CLIL in English-Medium Nursing Education: Teacher Collaboration via Translanguaging–Trans-Semiotising Pedagogy for Enabling Internally Persuasive Discourse and Professional Competencies

Abstract

Academic English support is crucial for English as an Additional Language (EAL) nursing students in English-medium nursing education programmes. However, empirical research on content and language integrated learning (CLIL) within this specific context remains limited. This study, informed by recent advancements in translanguaging and trans-semiotising (TL-TS) theory, investigates the patterns of teacher collaboration in nursing CLIL and its impact when employing a TL-TS pedagogical approach. Analysis of students’ pre- and post-tests and multimodal classroom interactions reveals that effective collaboration between nursing specialists and language experts in CLIL can be fostered by (1) aligning with language education principles through the incorporation of internally persuasive discourse (IPD) about language learning and TL-TS practices; (2) simulating potential professional contingencies and co-developing coping strategies using TL-TS; and (3) elucidating nursing language norms through TL-TS and IPD. We advocate for re-imagination of CLIL in English-medium nursing education through an organistic–procedural TL perspective and highlight its potential to enhance EAL nursing students’ development of language proficiency and professional competencies.

1. Introduction

Internationalisation is a growing trend in higher education for facilitating academic exchange, enhancing reputation, and encouraging the mobilisation of students and scholars. Within this context, English-medium instruction (EMI), where teaching and learning occur in students’ additional language, has gained popularity, particularly in fields that require graduates to excel in intercultural communication. To enhance the efficacy of EMI programmes, various instructional approaches have been developed, each with different orientations to content and language. CLIL, which assigns both content and language an integrated curricular role (Marsh, 2002), is one such pedagogical approach.

Successful CLIL implementation relies heavily on close collaboration between content and language teachers, as evidenced by Lo (2020) and Liu and Lin (2024). This collaborative prerequisite is a primary reason why CLIL has been predominantly implemented in primary and secondary schooling, with limited adoption in nursing education (Granel et al., 2019). Another constraint stems from routine practices of offering language support for English as an additional or foreign language (EAL or EFL) to students in the form of English for academic purposes through remedial lessons in English-medium nursing education (e.g., Abriam-Yago et al., 1999; Salamonson et al., 2010). Empirical studies on CLIL implementation in nursing education worldwide are scarce, with two notable exceptions conducted in Spain. Angulo Jerez et al. (2013) conducted a CLIL pilot study on human anatomy in nursing programmes at the University of Alicante Angulo, Spain. The study had mixed results caused by students’ lack of knowledge of terminologies in healthcare and the professors’ insufficient English skills. Granel et al. (2019) examine nursing students’ perceptions of CLIL in an English-medium clinical skills course in Spain and reveal that the Spanish nursing students hold positive attitudes as nursing CLIL enables professional internationalisation and improves professional English skills. However, the systematic and continuous implementation of CLIL in nursing degree programmes remains uncommon (Garone & Van de Craen, 2017).

Furthermore, inadequate discipline-specific English literacy has been identified as particularly detrimental for English-medium medical and health disciplines, which demand a high level of cognitive academic proficiency (Guhde, 2003). English communicative skills are critically important as health professionals increasingly care for more and more culturally and linguistically diverse patients (Lu, 2018). In this circumstance, EFL/EAL nursing students are notably disadvantaged, as they are reported to have difficulty with the academic and technical aspects of English (Salamonson et al., 2008), comprehending EMI lectures, learning health terminology, and interacting in tutorial and clinical settings (Shakya & Horsfall, 2000). Given this research gap and the pivotal role of English in nursing education, further research on CLIL pedagogy in this field is clearly warranted.

2. The Organicist–Processual Approach to Translanguaging and Trans-Semiotising

Recent development in CLIL has benefited from the conceptualisation of translanguaging (TL) (Li, 2011, 2018; García & Li, 2014), which refers to the spontaneous multilingual, multisensory, and multimodal meaning-making processes that transcend the named language boundaries. Echoing with Halliday’s (2013) “trans-semiotic view,” Lin (2015) has coined the notion of trans-semiotising (TS) as a further development of TL to describe the process of using both multimodal and multisensory meaning-making resources (Lin, 2019). Although TL (e.g., García & Li, 2014; Li, 2018) and TS (Lin, 2015) both capture fluid whole-body meaning-making processes, the two notions have slightly different foci; TL underscores the “deployment of a speaker’s full linguistic repertoire” (Otheguy et al., 2015, p. 3) for thinking and communicating thoughts, while TS focuses on the entanglement of many other semiotics in sense-making (Lin, 2019).

