Designing an online work-related language skill for nursing students: a developmental research

Technology brings opportunities to extend the learning environment outside the classroom. An online course can be an extracurricular activity which allows the students to learn English for their career preparation. This article reports a developmental research for designing an online learning module for nursing students to pursue their career abroad. One English teacher and 40 nursing students from a private university participated in this research. Interview, validation checklist, questionnaire and observation were employed to collect the data regarding the students’ need, usability, and the implementation of the product during the field try out. Two experts were also invited to evaluate the quality of the product’s content and instructional technology. The result of this developmental study is an online course and a workbook to accompany the students learning. The findings reveal that online learning has an opportunity to help students to shape their work-related language skills at home. The students’ engagement in learning is considered high and they also become more autonomous in learning. Technological readiness and internet connection become the main challenges for the online course implementation. To deal with those challenges, some recommendations are offered.


INTRODUCTION
In the globalization era, learning English for Specific Purposes (ESP) in the field of nursing become important. Developing English language skills for nursing is to communicate and give full care to patients from different nationalities (Moradimokhles & Hwang, 2020). However, teaching English for nursing has many challenges, especially for countries that English is a foreign language. Kailani & Murtiningsih (2019) stated that from the teacher's side, the challenge of English teachers in Indonesia is the limited time to prepare the interactive lesson. While for the nursing students' challenges to learn English are their low language proficiency, and their low learning motivation to do the entire stages of the simulation.
The advancement of technology devices and internet connection makes online learning become commonly used in educational settings nowadays. Especially during the COVID-19 pandemic, online learning becomes more urgent and mandatory. The use of online learning is to facilitate the needs of nursing students to learn at their own pace and time, so they can construct their own understanding related to the certain subjects as active learners (Lindeiner-Stráský et al., 2020). Furthermore, in order to ensure the success of online learning, it needs the readiness of learners and teachers, especially for better internet connection and digital competency (Adedoyin & Soykan, 2020). In addition, many studies (see Lindeiner-Stráský et al., 2020;See Moradimokhles & Hwang, 2020;Rafidiyah et al., 2019) show that educational institutions have explored ways to make the students who joined online learning feel safe, encourage, motivated, and engaged with their teachers and peers.
This research based on several studies related to online learning, flipped classroom or blended learning in the field of teaching language. The concept of online learning through flipped learning was delivered by Lindeiner-Stráský et al. (2020). The study was about teaching Germany for beginners in Open University UK. Two-hundreds and eighty-three students were joined in a blended format, so they can join either online or face-to-face tutorials. The results show that the teachers must consider students' initiative and engagement to learn the language. The preparation of online learning needs lots of effort to ensure collaboration with other teachers in form of ideas and resources. Relevant topics to the learners have a significant contribution to the success of language learners. Using flipped principals in an online learning courses can encourage active learning.
In the field of teaching English, the study examining the effect of online and blended learning using an experimental study for sixty nurses in Asadabad Nursing Faculty, Iran was conducted (Moradimokhles & Hwang, 2020). The respondents were divided into three groups randomly. The control group was using face-to-face through the communicative approach. The online group was using the Learning Management System model, while the blended learning using the blended learning instructional model. There were pre-test and posttest for standard general English (TOEFL). The result of the study shows that blended learning has a positive impact on learning English skills. Online learning still can contribute positively if the learners got adequate and accurate feedbacks. The most important thing is the teachers who are going to use the online setting must have prior training to ensure that they can use online learning effectively.
