English in the nursing degree: a pending subject

Objective: The new competence profile of nursing professionals, scientific and medical development, the free circulation of health professionals worldwide, and the increasing social and cultural diversity requires that nurses have specific abilities in spoken and written English. The objective of this research is to describe the characteristics of the English language training required for a Bachelors of Nursing in Spain. Method: A descriptive cross-sectional observational study has been performed in forty-six Spanish universities that offer the Bachelor in nursing degree. Results: In line with the directives of the European Higher Education Area, all universities contemplate the mandatory credit of a second language emphasizing English, although there is considerable variability in the emphasis: 39.4% do not include any English subject, and of the remaining 60.6% who do include it, 60% considered it an elective subject, 32.5% basic education, and 7.5% mandatory. Conclusions: The English training has different characteristics in each university, which implies a different commitment from each center for this learning. This fact questions the adequacy of the education in relation to the new competence profile required by the European Higher Education Area, which may adversely affect future professional development.


Introduction
In the current reality, an unprecedented worldwide transformation is occurring in higher education. As reflected in the World Declaration on Higher Education in the XXI century by UNESCO (1) , higher education and research are fundamental to the development of individuals, communities, and nations, which are the engine of the global knowledge society.
Thus the Convergence Process among National Higher Education Systems of European Universities arises, whose primary goal is the creation of a single European Higher Education Area (EHEA). The purpose of this ambitious project is to increase the mobility and employment of graduates, ensuring international competitiveness and the quality of higher education.

Within this process of change the Tunning Project for
Latin America (2) has been designed in order to define the academic and professional profiles based on abilities and to achieve higher educational convergence in this environment.
In the European context, numerous initiatives have been developed to promote learning of a common language to facilitate the exchange of students and professionals. Among them, the Common European Framework of Reference for learning, teaching, and evaluation of languages, which is part of the language policy of the General Council of Europe, promotes an intensification of learning and the teaching of languages to facilitate greater mobility, more effective international communication, increased access to information, and improved industrial relations (3) .

Spain: English language education
The National Agency for Quality Assessment and Accreditation (ANECA) developed in 2005 the basis for the formation process of the nursing degree in the White Paper of the Nursing Degree (el Libro Blanco del Grado en Enfermería) (4) , redefining job profiles and abilities (5)(6) .
The list of the most relevant abilities related to the learning of a second language is described in Figure 1.
Source: White Paper of Nursing Degree (4)

Code
General Competencies

CG7
Knowledge of a second language CG11 Information Management Skills (to search and to analyze)

CG22
Appreciation of diversity and multiculturalism

CG23
Ability to work in an international context

CE 11
Capacity to enforce clinical judgments to ensure that quality standards are achieved and the practice is based on evidence

CE 23
Relevant knowledge and ability to implement national and international policy In parallel, the new regulation of college graduate studies introduced access to Master and Doctoral programs in the Spanish university system, opening a complete educational development for nursing, which also emphasizes English training and mobility within the European Area (7)(8) . There are numerous studies that highlight the need to encourage training in English in both the clinical and teaching fields, as well as in the undergraduate and postgraduate researcher (9)(10)(11) .
Curricular strategies should be oriented towards including specific assignments that include clinicalcare application and that deepen the approach in the scientific and research field, with reference to the new competence profile and with the aim of optimizing the teaching-learning process (12) .

Competence Profile of Nursing Professionals
Among the objectives of the nursing studies within the higher education framework, reform is intended to respond to the current complexity of the health services reality (13) . The heterogeneity in nursing education in Latin America, as reported by several authors (13)(14)(15)(16) also reflects the need to unify criteria, especially those related to research and the use of scientific evidence.
In this sense, and because of the common linguistic characteristics between Latin America and Spain, it is imperative to establish English language transmission mechanisms to enhance the full development of the nursing discipline.

New horizons in the academic and scientific-research field
In the scientific and academic fields, English is the common language and the implementation of English is essential for analyzing the most relevant results in research, and therefore, the incorporation of scientific evidence into practice. The International Council of Nurses (ICN) argues that the general care nurse must possess skills related to the design and evaluation of programs and research projects (17) .
Among the most notable difficulties for the full development of nursing research includes, among others, limitations in the use of the English language, essential for searching international databases and for the international dissemination of research, given that the scientific journals with the greatest impact are published in this language (8)(9)(18)(19) . The new competencies related with research highlight the urgent need to base nursing practice on the results of scientific evidence and as key to its achievement, English proficiency (20) .