A more recent development in this area features an organicist–processual approach (Thibault et al., forthcoming) to TL-TS. This new theoretical re-orientation to TL-TS has drawn on ecological psychology (Gibson, 1986) and a dynamic, distributed view of language (Thibault, 2011). The organicist–processual view has revealed that an important dimension of human interaction with others in the surrounding ecology involves perception or recognition of affordances and preparation or rehearsal for future actions. As conceptualised by Thibault (2011), first-order languaging denotes the real-time, whole-body integration of perception–action cycles, where meaning emerges through the dynamic coupling between the organism and its environment, rather than through pre-existing representational systems, while second-order language refers to different named languages/language use patterns stabilised on longer cultural timescales. Therefore, TL-TS is not just about sense-making beyond boundaries of language and semiotic systems but also denotes the process of entraining language and knowledge accumulated over longer time scales (second-order language) into events and activities in the here and now (first-order languaging). In other words, social agents get things done here and now (first-order languaging) by integrating voice dynamics, other bodily movements, artefacts, and technology with different second-order languages, cultures, and histories.

Building on its theoretical advancements, pedagogical applications of TL-TS have gained traction at various education levels. In health science higher education, although the concept of TL-TS is not explicitly invoked, its principles resonate strongly with the rich body of work on multimodal and digital instructional strategies. For example, it was found that MOOC micro-video teaching is as effective as traditional face-to-face nursing education but with higher teaching and learning satisfaction (Zhou et al., 2020); a multimodality approach has been found to be effective in improving nursing students’ knowledge, attitude, and comfort level with palliative and end-of-life care (Mason et al., 2020). Additionally, three-dimensional virtual environments in which users are represented as avatars have been used for academic education, professional education, treatment, evaluation, lifestyle, and modelling in the healthcare sector (Ghanbarzadeh et al., 2014).

While the research reviewed above has shed light on the challenges and pedagogical affordances of TL-TS in nursing education, none of it has provided explicit knowledge about the impact of TL-TS pedagogy for improving content and language learning in English-medium nursing education. It is therefore necessary to examine how university educators can systemically engage in TL-TS for maximising the pedagogical potential of CLIL for preparing and developing effective healthcare professionals.

To this end, this study implements TL-TS pedagogy in English-medium nursing education to explore its potential for enhancing CLIL. Such pedagogy was designed based on the heuristic curriculum model from Lin’s (2015) Multimodalities/Entextualisation Cycle (MEC) (see Figure 1). Inspired by Rose and Martin’s (2012) Reading to Learning Cycle, the MEC is a curriculum genre that can guide EMI disciplinary teachers to systemically build in academic literary support with an array of linguistic and non-verbal resources. There are three core stages in the MEC (see Figure 1; Lin, 2015). While Stages 1 and 2 in the MEC allow for a continuous dynamic flow of knowledge co-construction and pedagogical support through TL-TS, Stage 3 can provide students with opportunities to practise meaning making towards the target discourse/action patterns required by the institution for successful participation in future assessment tasks/careers.

3. Internally Persuasive Discourse (IPD)

The notions of authoritative discourse and internally persuasive discourse (Bakhtin, 1981) have profoundly impacted humanities and education scholarship. Bakhtin views language as something transferred “from one mouth to another, from one context to another context, from one social collective to another, from one generation to another generation” (Bakhtin, 1984, p. 202). Under the condition of heteroglossia, speech and writing are always dialogic, constantly engaging with and informed by different views from others and the self. Among these, two discourses are most prominent: internally persuasive discourse (IPD) and authoritative discourse (AD). AD is what “demands that we acknowledge it, that we make it our own” (p. 342), while IPD is “opposed to one that is externally authoritative” and “affirmed through assimilation, tightly interwoven with ‘one’s own word’” (p. 346). IPD has been applied and treated in education from three different approaches (Matusov & von Duyke, 2009): (1) the appropriation approach, focusing on whether and how students master and freely accept knowledge and skills; (2) the authorship approach, concerning whether and how students gain authorship of work that is recognised by the community; and (3) the dialogic approach, which considers whether and how students “become familiar with historically, culturally, and socially important voices and learn to address them” (Matusov & von Duyke, 2009, p. 179). Therefore, Bakhtin’s notions of dialogism and IPD provide valuable theoretical lenses for revealing the nature of learning unfamiliar professional ways of speaking, writing, and doing, but they have not been extensively used as a lens for professional education in nursing. In view of these research gaps, we aim to address the following research questions:

(1)

How effective is TL-TS CLIL pedagogy in facilitating EAL nursing students’ development of content and language knowledge as the foundation for developing professional competencies?