Another research was done by Rafidiyah, Yansyah, & Nadia (2019) using research and development adapting Borg & Gall model. This study is to develop skill-based materials for Nursing Diploma Program to work abroad. There were fifteen nursing students in one of the private universities in Indonesia involved and the results are six units related to skilled-based materials that the students need. The course was designed for face-to-face classes, therefore, in the situation nowadays especially after the strike of the COVID-19 pandemic we need to focus on developing online courses. Thus, adequate planning and design instructions must be designed and developed to ensure the effectiveness of the online courses particularly in the field of work-related language skills for nursing. This study is focused on preparing nursing students for their future job interviews. These are important issues that can be used as motivations for nursing students to master English autonomously.
This study is expected to be able to contribute theoretically and practically to ESP materials development.
The presence of COVID-19 pandemic helps us to realize the importance of migrating our lesson into online mode. Furthermore using technology or online platform is considered new (Walters et al., 2015), so we need to prepared both teachers and students to be ready with any possibilities in the future. In addition, preparing nursing profession to work across countries and cultures is relevant with the situation lately in the new normal era. Therefore, this study is essential not only for Indonesian nurses to work abroad, also for other nurses from different countries to understand more about working in international settings. The benefit of preparing nurses using online platform may help the nurses around the world to prepare themselves for their future jobs.
As the advancement of technology has evolved rapidly, now, this situation also affects our current learning format. The traditional face to face meeting has been replaced by an online classroom interaction. Even, people has blended between live online meeting and asynchronous classroom. Both of the modes have been deployed in order to reach a better learning achievement. This mode has been so called blended classroom. Without an exception, in nursing discipline there have been massive use of these modes as a current trend of teaching delivery methods (Jones et al., 2020). This is aimed to give an equal chance to every learner in order to get the same learning experiences. In this way, learners are able to access the learning materials 24 hours 7 days, anywhere and anytime. More importantly, they can save much more time than a time allocation for a traditional meeting with their lecturers (Coopasami et al., 2017).
Comparatively speaking, the design and development of learning content of nursing education is not far different from that of traditional one. Several crucial things need to be taken into account, for instance, the learning content that may stimulate learners to be more active and engaged during online classroom interaction (Walters et al., 2015). Furthermore, blended learning has been proven to give a significant impact on students' learning outcomes. Especially, blended learning that has been adopted in nursing English classes. Moradimokhles and Hwang (2020) found that students' learning outcome increased after they experienced blended learning. Students had plenty of time to navigate learning materials online after class.
Good communication patterns and interaction between the client and the nurse are needed when they are in a hospital or a clinic. English mastery is another supporting skill to achieve the expected nursing service. Possessing a good command of English may prevent nurses from miscommunication and misunderstanding in a clinical interaction. Thus, a good command of English is a-must have skill for a nurse (Allan et al., 2009). Within an online classroom context, the design and development of learning content is really important, particularly, in a nursing class. This would be another plus for nurse students who are willing to work overseas or work in a multinational hospital.

