September 2005 Volume 1
Article 1.

The Author
Ming-Nuan Yang is currently teaching English at Chang Gung Institute of Technology, Taipei, Taiwan. Her research specialization is in foreign language teaching, language learning strategies, and English for specific purposes.
The author is a doctoral student in Teaching English as a Second Language at National Cheng-chi University in Taiwan. She holds an M.A. in Education, School of Education, University of Southern California and an M.A. in Linguistics, Graduate School of Linguistics, Fu-jen Catholic University, Taipei, Taiwan.

Nursing Pre-professionals' Medical Terminology Learning Strategies

Abstract
This study is concerned with the learning of medical terminology by nursing pre-professionals in Taiwan. It aims to investigate the use of learning strategies in relation to medical vocabulary use. The subjects under study were composed of 89 Taiwanese college nursing majors. Participants' mid-term scores of medical terminology and medical terminology learning strategy questionnaires were used to inquire learners' use of learning strategies. The results of this study indicated that students in general prefer to use written repetition, verbal repetition, and bilingual dictionary strategies. In addition, the most proficient students used various kinds of strategies more often than the less proficient students. Implications of these and other findings are discussed and suggestions are made regarding the teaching of learning strategies in medical terminology courses.

Introduction
Of interest for the present study is the learning of medical terminology by nursing pre-professionals in Taiwan. We are particularly interested in learners' strategy use in the learning of medical terminology. Medical language is the language employed by doctors and nurses in writing medical records and communicating with each other. Doctors need to learn to read and write medical terminology to complete hospital admission notes, diagnoses, and orders, which, later on, nurses must read and follow in order to carry out nursing interventions and take care of their patients. For these medical and nursing professionals, their first step to access medical language is to learn medical vocabulary.

In Taiwan, nursing pre-professionals are required to take the course "Medical Terminology" to meet the demands of their future jobs. Insofar as the researcher knows, the nursing pre-professionals of the nursing college where the researcher is teaching have to take Medical Terminology courses from their second to fifth years. Every semester, more than one third of nursing pre-professionals fail their Medical Terminology courses. In order to help teachers to overcome the challenge of teaching medical terminology and help nursing pre-professionals learn medical terminology more effectively and efficiently, the researcher is motivated to explore the learning of medical terminology.

In view of Gylys and Wedding (1983), medical terminology is a specific terminology which is used to achieve the purpose of communication in the health care field efficiently and precisely, such as in writing diagnoses and nurses' notes. Basically, medical terminology has two characteristics. First, except for the one-syllable words, most medical words are made up roots and affixes. The affixes can be classified into prefix and suffix. Any single medical term has at least one root determining its meaning and one or more prefixes or suffixes to modify the meaning or part of the meaning. Teachers generally use this specific word formation to help students deal with these words. But, recognizing the word parts used to build medical terms still seems to be a major obstacle to students' learning medical terms. Moreover, using word parts occasionally has pitfalls in guessing word meaning from context. Schmitt (2000) warned when students use word parts as an initial word-guessing strategy, they must be careful to check the surrounding context to see if their guess makes sense. Haynes and Baker (1993) also found that students sometimes made an incorrect guess about what an unknown word meant in a given text and then stuck with that erroneous meaning in other textual contexts even though the surrounding context made clear it made no sense.

Second, medical vocabulary is an open system with a large number of low-frequency words and newly created words. Teaching and learning all the words seem an impossible task. Hence, teaching vocabulary learning strategies for inferring word meanings is more efficient than teaching every vocabulary item encountered. As Nation (1994) suggested, teaching students strategies is especially important when it comes to dealing with low frequency words. Indeed, following Nation, Schmitt (2000) also suggested that high-frequency words should probably be taught, whereas learning low-frequency words will require strategies for determining their meaning.

Could learners use appropriate learning strategies based on the characteristics of medical words, such as guessing from context and using word parts when learning medical words? Chamot and Kupper (1989) indicated that high proficiency language learners know how to use appropriate strategies to reach their learning goals. Oxford (1985) asserted that successful learners use a wide range of strategies which are appropriate for their learning tasks. Do high proficiency students use different strategy patterns from those used by low proficiency students as revealed by the above-mentioned studies? To get more insights on the use of learning strategies of successful students, the strategy patterns used by successful and unsuccessful learners are also the focus of attention in the present study.

