English and Student Anxiety:  How to Turn it Around


Gregory Hadley




         In this article we will study the reasons why nurses are still unable to speak English even after years of study.  I will then explain the problem of learner anxiety, which I feel is a major obstacle for students both in our classrooms and later on in the hospitals.  We will review the major contributing factors to learner anxiety.   From my experience, using the communicative approach has helped alleviate the problem of anxiety in my classes as well as enable students to speak more English, and I will describe the results I have had in my classes through using this approach.


The Current Challenge


         Any foreigner who has recently come to Japan will tell you that going to a hospital can be a very trying experience.  Especially if the person is of European or African descent, many times hospital staff can become so anxious they are left speechless.  Some even tell stories where they have observed nurses frantically discussing who will be the one to speak to "the gaijin".  If the foreigner is very sick and frightened, as is often the case, he may become angry.  This usually worsens the already stressful situation.  The number of foreigners coming to Japan are increasing, and these types of encounters are becoming more and more common.  This is especially the case in the rural hospitals where people are not used to seeing foreigners.     


         Foreigners are usually surprised to find out that all nurses who study at Nursing Specialty Schools (Kango Senshu Gakko) are required by the koseisho to study 120 hours of foreign language instruction.  Most schools offer English, because of it's international scope, and the abundance of native or near-native speakers in Japan. 


         Why are our graduates from nursing school, after studying English for two to three years past the high school level, still unable to speak English?  The traditional method of teaching English in nursing schools often consists of mastering the grammar and vocabulary in textbooks.  The students listen to lectures, take notes, and are at times asked to verbally answer some cursory questions.  This is a continuation of the type of instruction they received in high school.  Unfortunately, this method by itself is simply not working. 


         What is it that prevents them from communicating with their foreign patients?  One reason is that our nurses are learning to read and write English, but are not learning to speak the language.  This is why I feel our nurses need to learn Communicative English, which we will discuss later.  The other is the debilitating factor of student anxiety.          


Anxiety:  A Major Barrier


         When I first began teaching nursing students, I noticed they were extremely shy in class.  It was difficult to get them to respond to almost any question.  In fact, the more I tried, the more frightened most of the students would become.  Others would sleep.  Whether I tried the drills in the textbook or some that I would make on my own, many times I would be met with dazed, confused or nervous stares.  Only after great effort and some clowning around on my part would some the students begin to participate.  This would take almost all of the 100 minute period.  Since the class met only once a week, by the time the next class started I would find myself encountering that same wall of anxiety that seemed tower before me.  I would often leave class discouraged and exhausted.  I wondered if there could be any way to break through this "anxiety barrier" and reach my students.    


         Although researchers differ on exactly how to define the terms stress or anxiety, a lot of research over the years has studied their effects upon second language acquisition.  Naimon, Frohlich, Stern and Todesco (1978) found in their study that a high fear of rejection, classroom anxiety and other feelings can affect whether or not a student will be successful in learning a second language.  Wittenborn, Larsen and Virgil (1945; reported in Pimsleur, Mosberg and Morrison, 1962) showed a correlation between low and high scoring language students by their corresponding levels of anxiety and self-confidence. 


         Much of the impact that anxiety has upon nursing students may have to do with how they think about themselves in relation to studying English language.  Lazarus and Folkman (1985) showed in their research that if a situation is viewed as a threat, people will tend to have increased anxiety.  Also, if a person doesn't feel as if he has the confidence to succeed in attaining a certain goal, the anxiety becomes even more severe (Bandura, 1977).


         This research sheds much light upon the effects that a traditional English class may have on many of our nursing students.  Imagine for a moment what it must be like for our students:  They are crowded into a room with 40 to 50 other students.  Very few are willing to speak up for fear of making a mistake in front of 50 of their peers.  Many already lack confidence in their ability to speak English.  All their lives, they have heard people repeat the phrase, "English is difficult, isn't it?"  To further reinforce this thought, they are given textbooks requiring them to master grammar and medical terms that are far beyond their current level of comprehension.  Hardly anyone would want to try and participate in a class where they felt set up to fail from the very beginning.  Add to this factor that the teacher may be a foreigner who is speaking to them in a foreign language and you can quickly see the typical English class is a place that has a very threatening atmosphere.  It is no wonder that many nursing students feel anxious about speaking English once they are on the hospital floor.  They learned to feel that way in English class.  This anxiety was definitely working against my students.  However, stress in itself is not necessarily bad.  Researcher Hans Seyle, in his book The Stress of Life, remarked wryly that only the dead are totally without stress (1976). 



         Research on anxiety has separated it into two types: debilitative and facilitative anxiety (Alpert and Haber 1960, cited by Scovel 1978).  Debilitative anxiety is destructive and counterproductive to learning English.  It is characterized with a fear of failure and lack of confidence to succeed.  Facilitative anxiety, however, is helpful.  It can prepare one to be adequately concerned over a task, such as the anxiety one may feel before giving a speech.  It is characterized by confidence that one can succeed if making an effort.  What our students experience in their English class (and later in the hospital) is clearly debilitative anxiety. 