Socio-demographic and cultural changes
The growing cultural diversity within our society requires that health care services and its professionals have the ability to respond to a very diverse population with significant language barriers, which make it difficult

International mobility
The importance of international mobility, one of the cornerstones of the EHEA, aims to promote the free movement of students and professionals from different fields. This international mobility in the field of nursing materializes from two perspectives: on one hand, the exchange of teachers and students through mobility programs and research visits, and on the other, the mobility of already skilled professionals who contemplate international projections as a new labor perspective, where English language proficiency plays a fundamental role (23) .
These exchanges are for learning or perfecting a second language and to promote projects of cooperation and exchanges of experience in teaching and research.
This reality, coupled with the restructuring of health systems in many countries, is causing a massive demand for healthcare professionals, which translates into new opportunities in the labor market.

Objectives
To describe English language training within the new study plans (SP) of the Bachelor of Nursing in Spain.
To determine its characteristics in relation to the number of courses, number of credits, structure, methodology, objectives, content, skills and assessment systems.
To assess the adequacy of English training according to the guidelines set by the EHEA.

Data Analysis
Given the nature of the study, a quantitative analysis was performed, by calculating frequencies and percentages through the SPSS statistics program, v.18, and a qualitative analysis through which the designation of the subjects, the objectives, content and skills set were analyzed.
To protect the interests of each university, the centers have been listed, but without specific details about each one of them. The data has been described broadly, in line with the objectives of the study.

Access profiles to the title of Degree in Nursing
The

Type and number of credits
Of the 66 centers included in the study, the mean frequency of SP that did not include a specific English subject was 39.4% (n=26), with a 60.6% (n=40) of the SP that did include. Among the centers that offered a course in English, 60% (n=24) considered it to be an elective, 32.5% (n=13) included it in basic training, and 7.5% (n=3) considered it mandatory, as detailed in Figure 2.

Abilities
The general competencies proposed within the English subjects in the nursing degree can be summarized as:

Ability to communicate verbally and in written
English, according to the needs of the field of study and the demands of the academic and professional environment.
Information management skills (ability to retrieve and analyze information from various sources).
Ability to work in an international context.
Knowledge and ability to speak, understand, and write a second language.

Methodology and assessment systems
These areas exhibited similar characteristics, highlighting the continuous monitoring during the teaching-learning process and the use of resources to promote interaction between teachers and students, with an emphasis on progressive self-learning. The most often used assessment systems were portfolios as evidence of learning, combined with written and oral tests.

System of accreditation in a second language
All the SP of the Nursing Degree manifested the mandatory accreditation of a second language, assessing English as one of the indispensable languages, even in universities which did not offer any English subject.
Second language accreditation systems varied slightly from one university to another, but in general, the guidelines set by the Common European Framework for Language were followed, which determined that the acquisition of B1 level certifies an acceptable level of language proficiency in those places where it was used (work, study, and leisure) and to standardize international requirements. In this sense, and despite the fact that the Therefore, in order to obtain a Bachelor's in Nursing, it will be necessary, despite passing all subjects in the study plan, to demonstrate proficiency in English or another foreign language (2) .

Existence of mobility programs
All universities had mobility programs for teachers and students through Erasmus or pre/postdoctoral research programs.

Discussion
There is little doubt that learning a second language is one of the cornerstones of the new EHEA, as evidenced by the documents in the framework of the Nursing Degree and numerous studies which recognized that proficiency in English is essential at the academic, clinical, and research level (1)(2)(4)(5)(6)(7)(8)(9)(12)(13)(14)(15)(16)(17)(18)(19)(20) . However, this These differences may adversely affect the motivation and interest of students towards learning English, as some studies describe (25) .  training needs that are not being covered in a uniform manner. Thus, the need arises to reach consensus on English language formation within the Bachelor of Nursing, and to potentiate the educational opportunities available, integrated into the required accreditation system and with adequate guidance regarding the needs of students, and the new competency profiles within the national and international health care system, which serve to consolidate a true knowledge society without language differences as a barrier.