Gynecological Consultations."
Sociology o f Health & Illness 15: 295314.
West, Candace. 1985. Routine Complications: Trou-
bles with Talk between Doctors and Patients.
Bloomington: Indiana University Press.
Widdowson, Henry. 1981. "English for Specific Pur-
poses: Criteria for Course Design," 1-1l , in Larry
Selinker, Elaine Tarone, a n d Victor Hanzeli,
eds., English for Academic and Technical Pur-
poses. Rowley, MA: Newbury House Publishers.
Wolfram, Walt. 1991. Dialects and American Eng-
lish. Englewood Cliffs, NJ: Prentice Hall.
Wolfson, Nessa. 1989. Perspectives: Sociolinguis-
tics and TESOL. New York: Newbury House.

218