         My personal strategy has been not to remove anxiety, but to find ways to change it into facilitative anxiety.  The approach I feel best works in my classroom is the Communicative Approach.  What I do in class are not simply "feel good" techniques.  I've seen a significant turn around in attendance, motivation, participation and, most importantly, communicative ability in my classes. 


The Communicative Approach


         There are numerous textbooks and teaching materials being published which carry the name "communicative".  What exactly is the communicative approach?  Communicative Language Teaching, or CLT, has been around since the late seventies.  Precise definitions of the approach vary among it's exponents.  Researchers Finocchiaro and Brumfit (1983) define it as an approach where meaning and effective communication, not grammar, is the most important factor, and communicative competence is goal.  Communicative competence is the ability to use language in an appropriate manner. 


         Breen and Candlin (1979) feel that to be communicative means for the teacher to be less controlling in the class and become an interdependent member in the learning-teaching group.  The role of the teacher is to value the contribution students make to learning, and to nurture the process of education through interaction.  The students are responsible to learn how to learn the target language, but this responsibility is shared with the group as well as individually.         


         While some supporters of the Communicative Approach feel that people should forget grammar studies and strive to communicate from the beginning, I agree with Professor William Littlewood of the Institute of Language Education in Hong Kong, who feels the study of grammar is an important foundation for speaking English (Littlewood, 1981).  The work of the high school teachers has made the job of foreign English teachers much easier.  Learning grammar and vocabulary are only half of the process.  Students must move beyond the form of the language to communicate meaning (Littlewood, 1981). 


         This process of moving through grammar and vocabulary to the communication of meaning is a key element of the communicative approach.  My own style of teaching is closely in line with the approach that Littlewood advocates, which starts with pre-communicative activities, which are defined as structural and quasi-communicative, and then to move onward to true communicative activities, which are defined as functional and socially interactive  (Littlewood, 1981).  To accomplish this goal, I take my class through a process of drills, jazz chants, information gap activities and role play.       




         I start out the first class by drawing a big circle on the board and putting a large letter "E" in the middle of the circle.  I tell them, "This circle represents the entire English language.  This English is hard."  I then draw a much smaller circle within the large circle.  "But this is the English that you must learn in class.  This English is easy.  You can do this.  I know that you can."  Many times we start out our weekly class by repeating the phrase, "English is easy.  I can do it!"  This helps to instill confidence in their ability to speak English.  I show that their class goals are attainable, if they will try.


         I simplify the demands of the text for my students.  Suitable texts for Nursing English are not easy to find.  The one I use in my class is Let's Speak, Let's Learn by Niiki, Sukegawa and Engle.  Most of the dialogue and grammar are simple and practical enough to be used in my approach.  I do not emphasize grammar, but instead focus on understanding and communicating the ideas in the dialogue.     

         I read the dialogue several times while walking up and down the rows of the classroom.  The students listen.  Then as an entire class, we will practice the dialogue once or twice chorally.  When I am sure they understand the general meaning of the dialogue I go on to the next stage.


         I lead the class in a series of jazz chants that are based upon the dialogue and situations in the lesson.  I do this for a couple of reasons:  first, to practice pronunciation, rhythm and listening; but also to move the students away from simply reading the text to having fun with the language.  This type of enjoyable experience tends to help lower student anxiety.


         After this activity, I break the class up into small groups of about four to six students each.  I find this has the effect of making the class feel smaller.  Not only do the students have a group in which they work together and support each other, but the emphasis has been taken off of me and is put upon them as they must begin to communicate with each other in English.  In the small groups they will practice the dialogue several times.  While they are practicing, I wander through the class and listen.  When the students are doing well, I encourage them.  I refrain from correcting the students too much, and only do so when I encounter serious errors.


         By this time most of the students understand the dialogue and vocabulary in the lesson.  Most have gained enough confidence to use the language in their small groups.  This is a major step forward, and crucial for success in the next stages. 


         However, we have still only practiced the form of the language.  If I were to stop here, they would have only learned a series of unrelated phrases.  The class must move from form to practice.  The key is when students begin using what they've learned in a living conversation.  To accomplish this goal, I rely heavily on information gap activities. 


         An information gap activity is one of the main techniques of the communicative approach.  In it, one person or group is given a sheet with information that the other person or group does not have, and vice versa.  Both groups have some of the same information on their sheets.  Using what they have in common, the person or group interacts in English so that by the end of the exercise, both sides should have shared all their information, and both their sheets look identical. 


         On average, it takes a couple of times of trying this activity before the students really catch on.  Once they do, they find it one of the most enjoyable parts of the class.  Only two rules prevail during this exercise.  One is not to show the other partner your sheet while communicating.  This would destroy the whole purpose of the information gap activity.  The other is to strive to speak only English.  Since I base my information gap exercises on what we've studied in the lesson, there is usually no excuse for not working out the activity in English.


         Next we simulate the communicative functions of the lesson through role play.  I write on the blackboard the communicative functions the dialogues are teaching, such as introductions, asking questions or introducing another nurse.  I put numbers besides these functions.  I then put the class back into groups and tell them to decide which persons in their group will perform these functions.  The reason is because later they will come in front of the class and perform these functions in the form of a skit.