(2)

How do nursing and language specialists collaborate to facilitate EAL nursing students’ development of content and language knowledge through TL-TS practices?

4. Research Methods

This study is a collaborative project between the researchers (language experts) and five nursing educators from English-medium nursing education programmes at three nursing schools in Hong Kong. We implemented the CLIL approach to EMI and the TL-TS pedagogy, examining its potential impact on nursing students’ learning.

The researchers adopted a quasi-experimental design involving an extended period of intervention. Two units of nursing course lessons were co-designed with each nursing educator participant using the MEC framework. Two groups of nursing students in each teacher’s major nursing courses were recruited to allow for comparison between an experimental group and a control group. In the first unit, the intervention was delivered to the experimental group, while the control group received the original non-CLIL instruction. In the second unit, the experimental and control groups were swapped to alleviate ethical concerns and mitigate the influence of potential differences in learning capabilities and English language knowledge. After implementing both units, we shared the experimental groups’ lesson materials with all of the EAL nursing student participants.

The collaboration between language experts and nursing educators occurred across four key stages.

(1)

Professional sharing sessions: Establishing mutual understanding

Language experts led sessions introducing CLIL pedagogy, the TL-TS framework, and practical strategies for integrating content and language learning using the MEC framework. Nursing educators reciprocated by sharing insights about the EMI nursing curriculum and their EAL students’ specific needs and challenges.

(2)

CLIL material development: Integrating expertise

Language experts analysed course materials to identify content and language demands that might challenge EAL students. Based on these findings, they incorporated explicit TL-TS support into EMI nursing lectures, including scaffolding for technical vocabulary, unpacking textual organisation of subject-specific genres, visualising implicit networks of content and language knowledge, and annotating teaching tips for the CLIL components. Nursing educators reviewed and refined these materials to ensure feasibility and pedagogical soundness.

(3)

Assessment design and intervention implementation

Language experts and nursing educators jointly developed pre- and post-tests to gauge students’ content and language gains after the pedagogical intervention. The pre- and post-tests comprised multiple choice questions, word definition matching items, and writing tasks. Nursing educators delivered the EMI lectures to both the experimental and the control groups and administered the tests. Language experts conducted video-recorded classroom observations and co-taught the CLIL components if nursing educators requested it.

(4)

Joint development of the assessment framework for CLIL writing tasks

Both parties collaboratively developed the marking rubrics for writing tasks in the pre- and post-tests, covering both the content and language domains. The content component assessed task completion and accuracy of nursing knowledge. The language component evaluated five domains: textual organisation, coherence and cohesion, lexical resources, use of relevant tense or sentence patterns, and the tone of language, based on Systemic Functional Linguistics (Halliday, 1985). This framework thus enabled assessment of experiential (i.e., nursing content knowledge), textual (i.e., how ideas are connected), and interpersonal meanings (i.e., the appropriate tone and voice) of students’ learning outcomes (Fang & Schleppegrell, 2010).

Following rubric development, the first author and her research assistant marked all written task responses for the pre- and post-tests independently and achieved an inter-rater reliability of 90%. Students’ scores for the multiple choice questions and the matching and writing tasks were compared using SPSS 30. Classroom interactions were transcribed verbatim.

Lesson selection for analysis was based on the following criteria: first, the lesson(s) should demonstrate different but recurrent patterns of CLIL collaboration in facilitating content and language learning; second, the EAL nursing students’ post-test results should show significant improvement over their pre-test scores. Video recordings were reviewed repeatedly to identify relevant episodes. The selected excerpts were then divided into “frames” as units of analysis (e.g., Liu & Lin, 2024). We selected students’ and teachers’ languaging practices, as well as the use of gestures and spatial movement as actional modes (see Appendix A for transcription conventions).

5. Findings

5.1. Results of the Pre- and Post-Tests

All experimental groups for the chosen course topics taught by three EMI nursing educators showed significant improvement in content and language test items, as indicated by paired sample t-tests (

Table 1. Results of the pre- and post-tests in the experimental groups based on the paired sample t-test.