Research Questions
The main purpose of this study is to explore the learning of medical terminology by Taiwanese nursing pre-professionals. It focuses on the frequency of strategy use by nursing pre-professionals when learning medical terminology and identifies the strategies related to success or failure in learning such terminology.

In brief, this study attempts to seek answers to the following research questions:
1. Does the use of six categories of medical terminology learning strategies vary across student proficiency levels?
2. What are the strategies used most and least frequently by the learners in the study?
3. Which strategies are used most frequently by the high proficient students?

Literature Review
In order to get more insights on the study of medical word learning strategies, this section will first review two recent studies of L2 vocabulary learning strategies and then studies of individual medical terminology strategies.

Fan (2003) surveyed a sample of 1067 students at seven institutes in Hong Kong to examine the relationship among frequency of use, perceived usefulness, and actual usefulness of L2 vocabulary learning strategies. The findings of Fan's study indicated that the students used the strategies for reviewing and consolidating their knowledge of known words and perceived them as useful, and that they had a preference for dictionary strategies. The most proficient students depended much more on sources, guessing, dictionary, and known words strategies than the less proficient students. Regarding the discrepancies between frequency of use and perceived usefulness in learning L2 vocabulary, the findings revealed the complexity involved in strategy use. For example, even though students reported using more guessing strategies, they did not perceive these strategies as useful. In contrast, though the students seldom used management strategies, they thought these strategies were useful.

Schmitt (1997) conducted a large-scale study in Japan to assess which vocabulary learning strategies the learners actually used and how helpful they believed them to be. Schmitt found that the learners used more repetition and dictionary strategies and considered them more useful than other strategies. Semantic grouping and imagery strategies were less used and regarded the least useful. There was also some evidence that more advanced learners tended to use more complex and meaning-focus strategies than less advanced learners. Whether these findings are supported by the learning of technical terminology in the fields of English for Specific Purposes (ESP) and English for Nursing Purposes (ENP) needs to be further explored in related research. This is exactly what the current study is going to do.

A number of studies have sought to examine the effectiveness of some specific strategies for learning medical terminology (Fang, 1985; Troutt, 1987; Dunkle, 1983). Two studies that are relevant to the current study will be reviewed here.

A study by Fang (1985) investigated the success of two medical terminology learning strategies: (1) the analysis of affixes and roots and (2) finding the relationship between sound and script. The strategy 'to analyze affixes and roots' engages learners to analyze word structures. For example: to learn the medical term 'endocarditis', internal inflammation of the heart, learners must learn to analyze it into endo- (prefix, within), card (root, heart), and -itis (suffix, inflammation). On the other hand, the strategy 'finding the relationship between sound and script' involves attempts to find the relationships between pronunciation and spelling of medical words. Fang's study has provided some initial evidence to suggest that the use of analyzing affixes and roots promotes more medical terminology learning than the method of finding the relationship between sound and script.

Troutt (1987) investigated how method of instruction for college students, keyword versus traditional, was related to acquisition and retention of medical terminology in a classroom setting and in individualized learning. Five intact classes containing a total of 120 college students were taught three lessons of medical terminology by one or more of three methods: traditional, keyword in a classroom and keyword in individualized learning. The results indicated that the class taught using a keyword strategy retained significantly more words than the class taught by a traditional method for initial acquisition of medical terminology. However, there was no significant difference between traditional and keyword methods for long-term range retention of medical words at four and eight weeks. No difference was found in medical word scores between a keyword/classroom method versus a keyword/individualized method for either acquisition or retention. This study provided empirical evidence regarding the effectiveness of keyword methodology for initial acquisition of medical terminology.

Both Fang and Troutt focused on the effectiveness of two strategies. However, two learning strategies alone are not enough for us to get the whole picture of how students learn medical terms more effectively. In order to gain an overall picture of the optimal use of learning strategies for medical terminology learning, a study that deals with all strategy groups would be a complement to Fang's and Troutt's research.

Methodology
Subjects
Two intact second-year classes at one Taiwan nursing college were recruited as the subjects of the study. The two classes were composed of 89 students in total. They were selected because they were available at the time the research was conducted. These subjects were female nursing majors. Medical terminology is a required subject in this five-year nursing college from the second to fifth years, so all participants were taking a Medical Terminology course.

Instrument
The test for evaluating the subjects' proficiency level in the current study was the Medical Terminology mid-term exam made by nursing teachers in the school. This is a curriculum-specific achievement test, rather than a general proficiency test. There were 50 questions in total in the test (see Appendix A). The test included matches, completing the medical words on the basis of their English definitions and filling in the meanings for prefixes, word roots and suffixes.