         The stress and anxiety had been lessening gradually up to this point.  When they realize they will have to speak in front of the class, the anxiety level naturally gets higher.  To change this into facilitative stress, I show them that their goals are attainable:  If they can practice the dialogue in their skits, speak some English and answer some questions, they are guaranteed success.  When they understand that they can do well if they study and practice, they tend to study quite hard in their groups.


         After the groups have decided who will do what, they close their books.  From here we play the skit that we call "Sick

Gaijin".  With me playing the role of the foreigner, the groups will come up and role play some of the dialogue they have practiced.  I encourage them not to worry about repeating the dialogue word for word, but to just talk to me.  After each group finishes, I encourage the class to applaud and to encourage each group in their efforts, even if in the beginning of the term they can do no more than speak a few words.  Just coming up in front of the class and speaking is a great accomplishment. 


          Later in the term we make this activity more and more realistic by using the real hospital equipment which is available at the school.  Our school has the luxury of having a room next door to our classroom which looks exactly like a hospital patients room.  We use this room extensively to come as close as possible to simulate reality.  We act out scenarios from dealing with an angry, frightened patient to life-threatening emergency situations.  The shock of seeing and then dealing with such simulated emotional outbursts is very difficult for the nursing students to handle in the beginning, and I must encourage them a lot to make progress.  I am happy to say that over half of my students gradually learn to remain calm and communicate in spite of these difficulties.




         In the beginning most of the class is very anxious with this approach.  Putting them on the "hot seat", so to speak, is for most of them a radically different way to learn English.  I explain that the stress they experience during the skit is the same they will feel in the hospital when they see a foreigner.  I encourage them to work together and overcome this anxiety in class as training for the future.  I remind them of their goal to simply communicate their ideas and gather accurate information from their foreign patients.   


         As the students begin to realize how the class applies to their future as nurses, the overall motivation of the class increases.  It is by this time most of the students actually start to believe they really can accomplish the communicative goals of the class.  Everyone works together in their groups.  Nobody sleeps.  I have very few absences.   


         I have seen even some of my most bashful students begin to communicate quite well for their level in English.  Of course, there are always some students who were extremely shy, bored or grossly unmotivated from the very beginning and remain that way throughout the entire term.  I suspect many of these students have the same attitudes in their other classes as well.  There are others who never really acquired even a passive knowledge of English, due to the varying levels of English education in schools.  These students I treat with gentleness, and encourage them to study.  I hope that a positive experience they have in their classes will motivate them to continue to study even after graduation.  I'm glad to say, however, that these students are a  minority in my classes. 


          The majority of the class becomes like a support group as they work together to learn English.  It is not uncommon to hear students cheering each other on as they come up to the front of the class.  When mistakes are made, I frequently observe the groups immediately studying to correct their errors before I even have a chance to tell them.  The nursing students begin to teach themselves English.  During the course of the term, I have seen my classes shift from an atmosphere where the students felt inferior and threatened, to an atmosphere in which they felt confident and encouraged.  The barrier of anxiety is definitely much lower by the middle and end of the term.  The students no longer look confused and fearful.  We finish classes feeling energized.  Test scores at the end of the term are usually quite high, as the motivation to study is quite high.   




         In this article we have looked at the needs for nurses to be able not only to read, but to communicate on simple terms in English with their foreign patients. I have shown that student anxiety is a major obstacle in Nursing English classrooms.  While nursing students are often shy and lack confidence in their ability to speak English, this situation can be turned around using a Communicative Approach.  Students soon learn that English communication is attainable, and classroom study has practical application for their future.  


         Through the techniques described in this article, I have seen an increase in the motivation and communicative skills of my students.  It is hoped that sharing my experience can be of some value, and that it will offer help in curbing anxiety, and free our nurses to excel both in the classroom and in the hospital.





Alpert, R., and Haber, R. (1960). Anxiety in Academic Situations.  Journal of Abnormal and Social Psychology, 61: 207-215.


Bandura, A. (1977).  Self Efficacy:  Toward a Unifying Theory of Behavioral Change. Psychological Review, 84: 191-215.


Breen, M., and Candlin, C. (1979).  The Essentials of a Communicative Curriculum in Language Teaching.  Applied Linguistics 1 (2): 99-104.


Finocchiaro, M. and Brumfit, C. (1983). The Functional-Notational Approach:  From Theory to Practice. New York:  Oxford University Press.


Lazarus, R. and Folkman, S. (1984). Stress, Appraisal and Coping. New York:  Springer Publishing Company.


Littlewood, W. (1981). Communicative Language Teaching:  An    Introduction. New York:  Cambridge University Press.


Naimon, N., M. Frohlich, D. Stern, and A. Todesco (1978). The Good Language Learner. Toronto, Ontario Institute for Studies in Education.


Pimsleur, P., L. Mosberg, and A. Morrison (1962). Student Factors in Foreign Language Teaching. Modern Language Journal 46: 160-170.


Seyle, H. (1976). The Stress of Life.  New York:  Knopf.