Participants
This study is based on design-based research (DBR) to ensure how online learning using Canvas can work in the English classroom for nursing students. The research was done in one of the private universities in South Kalimantan Province that have an undergraduate nursing study program. The reason to choose this institution is that they have the focus on preparing their students to be ready to work abroad as nurses. They do not have a special program to teach work-related preparation. Therefore, for the sake of this research, we focus only on the preparation of job interviews in English. Actually, we planned to do blended learning. We would have face-to-face classes and also online learning through Canvas. However, the outbreak of COVID-19 pandemic, since March 2020, forced usto switch every meeting to be online. For testing the prototype, we asked the help of forty students in their fifth semester. Hopefully, by joining the project, they could get the benefit of the material and at the same time. We explained that they could motivate and prepared themselves to apply for nursing jobs abroad. Based on the interview with the English teacher, the English level of the students is intermediate. They had intensive English classes for one year (course) and an English subject in their curriculum.

Procedure
The present study adopted DBR model from Schmitz, Klemke, Walhout, & Specht (2015). Drawing from that model, there are four steps in designing work-related online learning for the candidate of nurses.
1. Identify and analyze problems by interviewing the nursing teacher and English teachers related to their expectations for the nursing students after they finish their studies. 2. Develop the prototype of online learning using Canvas based on theories, existing design principles and technology innovation. 3. Use it in the real nursing classroom for a one-month trial 4. Reflection to produce online learning design and how to implement it in practice. First, prior to the identification and analysis of the problem, the researchers asked for permission to conduct a study in that institution. It took several months to explain the aims of this research and how to do it. We also had to wait for the fifthsemester nursing students to get the schedule from their tight schedule of classes and clinical practice. Meanwhile, we used the time to conduct several interviews and discussions with the nursing teacher and the English teacher about their expectations for the nursing students, the teaching and learning conditions, the goals of learning English, the students' ability, and their agreement to involve in the study.
Then, the second step, we developed the prototype of online learning using Canvas to teach job interviews in English for nurses. We added up some topics, such as the reason to work abroad, job interview preparation, describing skills, strengths and weaknesses, research to make job applications, and common questions for job interview of nursing position based on the discussion with the teachers and the result of need analysis questionnaire. The design of materials, videos, and assessment also was made to complete to online learning module for work-related material for the nursing candidates.
After that, we tried in the nursing class. The first meeting was through Zoom Meeting so we could explain about the research and how they could use Canvas. After that, the students enrolled themselves to the Canvas class to access the materials. The Canvas class contained the materials, quizzes, and tasks. We also provided a WhatsApp Group for sharing in case they had any technical or material problems. This try out ran for one and half month. The duration of the course was considered shorter than what we expected. However, the institution only allowed us to conduct the study during that period since the students would have other classes to take. Therefore, we decided to try out only one of six chapters in the e-learning module. Job interview was selected based on the teacher's recommendation and the students' choice.
For the reflection, we conducted with the teacher by having an interview. We asked about what she had learnt and reflected during the implementation of the online course. She was requested to tell what happened in the class and how to solve any problems occurred. Regarding the students' opinion, we shared a questionnaire by using Google Form. We also interviewed five students to enrich the reflection of the online learning practices.

Data Collection and Analysis
The present study employed four main instruments: interview, validation checklist, questionnaire, and observation. The interview was conducted with the head of nursing department and the English teacher. It aimed to revealed the data regarding the curriculum, the students' ability, the teacher's and student's necessity for learning work-related language skills, as well as their readiness to join the online course. This instrument was also used to collect the data related the teacher's reflection. She was asked about what she learnt, the challenges she dealt with, and the opportunities she observed during the implementation of the online course. It was in form of a semi-structure interview. In the interview, the conversation was recorded to make the transcription easier. The participants were informed about the recording process before the interview was started.
The validation checklist was developed so the experts could give their rating for the online course designed in this study. The rating ranged by using Likert-Scale from one to five. One meant the expert agreed with the statements listed in the checklist and five means she/he strongly agreed. Two experts were invited in this study. The first expert had expertise in English for Nursing and the second one was in the E-Learning design. Their expertise was considered based on their experiences and education background. The validation checklist for the first expert contained 15 statements belong to some aspects, including content, language, context, and attractiveness of the materials. For the second expert, it listed 16 statements belong to these variables: functions, accessibility, technical problems, registration, copyright, social and pedagogical aspects.
The questionnaire was adapted from the previous study . The present study was same in the term of skills investigated, but it was different in terms of the students' level and the mode of learning. It was intended to gather the data about the students' responses toward the online course. It focused on asking students' satisfaction for joining the program. Using a Google Form, the questionnaire was distributed online after the course finished. To get additional data related to the students' responses in the class and what happened during the implementation, observation was conducted during the try out stage. The researchers joined the online classes and took some field notes.
A mixed method was used to analyze the data obtained from this study. The quantitative approach was used to analyze the data from expert validation and questionnaire. While for the data from observation, the interviews, and reflections of nursing teacher, English teacher, and students were scripted, coded, and categorized with thematic analysis.