The instrument employed for collecting data on strategy use is the medical terminology learning strategies questionnaire developed by the researcher (see Appendix B). The categories of learning strategies were based on Schmitt's (1997) taxonomy for studying vocabulary strategies. Subjects were required to answer questions on their strategy use on a five-point Likert scale ranging from 1 ("never or almost never true of me") to 5 ("always or almost always true of me.") The questionnaire was made of two sections. Section one contained five questions, the purpose of which was to collect such background information as subjects' English proficiency and their medical vocabulary learning experience. Section two included 42 items grouped into six categories of medical terminology learning strategies:

I. Discovery strategies
1. Determination strategies for discovering new word meanings by guessing and using reference materials.
2. Social strategies for discovering new word meanings by asking someone who knows.

II. Consolidation strategies
1. Social strategies for learning and practicing vocabulary, such as cooperative group and native speaker interaction.
2. Memory strategies, such as grouping, imagery, rhyming, moving physically, and reviewing in a structured way.
3. Cognitive strategies, such as repetition and using mechanical means to study medical terminology.
4. Metacognitive strategies for controlling and evaluating one's own learning, searching for practice opportunities and planning for learning tasks.

The questionnaire was tested and revised following a pilot study with 48 nursing pre-professionals similar to the participants in the study.

Survey Procedure
All data were collected after the midterm week of the 2003 spring semester. Before commencing with the task, a brief explanation of the purpose of the study was provided. Subjects were advised that responses would not affect academic grades. Subjects were also told that they have to answer in terms of how well the statement of each item describes them. The answered questionnaires were collected right after the subjects completed them.

Data Analysis
Significant variation in mean strategy use in the six strategy categories (the dependent variables) as related to the independent variable (proficiency) was determined using a one-way analysis variance (ANOVA). A standard post hoc test, the Scheffe, was employed to determine where specific significant differences lay. The probability level of significance for one-way ANOVA is set at .05. In order to identify the most and least used strategies, the average mean score for each of the 42 strategies was calculated and rank ordered. After the statistical procedures, the relevant discussion based on the three research questions is presented.

Each subject's responses to the medical terminology test were given scores. A correct answer is assigned 2 points and an incorrect answer is given no points. The total possible points were 100. Based on the test scores, subjects were grouped into three proficiency levels. The high-level group refers to those who score higher than 80, and the low-level group refers to those who score lower than 60. Those who score between 80 and 60 belong to the intermediate-level group. Consequently, 36 subjects were defined as high-level learners (mean is 85.39, SD is 3.75), 28 intermediate-level ones (69.64, 5.31) and 25 low-level ones (42.32, 10.42).

A summary of the ANOVA results for the six categories is shown in Table 1. According to Table 1, proficiency level had a positive significant effect for the determination, memory, cognitive and metacognitive categories (all representing positive variation, i.e., more use by more successful students). With the determination and metacognitive strategy groups, the post hoc Scheffe test indicated low-level students (means were 2.64 and 2.12) used these strategies significantly less often than intermediate (means were 2.82 and 2.15) and high-level students (means were 3.11 and 2.87) did, but there were no significant differences in levels of use at the intermediate and high levels. With the memory group, the Scheffe test revealed significantly greater strategy use by the high-level students (mean 2.98) than by the intermediate and low groups (means were 2.54 and 2.32 respectively). With the cognitive group, high-level students (mean 3.22) used strategies significantly more frequently than both the intermediate (mean 2.95) and low students (mean 2.65) did.

Table 2 lists the most and least preferred strategies for all subjects. Results reveal that item 29 (mean was 4.34, written repetition) has the highest average frequency, and next is item 28 (4.02, verbal repetition), followed by item 5 (3.84, use bilingual dictionary), item 33 (3.76, vocabulary section in the textbook) and item 32 (3.76, take notes in class). The least preferred strategies are item 9 (1.19, ask teacher for a new sentence including the new medical word), and next is item 34 (1.31, listen to tape of word lists), followed by item 11 (1.36, discover new meaning through group activity), item 35 (1.43, put medical words on physical objects), item 8 (1.52, ask teacher for synonym of new medical word).