Topic	No. of Students	Pre- and Post-Test Mean	t Value	Significance (p Value)
Nursing process	85	Pre: 56.34 Post: 71.26	−6.309	0.000
Reflective practice	85	Pre: 28.29 Post: 34.73	−4.029	0.000
Introduction to evidence-based practice	31	Pre: 40.64 Post: 65.58	−8.426	0.000
Contemporary issues in nursing	31	Pre: 47.64 Post: 53.66	−2.197	0.022
Disease screening	59	Pre: 55.60 Post: 60.20	−4.041	0.000
Individual report for community and public health nursing	59	Pre: 22.38 Post: 29.68	−3.045	0.007

). Where a comparison between the control and experimental groups was available, the experimental group in the topic “Nursing Process” taught by Dr Fung (pseudonym) statistically significantly outperformed the control group in both content and language knowledge. Specifically, the experimental group performed statistically significantly better than the control group in (1) overall scores in the post-test; (2) using imperatives for nursing actions in the nursing care plan; (3) using appropriate verbs for nursing action sentences; and (4) using appropriate tone and lexical resources in the nursing diagnosis statement (see

Table 2. Comparison between the control and experimental groups for the topic “Nursing Process.”

Topic	Pre-Test Total	Post-Test Total
Nursing process	56.34 (Exp.)	71.26 (Exp.)
	52.02 (Cont.) (p = 0.13 > 0.05)	62.19 (Cont.) (p = 0.006 < 0.05)

). In another unit, “Introduction to evidence-based practice,” which was taught by Dr Tan (pseudonym), although there was no statistically significant difference between the control and experimental groups, the experimental group showed significant improvement when the nursing educator adopted another mode of CLIL teacher collaboration. The classroom interactions in “Nursing Process” and “Introduction to evidence-based practice” were therefore selected to exemplify the patterns and processes of CLIL teacher collaboration in EMI nursing education.

5.2. CLIL Teacher Collaboration Patterns in English-Medium Nursing Education

It was found that the focal nursing educator participants, Dr Fung and Dr Tan, collaborated with the language specialists of the research team in two modes: (1) dividing and sharing the teaching with the language educator in MEC-inspired nursing CLIL lectures while incorporating IPD about language learning with TL-TS; or (2) teaching the whole MEC-inspired nursing CLIL package alone while enriching language support through TL-TS and both their own and possible IPD of their EAL nursing students. During this process, the nursing educator constantly invited her students to join the flow of interaction and adopt desired subject positions. The dialogism enacted in both modes of CLIL teacher collaboration managed to cultivate the EAL nursing students’ professional competencies in clinical settings. Additionally, such critical moments of interaction were imbued with various semiotic resources in the lecture rooms, including linguistic resources and bodily movements, to unpack nursing content knowledge and provide academic literacy support for students. Excerpts showcasing such interactive patterns are analysed below.

5.2.1. Echoing Language Education in the MEC-Inspired Nursing CLIL Lectures and Incorporating IPD About Language Learning with TL-TS

Dr Tan is an experienced nurse and nursing educator. In the CLIL nursing package on the topic of “Introduction to Evidence-based Practice,” Dr Tan mentioned that she was more comfortable letting the research team’s language experts teach the topic-specific English support in her EMI nursing lectures. This topic is part of a 2nd-year EMI nursing course titled “Perspectives in Professional Nursing,” in which the EAL nursing students need to make presentations and complete essay-type assignments. The topic aims to equip students with the professional competencies of examining sources of evidence for nursing practice, describing the concept of evidence-based practice (EBP), examining basic models of EBP, and describing the process of EBP. Based on this topic, Dr Tan and the research team devised the list of language learning goals: “(1) use and recognize reporting verbs in EBP writing; (2) discuss your research findings and evidence using commenting adjectives to show your appraisal of them.” To achieve these language learning objectives, the research team used the MEC to offer language and content support. After the English language expert explained the topic-specific language features concerning reporting verbs and commenting adjectives (see Figure 2) in the lecture, the nursing specialist Dr Tan echoed the language educator, drawing on both English and Cantonese (translated into English and written in square brackets), the students’ mother tongue, to underscore the importance of such language skills:

Excerpt 1

Thank you. Wow. That was very useful. [When you write your] report, [you shouldn’t just write] “however,” “however,” “however.” [If you use words like,] “contradictory,” [it’s very useful, right? So, to repeat, you can use different words to write your] report [so that your homework looks much better. Because as you continue your studies, you will notice that you will see a lot of] essay-types of questions. [And another] point [is why you need to have good] language [skills. During] clinical practice, [you will find the workplace English used is not proper English, expressed mainly in the sentences and words. But when you submit your homework or when you are studying, you will notice that a lot of] essays- [I notice that what a lot of students answer well are questions like,] okay, what are signs and symptoms of diabetes? Okay. [What are the signs and symptoms of diabetes?] [They can answer in] point-form [well. But once they have to do] essay-writing, [they will have] difficulties. [I have asked students to] just write, [but some students cannot express their] views. They don’t know how to link them. [So this is very important.]