The Result of Need Assessment
Needs assessment was conducted by interviewing the head of nursing department and the teacher. Based on the interview with the head of nursing department, it was concluded that they have included English into their curriculum, but it was not specifically designed to meet their work-related needs. It was focused on general English and English for specific purposes. This finding was in line with the researchers' previous research Yansyah et al., 2019) that nursing departments were actually aware with the importance of English for their students. However, English materials related to their career preparation were not programmed in their curriculum. Therefore, after we showed and explained our previous research product to the head of nursing program, she agreed to implement this online research project.
Next, the teacher reported that the students had got English lesson before joining this research. In that university, English was taught from the first semester so the student had learnt English for five semesters. Based on her experience on teaching English to the students, she claimed that most of the students could be categorized having intermediate level. The students had taken English for general purposes and English for nursing courses so they already had sufficient ability to join the present research project. In addition, based on the result of questionnaire handed to the students, they were interested to learn topics offered in this online course. The topics offered are 1) introduction to advanced English, 2) Scientific writing, 3) Presentation, 4) Working Abroad, 5) Job Interview, and 6) Studying Abroad. These six topics were developed based on the previous research finding . Some adaptations were made to meet the level of the students (undergraduate degree) because the previous research product was designed for diploma degree. These findings supports the idea that English for specific purposes is always specific (Bielousova, 2017). It frequently requires adjustment so the materials developed suit the students' need.

The Development of the Online Materials
As it was discussed above, the development of the present research materials was adapted from the previous research product. Therefore, the main difference from the present and the previous research are on these two aspects: 1) the targeted level of the students and 2) the platform used to deliver the materials and instruction. First, the targeted students in the present research were undergraduate degree so some materials were adjusted to this level. Writing cover letter lesson, for instance, were changed so the examples included in that chapter suitable for the students. Meanwhile, the content and the distribution of each skill was still followed the previous research. See Figure 1 for the distribution of skill taught in the module. Second, the platform used was Canvas (https://canvas.instructure.com).
Canvas is considered for its user-friendly materials. The features allow teacher and students to access materials, to have discussion, to assignment, to collaborate in group, and to track their progress through the gradebook. The users only need to create account by setting their username and password to have access to the course. All these advantages make Canvas became the choice when deciding the platform for the online learning. The picture of the online course is displayed in Figure 2. Besides the online class, English for Nursing Career course is also equipped with a workbook. The workbook is intended to help students measure their understanding toward the materials in the online course as well as to guide their study. The workbook is designed to accompany the six online modules. In the online modules, for example, they will watch a video and, in the workbook, they can answer some questions related to the video. By doing this activity, the students can control their selfstudy. Therefore, the role of teacher in this course is as a facilitator to help the students to achieve the learning outcome set in the online course.

Try Out of the Product
Before trying out the product, it was validated by two experts to make sure the quality of its content and instructional technology. The content was evaluated by one expert in English for Nursing. She examined five areas, such as elearning content, workbook content, vocabulary and grammar, attractiveness of the product, and learning context. She gave a very satisfying rating, with average 4.4 out of 5. It means the materials are well designed so it can be used for teaching English in the nursing context. However, she also recommended to give more videos instead of text in the online learning. She argued that audio visual media might help the students better than only reading the text. Her recommendation is in line with Jung et. Al., (2019) that video can be an effective media for delivering content and message in learning. The second expert is a lecturer in an information technology department. He evaluated five aspects, including function, accessibility, technical issues, copy right and students' privacy, and pedagogical and social dimensions. He gave rating 4.3 out of 5, which means the instructional technology used was sufficient and can be used for online learning. He only reminded that since it was the first time for the students to use that application for learning, they should be informed for all features of the e-learning and given a guide how to deal with some possible technical issues.
All feedbacks from the experts were accepted and used for the revision of the workbook and the e-learning tool before it was ready for next stage. Next, the product was tried out for one and half month. When this project was implemented, it was out of the nursing department curriculum so it was assumed as an extracurricular activity for the students. For this time constraint, we only could try out one module for the students. Job Interview Module was selected for this purpose. After discussing with the teacher, we decided the spent six meetings for this module. The schedule of each meeting is provided in Table 1. Job interview practice Zoom The first meeting was through Zoom because we needed to introduce the course and Canvas to the students. In that meeting, the students were informed the purpose of the course, the benefits for joining it, and what the students should do to complete the course. During the implementation, a WhatsApp group was also created to make communication between the researchers, the teacher, and the students easier. They were allowed to ask questions about the course and the technical problem encountered during the course. This kind of treatment is important in an online course. Since the teacher and the students cannot see each other so the teacher quick response to the students' problem is necessary. Lindeiner-Stráský et al. (2020) found that students' engagement in an online learning is one of the factors contributing to the success of an e-learning implementation.

