English Language Proficiency and Its Relationship with Academic Performance and the Nurse Licensure Examination

Background: Studies have shown that various factors influence students’ success in nursing school and the Nurse Licensure Examination (NLE). Such factors should be studied as foundations of the nursing programs. Problems with proficiency in the language used by the instructor to teach curricular courses may be considered a barrier to effective learning and academic success. Purpose: This study ascertained the influence of English language proficiency on the academic performance of students in professional nursing courses and the NLE. Methods: This study employed a retrospective descriptive correlational study design. Secondary analysis of existing research data sets of 141 nursing students in one nursing school in the Philippines was performed. Pearson’s r was used to determine the correlation between variables. Results: Findings showed that there were significant correlations between academic performance and the Verbal Ability subscale of the Nursing Aptitude Test ( p =0.003) and the three English courses included in the nursing curriculum ( p =0.000). There were also significant correlations between the NLE ratings and Verbal Ability ( p =0.000) and the three English courses ( p =0.000). Conclusion: English language proficiency is an important factor in determining the academic and licensure success of nursing students. Nursing schools must ensure that approaches in improving students' English language proficiency must be well integrated into the undergraduate nursing program.

education, engineering, law, and healthcare (Cabigon, 2015;Nishanti, 2018). With the impact of globalization and economic development, command in the English language is vital for those who work in the global workforce.
The Philippines is acknowledged globally as one of the biggest English-speaking nations. Proficiency in the English language is also one of the country's assets that helped the country's economy (Cabigon, 2015). The Philippines is considered one of the top outsourcing destinations of foreign healthcare workers worldwide (Ubas-Sumagaysay & Oducado, 2020;Yeates & Pillinger, 2018). However, concern on the narrowing competitive advantage of the country was raised despite that the country is doing fine in terms of English competency (Cabigon, 2015). Recent studies are showing that the Filipinos' grasp of the English language requires an area of concern. Results of an online Standard English Test (SET) revealed a declining trend in the English language skills of Filipinos (Education First, 2019). A Philippine Senate Resolution 622 (2018) was filed in 2018 calling for an inquiry into the declining proficiency in English among Filipino students citing reports from Hopkins International Partners and the Common European Framework of Reference for Languages. The Hopkins International Partners study revealed that college graduates in the Philippines had lower English proficiency level than the proficiency target set for high school students in Thailand and the taxi drivers in Dubai. Moreover, the Common European Framework of Reference for Languages reported that the median score of Filipino university graduates was comparable only to the proficiency level of 5th and 6th graders in countries wherein English is the native language. There was also news that reported that many Filipino nurses failed the English proficiency test required to qualify for employment in a hospital in London (Byrne, 2017).
Internationally educated nurses or nurses from countries outside of the United States of America (USA), United Kingdom (UK), and Australia, to name a few, are required to take an English test or provide proof of English language skills prior to employment. It has been established that the tests used for estimating future job performance should be administered in the language used in the job because those with inadequate competence in that language may also perform poorly either on the test, on the job, or both (O'Neill, Marks, & Liu, 2006). In other words, the low English proficiency of Filipino nurses may negatively affect their future job performance or employment when they work in English-speaking countries.