In language support, while the language experts summarised the language skills for the literature review using the reporting verbs and commenting adjectives to communicate the students’ stances (i.e., the second-order language), Dr Tan foregrounded the significance of learning topic-specific English well by drawing on her observation about language use patterns in clinical settings and the disparity between nursing English and academic English required by nursing research. Interestingly, Dr Tan did not entirely draw on the authoritative discourses (e.g., the EMI policy or other regulations) but focused on students’ learning needs (by thematising “you” in most of her teacher talk) and directing students’ attention to future challenges. In addition, Dr Tan accentuated the nature of the given language support, mainly to actualise the interpersonal and textual meta-functions (Halliday, 1985), using everyday Cantonese and everyday examples, such as “[I have asked students to] just write, [but some students cannot express their] views. [They don’t know how to link them.” Although Dr Tan did not explicitly teach language support, she intertextually enacted the CLIL collaboration through TL with English, Cantonese, her own experiences teaching, and observations of the routine language practices in different ecological niches, which are mainly the second-order language and her first-order languaging, i.e., showing her recognition of and stance on language teaching.

5.2.2. Simulating Workplace Sexual Harassment and Coping Strategies Using TL-TS

Although Dr Tan did not offer explicit second-order English support (i.e., the relatively fixed language patterns specific to the nursing profession), she demonstrated how to do first-order languaging using second-order language in the face of professional contingencies, as demonstrated in her following talk:

Excerpt 2

Another topic that is also crucial is about harassment. Have you seen that video where the 20-something year old man was arrested for molesting a school girl on the MTR. The girl didn’t even know she was being molested. But it is crucial to speak out. As I always say, women may potentially be in a position where they are being touched but they do not know what to do and are very scared. But it is crucial to speak out. But rest assured, rest assured. This is why I think education is crucial. You are interacting with people. In the future, whether a patient unconsciously touches you or touches you intentionally, you really have to speak out. Okay? It turns out, as I spoke to my colleagues, it turns out eight out of ten of them have been sexually harassed by someone in their life. [It could have been a pervert touching their bottoms. It turns out a lot of people have experienced this.] Okay? [It happened to me too when I was in Canada. A foreigner stuck really close to me and touched me. I instantly yelled. At the time, I didn’t know what to shout. I didn’t know how to say “harassment” in English. Do you understand? So, I asked him,] “WHAT ARE YOU DOING? WHAT ARE YOU DOING? YOU TOUCHED MY HIP?” [Okay. Then, everyone looked at him. Everyone was looking. So, then, he swore. He said, “Hey. You stupid…” He said all these (racist) things like,] “Chinese” [so and so. But, at the time, I really didn’t know how to say “harassment” (in English). “HARASSMENT!” How do you say that? But I instantly yelled,] “WHAT ARE YOU DOING? YOUR HAND! TOUCHED MY HIP!”—Dr. Tan

Before Excerpt 2, Dr Tan guided students to complete an exercise identifying the Population (P), Intervention (I), Comparison (C), and Outcomes (O) in evidence-based nursing practice and analysed the PICO for the following scenario: “In high school children, what is the effect of a nurse-led presentation on bullying on a reduction in reported incidences of bullying compared with no intervention within a 6-month time frame?” (see Figure 3). After the EAL nursing students successfully attempted the analysis, she elaborated on scenarios where school nurses can intervene with nurse-led education. She began with school bullying resulting from discrimination against obese children and then moved on to sexual harassment towards schoolgirls and female nurses. To do so, she shared her personal experience of sexual harassment during her nursing training in Canada. Her self-disclosure was mainly in Cantonese, but she also re-enacted her angry and loud response to racial discrimination (as the foreigner made racist remarks about Chinese people) and sexual harassment (being touched by a foreign man) by yelling in English in front of her students: “WHAT ARE YOU DOING? WHAT ARE YOU DOING? YOU TOUCHED MY HIP!” She used a strong voice and higher pitch to relive the first-order voice dynamics she employed to respond to sexual harassment and racist discrimination. This served as a powerful demonstration of the attitude and bravery she encouraged the EAL nursing students (mostly girls and women, with one male student) to exhibit in cases of job-related harassment. By simulating the professional contingencies and her own solutions, Dr Tan enhanced students’ first-order languaging skills and coping strategies when facing potential workplace harassment.

5.2.3. Mediating Disciplinary English Use Norms by Explaining the Rationale via TL-TS IPD to EAL Nursing Students

In the other EMI nursing education programme where we collaborated with Dr Fung to design the nursing CLIL package, Dr Fung preferred to teach topic-specific English support for her EAL nursing students herself. Her teacher talk for the language support section serves as mediation (Feuerstein et al., 1988) for the co-developed nursing CLIL curriculum. She explained the rationale via TL-TS IPD, during which the EAL nursing students’ responses served as pointers for deeper exploration of nursing and relevant English language knowledge.