Table 3 indicates that the most preferred strategies for high-level learners are item 33 (4.53, vocabulary section in the textbook), item 32 (4.42, take notes in class), item 5 (4.25, use bilingual dictionary), item 28 (4.19, verbal repetition), and item 29 (4.07, written repetition). The least preferred strategies are item 13 (1.17, interact with foreign medical staff), item 9 (1.17, ask teacher for a sentence including the new medical word), item 11 (1.28, discover new meaning through group activity), item 34 (1.31, listen to tape or word lists), and item 35 (1.36, put medical words on physical objects).

The most preferred strategy for low-level learners are, as shown in Table 4, item 29 (4.04, written repetition), item 28 (3.76, verbal repetition), item 10 (3.60, ask classmates for meaning), item 4 (3.28, guess from textual context), and item 5 (3.28, use bilingual dictionary). The least preferred strategies are item 13 (1.12, interact with foreign medical staff), item 9 (1.16, ask teacher for a sentence including the new medical word), item 34 (1.40, listen to tape of word lists), item 20 (1.52, use new words in sentences), item 35 (1.52, put medical words on physical objects).

Discussion
In the present study, the statistical analysis indicates there are major differences in patterns of strategy use among students of different proficiency levels. High-level learners are better at gaining knowledge of a new word; they remember more effectively; and they control and evaluate their own vocabulary learning better than low-level learners. However, neither the high-level learners nor the low-level learners employ social strategies to discover new meanings and learn vocabulary. These social strategies involve asking for clarification or verification, cooperating with peers, and interacting with native speakers of the target language. Since a teacher-centered approach is employed by most Taiwanese teachers, students rarely have chances to discuss and cooperate with peers. Moreover, owing to the highly competitive high school and college entrance exams in Taiwan, classmates are usually regarded as competitors rather than cooperators. Teachers prefer to assess students' performance on the basis of individual work instead of teamwork. Hence, students are rarely asked to cooperate with classmates to work on assignments or learning tasks.

In answering research question two, we looked at the strategies used most and least frequently by nursing pre-professionals. It was found that nursing pre-professionals prefer to use written repetition, verbal repetition and bilingual dictionaries. This finding is consistent with Schmitt's (1997), which showed that repetition of a word's verbal or written form was used frequently in Japan. This can be attributable to the learning style encouraged by the Asian school system. Asian students are commonly required to memorize vocabulary and grammar through repetition. Compared to Japanese, Chinese are more likely to use modeling and repetition as a means of studying particular skills (Nelson, 1995). The practice of memorization is usually applied in the Chinese classroom so as to help students develop particular language skills through modeling and repetition (Sheridan, 1981). The practice of memorization is also linked to the Confucian tradition of reverence for authority. Thus, the strong preference for the bilingual dictionary can, at least partially, be attributable to Confucian tradition of reverence for authority as well. When students encounter questions or difficulties, they would check the dictionary to find the answer instead of resorting to the authority, represented by their teachers.

Not surprisingly, 'interact with foreign medical staff' is relatively unused by nursing pre-professionals. It might be attributed to two factors. First, it is probably that they can't understand foreign medical staff's fast speech and accents. Nursing pre-professionals would rather keep away from native speakers in order not to embarrass themselves or cause any communication breakdown during the flow of a conversation (Clyne, 1979). Second, according to Yang and Su (2003), being afraid of people's laughing at their poor pronunciation, vocabulary and grammar is one of the nursing pre-professional's major learning problems when speaking English. This psychological problem may make nursing pre-professionals unwilling to interact with foreign medical staff.

The lack of use of item 9 (ask teacher for a sentence including the new medical word) by the subjects has also been influenced by their education and cultural backgrounds. As stated previously, in the Chinese-learning context, Chinese students are expected to, not interrupt, sit quietly and listen attentively. As a result, they are reluctant to speak in the classroom even when invited to make comments or ask questions. Thus, when encountering a new word, they would listen attentively rather than ask for synonyms and contextual sentences. Many students believe that if they ask questions in class, there is a high risk of resembling a fool (Cortazzi & Jin, 1999). Some would reflect carefully before participating, in order to be sure their point is valid and useful (Scarcella, 1990). Others would rather ask after class in order to minimize the loss of face if the questions seem foolish-their class will not hear them if they ask alone (Cortazzi & Jin, 1999).