Reflection
During the try out stage, the students were trained to improve their job interview skills, such as describing their own skills, strengths, and weaknesses, finding a job online, drafting interview responses, and doing a job interview practice. After each meeting, the students were required to complete a quiz or to do a task to measure their progress. The assessment during this project implementation was not intended to judge their ability since the students joined the class voluntarily. It was merely for tracking their progress and measuring their own understanding towards the materials given in the online learning. Therefore, when doing the quiz, the students could retake it many times until they got the highest score. When doing a task, for example writing an interview draft, they were encouraged to submit it even if it was just a makeshift or a lowquality draft. Sometimes, some students submitted a draft which was written in Bahasa Indonesia and English because they were not sure the correct English for those words or sentences. Then, it became the teacher's task to give feedback to improve their work.
This kind of practice helped students to be more engaged during the training as well as to be more autonomous in learning. Based on the observation on the students' engagement through their participation in doing the tasks, 60% of the students were actively completed the tasks and got more than 70 out of 100 points. That percentage is considered high since dropout rates for online learning or training sometimes can reach 53% (Ginting, 2018). Daniel added that a low dropout rate of an online program showed that the program was well managed. One of factors contributing to the dropout rates is the workload of the online course and the students' willingness to learn. Therefore, the materials and tasks for online course should be carefully designed. Besides, teachers' feedback does matters to help students deal with the difficulty of the tasks. Regarding the students' autonomous, it was observed based on their willingness to retake the quiz and revising their drafts. Many of the students (60%) got more than 70% out of 100% for the quiz. During the interview, some of them said that they could take the quiz up to three times until they got that score. They learnt from their mistakes and sometimes read again the materials to earn that score. When writing the interview responses draft, the also learnt how to make good responses by learning from the teacher's feedback. According to Lengkanawati(2017), autonomous learning should be considered in designing a course because it will offer a better learning outcome. It can be integrated into the learning activities which requires the students to be more active and responsible for their own learning.
Regarding the improvement of students' language ability, based on the result of job interview test, it was shown that 60% of the participants could pass this interview practice. The average score got by the students was 70.76. This score was considered good since it was their first interview practice. This quantitative data supports that the product of the research could be implemented to elevate the students' work-related language skills. The students admitted that it was their first time to join a training related to a work preparation. The course was conducted for one and half month and they had confirmed that they did not take other English courses during the training. Therefore, it is justified that their ability is not interfered by other factors, such as previous or other English courses. However, it should be admitted too that this kind of score measurement is not like in the experimental study which was carefully designed to inform the effectiveness of the materials. The test was only intended to check the students' language ability progress, regarding the skills taught, in the end of the program. The students' score is described in Table 2. Next, the students' responses toward the implementation of this course were recorded in the questionnaire. Figure 3 shows the students' satisfaction for joining the program. FIGURE 3 | The students' satisfaction for joining the program Figure 3 points out that most of the students (41.2% & 52.9%) agreed and strongly agreed that the program helped them to improve their skills. Nana, one of the respondents, expected that this kind of program will be held again in the future since she needs it to prepare her career plan. Sarmila also expressed her opinion for the benefits of this program in the following excerpt.
"This program is like an eye-opening for me. I never imagined that I will have my career abroad because I don't know how to get the information and what I need to do to get that chance. In this course, we are taught about the reasons to get this opportunity. Then, we are equipped with the English skill for making ourselves ready." Sarmila's opinion shows that the program promotes a new knowledge for her. It makes her aware that she has opportunity to pursue her career out of her country. In addition, the eye-opening term she used in that interview shows that language course focusing on career preparation are not well embraced in the nursing curriculum. This finding supports the previous research  that English for nursing career preparation should be given a space in the curriculum so it will broaden the opportunity for the nursing students work abroad.