Excerpt 3

Turn	Speaker	Utterance	Action
1	Dr Fung:	If you just write, “Inspect the incisions or the wound,” I will ask, “how often will you inspect the wound?” Please tell me the frequency and the time that you will perform your intervention. You may also write “Instruct the patient or his relatives to report to the physician if any symptoms of infection occurred.” But I will ask when you will teach the patient to report the sign and symptom. So, besides choosing an appropriate verb [please also use these specific wordings. If you are describing something, please say it appropriately. As in, if you say,] “inspect [the] incision,” [then include when.] “Inspect it once.” If you say, “Assess the patient‘s vital signs” [I will also ask you since what you wrote is not complete.] “Assess the vital signs every four hours.” Okay. Don’t tell me, “Assess the vital signs regularly.” [Once a week is] regularly. [Twice a week is also] regularly. Okay? Please. You need to specify the time frame of the interventions for the patient. Okay? {The rest of Dr Fung’s explanation was omitted as she used a similar pattern.}
2	Dr Fung:	Okay. Let’s find some examples of imperatives. [What] imperatives [are there? I just gave you a lot of examples just now, a lot of] examples, [can you think of an example of an] imperative [yourself? For] nursing interventions. [It’s very] free-flow. [Think about it.] Let me make this easier. Let’s say the patient is in pain, earlier you already said some examples, but I want you to now break the sentence down. Now, the patient has the problems of the acute pain. Okay? You will write the nursing interventions. Solve these problems. Give me one example. [I’ll give you one minute to think. Just think of one sentence. Have any students thought of or written anything? Have a try. Please.]	(“break the sentence down”) (“write the nursing interventions”)
3	S30:	Administer painkillers to the patient.
4	Dr Fung:	Okay. Administer the painkillers to the patient. Okay. The imperative in this sentence is good. It is written correctly. But what is missing in “Administer painkillers to the patient”? [What do you think? This is already very good. The] intervention [is correct but it is missing something.]
5	S31:	[How frequent.]
6	Dr Fung:	[Yes. How frequent.] How do I know how frequently to do this? How do I know? What is the specific time frame? [Act ally do we know at this moment?]
7	S32:	[As prescribed].
8	Dr Fung:	[As prescribed]. Yes, you can write that but if we really have a patient’s profile. But if the patient is already prescribed to take medication every four hours then, we will write that, “Administer the analgesics or painkillers every four hours as prescribed.” [This is now fully complete. Understand? But you might ask,] “Dr Fung, [why do we have to write,] “every four hours?” [Because, remember that our] nursing interventions should be applied to individual patients. We will look at the] patient[‘s] profile [before writing them. If the patient must take a painkiller every hour, or take one every six hours, the intervention will be different]	(if the patient)

In Excerpt 3, Dr Fung, an experienced nursing educator, adopted a dual role as both the discipline expert and a literacy instructor. Dr Fung enacted these roles by contextualising language support within her IPD, drawing on both second-order language (content-specific English for nursing care plans) and her own first-order languaging (the embodied, experience-based communication of the here and now). Consistent with a dynamic, distributed view of classroom sense-making (Thibault, 2011; Shi & Thibault, 2022), the multimodal, plurilingual interactional data reveal that Dr Fung’s discourse practices went beyond regurgitating the nursing language patterns identified by the research team. Instead, Dr Fung actively recontextualised the language support designed in collaboration with language experts and elaborated on the functional rationale behind the language patterns by providing dialogic teacher feedback to hypothetical student writing.

For instance, Dr Fung actively engaged students in co-constructing the rationale for writing the nursing intervention statement in the desired manner. Before the lecture, the language specialists of the research team had synthesised the key elements of nursing intervention statements, namely, imperatives, time, and duration, and concrete examples (i.e., the second-order language for the topic; see Figure 4 and Figure 5). During the lecture, Dr Fung not only told students the what (i.e., the desired elements and structures found by the language experts) but also added the why with her IPD in first-order languaging, entraining her inner voice, students’ possible IPD and their future inadequacies, the PPT slides, and hand gestures. In Turn 1, Dr Fung pointed to the correct intervention statement on the slide “Inspect the incision every shift and document findings” but gave an alternative version that could be otherwise written by students (“If you just write ‘Inspect the incisions or the wound’”). She then shared her view on this alternative as mediation for students’ nursing English progression: “I will ask, ‘how often will you inspect the wound?’ Please tell me the frequency and the time that you will perform your intervention” (Turn 1). Her IPD of questions and requests served as scaffolding for students to become more accurate in writing nursing interventions. Again, when referring to another sample on the slide, “Instructure the patient and partner in the possible danger signs and symptoms that they should be reported to the physician immediately,” Dr Fung presented another alternative that her students might produce (“Instruct the patient or his relatives to report to the physician if any symptoms of infection occurred”) and shared her inner observation and question (“But I will ask when you will teach the patient to report the sign and symptom”).