The value of the English language in the Philippine educational system cannot be overemphasized. While Filipino is considered as the national language, the official languages of the country for purposes of communication and instruction are Filipino and English, as stated in the 1987 Philippine Constitution. Globally, in developing and even in some developed countries, a language other than the students' mother tongue is used in all levels of the educational system (Civan & Coşkun, 2016). The English language is widely used in the field of education, especially in highly technical fields like nursing. English as a medium of instruction has been adopted for decades by Philippine nursing schools. Published academic research and major references used in nursing schools in the country are written mostly in English. It is said that the language of instruction plays Nurse Media Journal of Nursing, 10(1), 2020, 48 Copyright © 2020, NMJN, p-ISSN 2087-7811, e-ISSN 2406-8799 an essential role in facilitating learning of course contents and in teaching the subject (Ibrahim, Shafaatu, & Yabo, 2017).
Understanding the performance of students in nursing school and the licensure examination are important to identify students who are at risk of not performing well (Oducado, 2019). Past researches have shown that various factors influence nursing students' academic performance (Belo-Delariarte, Oducado, & Penuela, 2018;Mthimunye & Daniels, 2019;Mthimunye & Daniels, 2020) and success in the licensure examination in countries like Kenya (Okanga, Ogur, & Arudo, 2017), Ghana (Amankwaa, Agyemang-Dankwah, & Boateng, 2015), USA (Kim, Nikstaitis, Park, Armstrong, & Mark, 2019) and the Philippines (Oducado, Cendaña, & Belo-Delariarte, 2019b). Prior studies indicated that English language proficiency influences the academic performance of nursing students in the Philippines (Oducado & Penuela, 2014) and Kuwait (Vidal, Labeeb, Wu, & Alhajraf, 2017). Students who had high selfreported English language proficiency were also found to have the highest GPA in a study among international university students in the USA (Martirosyan, Hwang, & Wanjohi, 2015). It was also established that performance in academic influences performance in the NLE (De Leon, 2016;Oducado et al., 2019b;Soriano, 2016). However, despite the positive impact of English language proficiency on academic success, there are reported concerns on the potential negative effects on the learning process and students' academic achievement when the medium of instruction or language used to teach the subject is a language different from the mother or native tongue of the learners or students (Civan & Coşkun, 2016). This may be true within the multi-lingual context of the Philippines and in the setting of this study wherein English is the medium of instruction, and Hiligaynon is the local dialect spoken by most of the study sample. Nursing students with English as an additional language or English as a second language (ESL) may experience more learning challenges and may not perform well academically (Glew, Hillege, Salamonson, Dixon, Good, & Lombardo, 2015;Salamonson, Everett, Koch, Andrew, & Davidson, 2008). The study of Green (2015) relayed that ethnicity and English proficiency were predictors of academic performance and progress. Language barriers were also identified as a significant barrier faced by ESL nursing students in a critical review of the literature (Olson, 2012).
While a number of scholars have investigated the association between English language proficiency and academic performance, literature is scarce on the relationship between English proficiency and NLE in the Philippines. Lack of English proficiency may be an impediment to students' academic success and in acquiring nursing knowledge and skills to produce globally competitive nursing graduates. Understanding the influence of English language proficiency on the academic performance in professional nursing courses and the NLE is thereby necessary.

