Award Date


Degree Type


Degree Name

Doctor of Philosophy (PhD)



First Committee Member

Michele Clark

Second Committee Member

Carolyn Yucha

Third Committee Member

Jennifer Kawi

Fourth Committee Member

LeAnn Putney

Number of Pages



This project’s long term goal was to improve English-as-a-Second-Language (ESL) nursing student retention. Improving the quality of multiple choice exams is a first crucial step. ESL students find multiple-choice exams to be one of the most challenging aspects of nursing school. One reason for this is the presence of linguistic errors in exam questions. Linguistic errors include: irrelevant question content, poor sentence structure, and culturally biased words or phrases. Non-ESL students are less affected because exams are written in their native language. Linguistic modification, as part of best practices in item writing, removes these types of errors. The U.S. Department of Education indicated that ESL students gained 6% points on linguistically modified mathematics exams in comparison to non-modified exams. The specific aim of this study was to compare exam scores of ESL to non-ESL nursing students on a standard multiple-choice exam compared to a linguistically modified exam. Current research highlights the needs of ESL nursing students along with the general role of linguistic modification. However, no identified quantitative studies evaluate the role of linguistic modification in nursing education. This study was unique in that it compared four subgroups of nursing students using an experimental method. Utilizing stratified randomization, nursing students were assigned to one of four subgroups. Two controls groups, ESL, and non-ESL students completed a standard exam of 50 questions. Two experimental groups, ESL and non-ESL students, took the same exam but with 50 linguistically modified questions.

There were 67 ESL students that took the experimental (linguistically modified) exam. Sixty-eight (68) ESL students completed the control (standard) exam. There were 252 non-ESL students that took the experimental exam and 257 non-ESL students that completed the control exam. Confounding variables were identified as GPA and program type (BSN and ADN). A 2x2 ANCOVA model was used for statistical analysis. The observed mean for the ESL students on the experimental exam was 69.94. The non-ESL students demonstrated an observed mean of 72.08 on the experimental exam. The observed mean for the ESL students on the control exam was 69.34 and non-ESL students 71.61. The combined means for both the experimental and control exam was 71.84 for the non-ESL students and 69.64 for the ESL students. The difference in observed means between the experimental exam and control exam for the ESL students indicate a 0.6% increase in the mean score. The non-ESL students had a 0.48% increase in mean score between the experimental and control exams. Students completed the experimental exam in 10% less time than the students that completed the control exam. The BSN students had a combined 3% increase in mean score over the ADN participants.

This research demonstrates several benefits from linguistic modification to nursing education. Students perceive linguistically modified exam questions to be clearer than non-modified questions, linguistic modification resulted in higher exam scores for ESL and non-ESL students, and finally linguistic modification resulted in decreased test completion time.


English as a second language; English language — Study and teaching — Foreign speakers; Item writing; Linguistic modification; Multiple-choice examinations; Multiple choice test; Nursing – Study and teaching; Nursing education; Nursing students


Education | Higher Education | Linguistics | Nursing | Other Nursing

File Format


Degree Grantor

University of Nevada, Las Vegas




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