In Turn 2, Dr Fung underscored the importance of “imperatives” (Figure 2), another grammatical feature of nursing intervention statements. When the students did not seem to understand how to provide an example of using imperatives in nursing interventions, Dr Fung invited students to attempt the task. She used both Cantonese and her downward and chopping gestures to amplify her instructions “break the sentence down” and “write the nursing interventions.” When Student 30 (S30) provided the example of “Administer painkillers to the patient” with the imperative, Dr Fung immediately acknowledged her response in English but invited the class to improve S30’s reply. When S31 said the frequency was missing (in Turn 5 in Cantonese), Dr Fung accepted S31’s L1 answer. She then reformulated it into the target L2 discourse. This TL move not only facilitated access to content and language but also fostered dialogic engagement and co-construction of meaning (Bakhtin, 1981). She then pressed the class to think about the time frame (Turn 6). When S32 answered “as prescribed,” Dr Fung pointed out that if the patient’s profile indicated the frequency, students should be as accurate as possible (Turn 8). She even entrained students’ possible IPD in “But you might ask…why do we have to write ‘every four hours?’” and addressed her students’ possible question by highlighting the caring and humanistic values in nursing care, “But remember that our nursing interventions should be applied to individual patients,” using both Cantonese and English.

In dialoguing with students’ IPD, Dr Fung was seen to incorporate students’ voices and her own voices as an experienced nurse and nursing educator in her CLIL lecture. By drawing on students’ IPD and actual responses, which served as pointers for deeper inquiry, Dr Fung provided dynamic assessment prompts (Poehner & Lantolf, 2005) and foregrounded the importance of specificity in nursing care plan writing. She was seen to engage students in co-constructing knowledge about how to write accurate nursing intervention statements and the principles of nursing care, namely, being caring, responsible, and humanistic.

Furthermore, Dr Fung collaborated with language specialists in devising the teaching materials but extended their utility by embedding her own IPD, i.e., her personal experience driven stance on why certain linguistic forms matter in professional practice. Rather than relying solely on the authoritative discourse of language rules or institutional policies, Dr Fung foregrounded the practical exigencies of clinical communication, urging students to specify the nursing interventions according to patient profiles (“If the patient must take a painkiller every hour, or every six hours, the intervention will be different”).

Through these discourse strategies, i.e., alternating between PPT-guided second-order language, embodied first-order languaging, and dialogic TL, Dr Fung empowered students to move from formulaic responses towards authoring complete, contextually appropriate nursing care plans. This approach fostered active student engagement, even among those with lower pre-admission English proficiency. This dynamic, asynchronous TL-TS teacher collaboration thus enabled students to appropriate the disciplinary discourse as their own, transforming it into their IPD (Bakhtin, 1981).

6. Discussion

This study aimed to examine the effectiveness of TL-TS CLIL pedagogy in English-medium nursing education, with a particular focus on teacher collaboration and its role in enabling internally persuasive discourse (IPD) and professional competencies among EAL nursing students. Below, we address the two guiding research questions in light of our multimodal discourse analysis.

6.1. The Effectiveness of TL-TS CLIL Pedagogy in Facilitating EAL Nursing Students’ Development of Content and Language Knowledge

Findings from both quantitative and qualitative data indicate that TL-TS CLIL pedagogy is highly effective in advancing EAL nursing students’ understanding of both disciplinary content and academic language. The experimental groups exposed to pedagogical interventions consistently outperformed their control group peers in the content and language assessments, with statistically significant gains. Beyond the test scores, classroom data reveal that the dynamic, distributed orchestration of TL-TS resources afforded richer opportunities for students to practice target discourse features and engage with the language patterns required for professional nursing practices.

Through the integration of multilingual, multisensory, and multimodal meaning-making (e.g., the bilingual PPT slides, the use of gestures, L1 scaffolding in teacher talks, visual artefacts, and embodied demonstration), students were able to bridge the gaps between everyday language, academic English, and the specialised discourse of nursing. This enabled them to move beyond rote memorisation towards authoring internally persuasive discourse characterised by agency, contextual appropriateness, and readiness for real-world professional scenarios. Our findings thus provide novel empirical nursing CLIL evidence from Asian contexts and show that TL-TS pedagogies can foster deeper disciplinary literacy and more robust professional identities among EAL nursing students.