In light of the findings of Yang and Su's study (2003), the main difficulty that nursing pre-professionals encountered in speaking is their poor pronunciation. Nonetheless, to the knowledge of the researcher, none of the textbooks used in Medical Terminology courses in my school include an audiotape on which word lists are recorded to improve pronunciation and aural understanding of the words. Even though nursing pre-professionals have problems pronouncing these medical words, they are not able to find any single tape useful for solving their problems. Obviously, this could explain why item 34 (listen to tape of word lists) is one of the least used strategies by all nursing pre-professionals.
Since the advantages of group work for language learning are not widely recognized, teacher-fronted classrooms are common. Some teachers are afraid of group work (Brown, 2001). They feel that they will lose control of the class; they can not monitor all groups at once and students' errors will be reinforced in small groups (Brown, 2001). Naturally, for teachers who prefer a teacher-centered approach, learning medical words is treated as an activity best achieved individually. The low usage of item 11 (discover new meaning through group work activity) could be attributed to this.

When the most used strategies by high-level and low-level learners are closely checked, it is found that first, the difference in medical vocabulary proficiency between high-level learners and low-level learners seems to be related to the quantities of learning strategies they employ; second, low-level learners generally employ written repetition and verbal repetition and use a narrow range of learning strategies. In contrast, the high-level learners did not totally employ memorization, and reported using more cognitive-oriented strategies, such as using the vocabulary section in the textbook and taking notes in class, rather than rote strategies in learning medical vocabulary. This finding lends support to the findings of the research performed by Oxford (1985) and Chamot & Kupper (1989), which showed that high proficiency learners used a wide range of strategies that were most appropriate for their learning tasks and learning goals, while low proficiency learners were less expert in their strategy use and choice.

Conclusion
This study sought to provide valuable information concerning the strategy use of Taiwanese nursing pre-professionals when learning medical terminology and to explore what kind of relationship exists between strategy use and proficiency in medical terminology. Like previous research, we found significant differences by proficient level in students' use of four strategy categories: determination, memory, cognitive and metacognitive. However, neither the high-level nor the low-level learners were good at employing social strategies to discover new meanings. In line with popular beliefs about Asian learners, findings of the study revealed that nursing-pre-professionals in general preferred to use written repetition and verbal repetition. In contrast, asking the teacher for a new sentence including the new medical word, listening to a tape of word lists, and discovering new meanings through group work activity were the strategies least used by learners. In addition, successful learners used a wider range of strategies than unsuccessful learners.

Pedagogical Implications
According to the results of the study, high-level learners appeared to use learning strategies more frequently than low-level learners. Investigating Chinese EFL learners' learning strategies for oral communication, Huang & Van Naerssen (1985) also found that successful learners were more willing to take risks to employ and practice different strategies than less successful learners were. Learning strategies can be taught as found by some studies (Cohen & Aphek, 1980; O'Malley, Chamot, Stewner-Manzanaraes, Russo, & Kupper, 1985). Here are some tips that teachers have to know when trying to teach learning strategies. First, awareness of strategy use should be raised. To help students cultivate their awareness of language learning strategies, teachers may introduce them to the wide range of alternative strategies, help students understand their current strategies, and assist them to find out the circumstances under which a given strategy can be applied effectively.

Second, Schmitt's (1997) findings suggest that learners naturally mature into using different strategies at different times of their life, so it seems reasonable to introduce a variety of strategies and let them decide which ones are right for them. Ellis (1994) stated the beneficial effect of strategies may be relative to the kinds of tasks that strategies are deployed in. Effective strategy use may consist of the flexible deployment of the right strategies in the right task. Third, therefore, teachers may introduce the learning strategies and demonstrate how to take appropriate strategies to meet students' needs in different learning tasks. For example, medical words are mainly composed of roots and affixes. Fang's (1985) study has revealed that analyzing prefixes, roots and suffixes is an effective strategy for learning medical vocabulary in the short term. Teachers may help learners develop this strategy when teaching medical terminology. Finally, these learning strategies should be practiced in different learning tasks. Only through numerous practices will students become more familiar with these learning strategies.

Limitations and Future Research Directions
The limitations of the present study are essentially about the recruitment of subjects. First, all the subjects come from the same nursing college. The findings would be more useful if we recruited more students from different nursing colleges in Taiwan. We need to know the extent to which the specific patterns of strategy use would occur in other nursing colleges. Second, also worthy of further investigation is the relationship of year of learning to the choice of individual strategies and combinations of strategies. Owing to the unique semester system of the school where the research was conducted, nursing pre-professionals of different year levels were not available at the time the research was conducted. To get a whole picture of the trends of nursing pre-professionals' strategy use, nursing pre-professionals in different years of study should be included in future studies

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