PURPOSE
The purpose of this study was to investigate the influence of English language proficiency on nursing students' academic performance in professional nursing courses and the NLE at one baccalaureate nursing program.

Research design
This study utilized a retrospective, descriptive-correlational design. A secondary analysis of existing data sets was performed. Secondary analysis "refers to the use of existing research data to find answer to a question that was different from the original work" (Tripathy, 2013).

Participants
The researchers analyzed secondary data of 141 nursing graduates at one baccalaureate nursing program in the Philippines. Power analysis using G*Power 3.1 software revealed that 115 is the required sample size given an alpha of .05, power of .95, and medium effect size of .3. The researchers, however, decided to include all 141 students in the analysis since data were readily available to the researchers. Students with complete records of the variables of the research and took the NLE in May 2015 were included. Those who repeated any of their courses in the program were excluded from the analysis.

Research instrument and data collection
Two measures were used to determine the English language proficiency of students: Verbal Ability and grades in English courses. The Verbal Ability subscale of the Nursing Aptitude Test (NAT) was used to measure the pre-admission English language proficiency of students. The result of the NAT was obtained from the Center for Educational Measurement, Inc. (CEM), the center that administered the NAT, as part of the qualifying admission requirements to incoming first-year nursing students in the college. In general, the NAT, a standardized test, gives an estimate of the student's mental abilities in the areas of Verbal Ability, Numerical Facility, Science, and Health Information (CEM, n.d.; Oducado & Penuela, 2014). The Verbal Ability subtest is composed of 60 items in a multiple-choice format measures proficiency or ability in the English language with content areas of verbal analogies and vocabulary and has a reported reliability coefficient of greater than .70 (CEM, n.  (Oducado, Amboy, Penuela, & Belo-Delariarte, 2019a) in all professional nursing courses were used as a measure of academic performance. To interpret the grades in English subjects and professional nursing courses, the following were used: 1.50-1.74 = Outstanding; 1.75 -1.99 = Very good; 2.00-2.24 = Good; 2.25-2.49 = Very satisfactory; 2.50-2.74 = Satisfactory. Data on the NLE ratings of the students were originally requested from the Philippine Professional Regulatory Commission and were interpreted as: 79.99 and below = low; 80-84.99 = average; 85 and above = high.

Statistical data analysis
Data analysis was aided by IBM SPSS version 23. Percentage, mean, and standard deviation (SD) were used to describe the data. Pearson product-moment correlation coefficient tested for the relationship between variables since data was found to be normally distributed with sig. value of Kolmogorov-Smirnov Test greater than .05. The level of significance was set at 0.05 alpha.

Ethical considerations
All secondary data remained confidential, were kept safe from unauthorized access, and were only made available to the researchers. The original research where the data were taken was granted an exemption by the ethics review committee of the University. Administrative clearance from the Dean of the College of Nursing was secured to conduct this secondary analysis.

Participants' profile
Nursing students who participated in this study were graduates of the four-year baccalaureate nursing degree program in one state-funded public university in the Philippines. The majority of subjects of the study were females (f=123; 87.2%). They were typically between 20 to 21 years old when they took the NLE. Table 1 shows that the majority of nursing students had an above-average (M=612.68; SD=60.65) English language proficiency in the Verbal Ability subscale of the NAT. In terms of English language proficiency in nursing school, nursing students had a very good performance in ENG 101 or Intensive English Grammar (M=1.76; SD=0.29) and had an outstanding performance in ENG 102 or Study and Thinking Skills in English (M=1.58; SD=0.21) and ENG 103 or Speech Communication (M=1.51; SD=0.25) respectively.  shown in Table 2 that nursing students had a good (M=2.13; SD=21) performance in professional nursing courses and had an average (M=80.74; SD=1.95) performance in the NLE.  Table 3 reflects the correlation between English language proficiency and nursing students' academic performance in professional nursing courses and NLE. Table 3 shows that Verbal Ability (p=0.003), ENG 101 (p=0.000), ENG 102 (p=0.000), ENG 103 (p=0.000) were significantly related to academic performance in professional nursing courses. It can also be gleaned in Table 3 that Verbal Ability (p=.0000), ENG 101 (p=0.000), ENG 102 (p=0.000), ENG 103 (p=0.000) were significantly related to performance or rating in the NLE.