6.2. CLIL Teacher Collaboration in EMI Nursing Education: Enabling IPD via TL-TS to Make Learning Accessible and Educate with Attention to Imaginative Scenarios

The data further illuminate how nursing and language specialists collaboratively make abstract and complex disciplinary knowledge accessible to EAL students. Two major patterns of teacher collaboration emerged:

(1)

In the planned curriculum-driven collaboration, nursing specialists and language educators co-designed intervention materials (e.g., MEC-inspired PPTs and worksheets) and jointly identified key content and language objectives. This division of labour allowed language specialists to foreground target linguistic features (e.g., reporting verbs and the genre stages) while nursing educators contextualised these features within authentic professional scenarios. The result was a pedagogical “double-voicing” (Bakhtin, 1981), in which authoritative discourse (institutional language norms) was dialogically interwoven with the internally persuasive discourses of the nursing educator, often using TL to bridge theory and practice.

(2)

In the moment-to-moment flow of classroom interaction, spontaneous and distributed collaboration emerged through dynamic orchestration of semiotic resources (e.g., talks, the PPT slides, gestures, and embodied demonstration). Nursing educators, such as Dr Fung, not only reinforced language support designed by language specialists but also continually recontextualised these forms with her clinical insights and personal experiences. For instance, Dr Fung’s use of Cantonese and scenario-based teacher questioning enabled students to appropriate disciplinary discourses and understand the rationale behind language choices in nursing care plan writing. This organistic–processual TL-TS (Thibault et al., forthcoming) CLIL teacher collaboration was particularly powerful in enabling students’ IPD. By inviting students to dialogue with both authoritative discourses of the nursing disciplines and teachers’ internally persuasive discourses through TL-TS and embodied demonstration, teachers created an inclusive, dialogic learning ecology. This ecology empowered students not only to master content and language but also to gain enhanced awareness of possible contingencies and challenges in learning and future professional work, thus enabling the EAL nursing students to become more agentive future participants in the nursing profession.

7. Conclusions: Towards Organistic–Processual CLIL Teacher Collaboration in EMI Higher Education

This study contributes to the growing body of research on CLIL teacher collaboration (e.g., Liu & Lin, 2024) by demonstrating how TL-TS pedagogy, enacted through both planned and spontaneous collaboration between nursing and language educators, can facilitate EAL nursing students’ development of subject-specific English literacy and professional competencies.

Effective CLIL teacher collaboration in English-medium nursing education is not confined to pre-planned curriculum alignment; rather, it flourishes in the dynamic, dialogic, and multimodal interplay between disciplinary expertise and literacy support. In other words, CLIL teacher collaboration should be perceived and reimagined at a more micro-level geared towards heteroglossia, focusing on how nursing educators can incorporate their own IPD and invite students into dialogue with these discourses. Such an approach can expand students’ repertoire in subject-specific English and their professional competencies, i.e., how to navigate the ecological niche of clinical settings with here-and-now actions, adjustments to elements in the immediate environment, and the disciplinary second-order language. Furthermore, as exemplified by Dr Fung, TL-TS in the classroom serves to anticipate possible chances of actions emerging within the learning ecology and can prompt further exploration and inquiry.

Our findings also underscore that TL and TS are not mere scaffolding tools but central mechanisms through which teacher–researcher collaboration can empower EAL students’ professional growth and make routine professional practices accessible, culturally relevant, and professionally meaningful. From a distributed languaging view, TL-TS pedagogy in CLIL collaboration supported flows of actions and emotions in teaching and changes in these, simulated possible actions and scenarios in the nursing profession, and focused the EAL nursing students’ attention on challenges in content and language learning. The study also paves the way for a more embodied analysis of the sense-making process (e.g., Shi & Thibault, 2022) in CLIL teacher development. By engaging students in co-constructing professional competencies across languages and modalities, CLIL teacher teams can foster the emergence of agentive, reflective, and professionally competent graduates equipped to face the challenges of contemporary healthcare contexts (e.g., The New Territories Group, forthcoming).

Future research should further investigate how such collaborative, TL-TS-informed CLIL pedagogies can be sustained and scaled across other professional disciplines and multilingual educational settings. It is also crucial to explore how institutional structures can best support the ongoing development of teacher collaboration to create inclusive and transformative learning environments that prepare students not just for academic success but for impactful professional lives.