Challenges and Opportunities during the Online Course Implementation
Regarding the online learning, the result of questionnaire reveals that most of students agreed and strongly agreed that the online course ran well and had been implemented as it was scheduled. Figure 3 presents the students' opinion about how the course was run.

FIGURE 4 | Students' Opinion on the implementation of elearning
According to the participants, Canvas was quite easy to use because the interface was user-friendly as well as simple. Most of them were new to learning management system, like Canvas. Coopasami et al., (2017) explains that it is important to ensure the students' readiness to make an online learning run smoothly. One of the readinesses is the students' technological readiness. It is related to the students' appropriate technological skills to access the e-learning. To deal with this issue, in the beginning of the try out, we already spent one meeting to introduce all the features of Canvas, how to use it, and tips to cope up with some technical problems which may occur. However, based on the result of interview and observation, we found one student could have more than one Canvas accounts because they got difficulty to re-login after logging out. Thus, the WhatsApp group was useful to help students to overcome such problem. Active interaction between the teacher and the students outside the online learning is still necessary in the e-learning environment so the students do not feel like they are left alone to complete the course. The teacher's support to keep the students engage during the course is considered important to make them active. In the end of the course, 60% of the students completed the course with the average 80% for their online participation.
The present research findings showcase that online learning has a good opportunity to support learning English outside the classroom. When this research was carried out, the outbreak of COVID-19 was an unpredictable situation that we need to face. It requires us to make the course become full online. An online course has benefits such as flexibility, interactivity, and selffacing (Adedoyin & Soykan, 2020). The latter advantage allows students to take the course and achieve the learning outcomes based on their preference. They can access it in their free time. This opportunity, of course, can be a solution if when wants to make a work-related language course out of the main curriculum. The institution can make it as an additional course or enrichment for the students who are interested in pursuing their career abroad.
However, this course also has some challenges for its implementation. The main problem stated by the students in the questionnaire was the internet connection. Since most of the students were at home during the COVID-19 pandemic, many of them lived in a remote area. Aris, for example, said that he frequently got trouble to submit the assignment or to watch the video due to the bad internet connection. Anik also stated that she could not join the interview practice because at that time she could not connect to the Zoom. This kind of problem can lower the students' motivation to participate in the e-learning. Therefore, another alternative for a low-internet connection app, such as accompanying with a Google Classroom or a WhatsApp group, should be considered to solve the problem.

CONCLUSION
The present research found that an extracurricular online course can be an alternative to support nursing students in pursuing their career abroad. Online course offers flexibility and self-facing learning, which can be accessed in the students' free time. It can develop the students' autonomous learning as well as provide a good solution for both remote and emergency learning, like what we have during the COVID-19 outbreak. The online learning brings opportunities for the institution to provide an extracurricular program, out of the main curriculum. This program is useful since most of the participants in the present research got advantages for the improvement of their work-related language skills. However, since online learning required technological readiness and good internet connection, it becomes a challenge for both institution and teacher to implement a full online course in the Indonesian context. A WhatsApp group or other lowinternet connection apps are recommended to accompany the e-learning tool so students can report their technical problem. The teacher role as an active facilitator is considered important because in the online learning environment, the students should not feel like they are in isolation. The social dimension should be presented by giving immediate feedback and responses to the students' problem during the course. This kind of treatment can help to maintain the students' engagement and participation during the course.