DISCUSSION
This research determined the influence of English language proficiency on academic performance and the NLE. This study found that nursing students in this study generally have good English language proficiency prior to admission in the college and while in nursing school. Additionally, this study revealed improvement in the English proficiency of students as reflected in their very good to outstanding grades from one English language course to another. Students having good command in the English language in this study may probably be due to the highly competitive admission policy of the college. As a state or government-funded university, only a limited number of students are admitted to the BSN program. Generally, the college is able to attract the best students within the region. Within the context of nursing, a high degree of English language proficiency is essential for effective communication to provide safe nursing care, to establish therapeutic relationships with clients, and to collaborate effectively as a member of the healthcare team (Alinezhad & Gholami, 2012;Garone & Van de Craen, 2017). The English language plays an important role and is useful in students' academic life. The use of English language for classroom instruction and in the students' RLEs requirements such as in case presentations, class reporting, and in documenting nurses' work may have contributed to the improvement of the verbal and written communication skills of student nurses in the English language.
Interestingly, the finding of this study and that of Racca & Lasaten (2016), which also found satisfactory English proficiency among Philippine Science High school students, are in contrast to the reports regarding the declining ability of Filipinos in the English language. The authors cannot be conclusive about the general or overall English proficiency of Filipino students. Bias in the sample may have been introduced, influencing the results of the study.
Moreover, this study demonstrated that English language proficiency is significantly correlated with academic performance. It must be noted that 1.0 is the highest grade obtained by the student in the grading system of the college. Hence, a low number or grade in academic performance indicates better performance or achievement. The finding of the study is generally consistent with other research findings among nursing students in the Philippines (Oducado & Penuela, 2014), nursing (Alharbi & Yakuot, 2018;Vidal et al., 2017) and medical (Kaliyadan, Thalamkandathil, Parupalli, Amin, Balaha, & Al Bu Ali, 2015) students in Saudi Arabia, medical students in Iran (Sadeghi, Kashanian, Maleki, & Haghdoost, 2013), and with pharmacy students (Green, 2015) among others. English-language acculturation was found to influence academic performance among first-year ESL nursing students (Salamonson et al., 2008). English reading comprehension ability was also found to positively influence academic achievement among Indian nursing students (Ponkshe, 2013). Students with better command in the English language were more likely to do better in their nursing courses. Since English is the medium of instruction, students who were more proficient in English were able to do better in writing, speaking, grasping and understanding the instructions and lessons given to them in professional nursing courses. Teaching the curricular content and having proficiency in the language used for instruction increases the learner's amount of exposure and opportunities to understand the content of instruction hence students develop greater control over what is taught in class (British Council, n.d.) resulting to positive outcomes on students' academic success.
This study also disclosed a significant relationship between English language proficiency and the NLE. Miñoza (2016) likewise found an association between English proficiency and licensure examination among agriculturists in the Philippines. Similarly, O'Neill et al. (2006) found a link between English proficiency and nursing licensure examination performance. The authors found that ESL examinees had a lower passing rate than English only candidates. This result suggests that an obvious issue in language competency may create an impact on the performance in the licensure examination. It also highlights the importance of proficiency in the language used in the target examination. Not having good ability in the language used in the examination may impede a better understanding of test item questions. Soriano and Lupdag-Padama (2009) found that reading proficiency was a factor influencing the performance of nursing graduates in the NLE. The findings of this study suggest that it is vital to take into consideration that students who are admitted into the BSN program have good English language competency. Likewise, academic nursing institutions should promote students' skills in the English language in both academic and clinical settings to safeguard students' academic success in nursing school and the licensure examination. Providing students with academic guidance remains a vital aspect of nursing education (Oducado, Frigillano, Gunce, Jover, Meliton, & Pangilinan, 2017).
This study has its limitations. The data used were only secondary data in one college of nursing, thus limits the generalizability of the findings. Another limitation is that the English proficiency measure used in this study did not specifically assess English skills in the dimensions of reading, writing, listening, and speaking. Language proficiency in English is usually defined by a combination of these four skills (Sadiku, 2015). Future studies may be conducted on a larger scale using standardized English tests to validate the results of the investigation. Also, a qualitative component was missing, which could have explored students' views on the influence of the English language on their academic and licensure success. Nonetheless, this study has addressed the paucity of research on the influence of proficiency in the English language has on licensure examination within the local context. Additionally, this study has provided support on prior studies affirming the impact of English language proficiency on students' academic performance where English is the medium of instruction in a non-native English speaking country.

CONCLUSION
English language proficiency significantly influences students' performance in professional nursing courses and the NLE. Enhancing students' English language proficiency is considered beneficial in promoting students' academic and licensure examination success in a country where the language used by the teacher or instructor to teach the language is English. The result of this study can be utilized in developing strategies to enhance students' English language proficiency to support students' academic and licensure examination success. Nursing schools must ensure that approaches in improving students' English language proficiency must be well integrated into the undergraduate nursing program.