Creative Nursing, Volume 16, Issue 2, 2010

Linguistic Bias in Multiple-Choice

Test Questions
Susan Lampe, MS, RN
Bess Tsaouse, MA, RN, PHN

Nurse educators are finding more and more nonnative speakers of English in the
classroom. These students bring a much-needed cultural diversity to the nursing
profession. Their success in nursing school can be enhanced when nurse educators
learn how to minimize linguistic bias in multiple-choice exam questions.

urse educators have a responsibility to prepare nursing students to meet the

needs of patients in the present and also in the future. Projections for the increasing elderly population and the high median age of the current RN workforce
raise concerns about the number of new nurses that will be needed. In addition,
as the United States gains more and more residents from other countries, it is
important to educate more culturally diverse nursing students who understand
the languages and cultures of our new residents. At Minnesota State University,
Mankato School of Nursing, the number of nursing students, both internationals
and residents, who are nonnative speakers of English (also known as English as
an additional language or EAL) has increased significantly in the past few years.
For these students, English is not their first language. In fact, English may be their
second, third, or fourth language. Commi ing to the success of these EAL students will strengthen our educational program and the profession as a whole, but
requires that we scrutinize all aspects of our teaching for possible linguistic and
cultural bias.
Recently, over the course of several semesters, faculty at our school noticed
that the EAL students were the last to complete wri en exams, which consist
largely of multiple-choice questions taken from the textbook publishers Web site.
In addition to requiring the maximum time allowed to complete the test, the EAL
students frequently had lower scores, in contrast to their demonstrated knowledge
in the classroom.
We asked four of our EAL students to talk with us about the exams. Each
student reviewed his or her own exam and chose test questions that were
especially dicult to understand. We asked each to explain how he or she
interpreted the questions: what did they think was being asked? Their responses
were very helpful in understanding their perspective. Here are two examples
from Medical-Surgical Nursing Assessment and Management of Clinical Problems
(Lewis, Heitkemper, Dirksen, OBrien, & Bucher, 2007).

2010 Springer Publishing Company

DOI: 10.1891/1078-4535.16.2.63

Susan Lampe, MS,

RN, is an assistant
professor at Minnesota State University,
Mankato School of
Nursing in Mankato,
Minnesota.

Bess Tsaouse, MA, RN,

PHN, is an assistant
professor at Minnesota State University,
Mankato School of
Nursing in Mankato,
Minnesota.
63

Committing to
the success of
EAL students
will strengthen
our educational
program and the
profession as a
whole, but requires
that we scrutinize
all aspects of
our teaching for
possible cultural
bias.

1.The nurse assesses a surgical patient the morning of the first postoperative
day and notes redness and warmth around the incision. Which action by
the nurse is most appropriate?
a.Notify the health care provider.
b.Document the assessment.
c.Assess the wound every 2 hours.
d.Obtain wound cultures.
The publisher chose b, document the assessment, as the correct answer. The EAL
students asked, Why is le er c not correct? In this case, none of the answers is
wrong, but the student is required to create a priority.
2.An assessment finding that alerts the nurse to the presence of osteoporosis
in a middle-aged patient is
a.The presence of bowed legs.
b.Measurable loss of height.
c.An aversion to dairy products.
d.Statements about frequent falls.
The publisher chose b, measurable loss of height, as the correct answer. The students asked, What is measurable loss of height? I dont know what that means.
This appears to be a use of an unfamiliar term; the students suggested that the
term shrinking would be clearer for them.
Susan Dandridge Bosher, in her chapter, Removing Language as a Barrier
to Success on Multiple-Choice Nursing Exams, (200 ) cites her own and others
research on linguistic bias in multiple-choice tests. (Editors note: see p. 95
for a review of this book.) She states, Both students and faculty rated taking
multiple-choice tests as the most dicult task out of 74 language and culturerelated skills and tasks that students must be able to perform successfully in the
nursing program (p. 263). Bosher (2009) and Klisch (1994) describe categories of
challenge for EAL students, including irrelevant diculty, linguistic/structural
bias, and cultural bias.
IRRELEVANT DIFFICULTY
Irrelevant diculty make[s] questions dicult to Case and Swanson, 1985 as
referenced in understand for reasons unrelated to the content or focus of the
assessment (Bosher, 2009, p. 264) and requires additional time to process. Examples of irrelevant diculty include completion format and best-answer items.
Completion format questions are lead-in style rather than direct questions. For
example:
Original: A patient with respiratory disease has a shi to the le in the
oxygen-hemoglobin dissociation curve. The nurse recognizes that this
finding indicates that
Revision: A patient has respiratory disease. He has a shi to the le in the
oxygen-hemoglobin dissociation curve. What does this finding indicate?
(Bosher, 2009, p. 264)
In the original, the reader must take extra time to decide what the question is. The
EAL students are already at a time disadvantage because many of them need to
process the questions in a language that is not native to them.

64

Lampe and Tsaouse

Best-answer questions require students to prioritize information. While it is

important for nursing students to learn to prioritize, the EAL students are again
at a disadvantage in trying to discern what the question is. Bosher suggests that
words such as most or first . . . should be highlighted in at least two or more
ways, for example, through bold-facing, capitalizing, underlining, and/or italicizing, to help readers quickly discern the nature of the task (Bosher, 2009, p. 265).
For example:
Original: Which of the following treatments for AIDS has been found to be most
eective?
Revision: Which treatment for AIDS is the MOST eective? (Bosher, 2009,
p. 265)

What are
the ethical
implications of

In the revision the intent of the question is easier to identify and students
can see that they need to choose the best answer from more than one correct
answer.

students failing
poorly worded
multiple-choice
tests, and possibly

LINGUISTIC/STRUCTURAL BIAS
Linguistic/structural bias includes . . . unnecessary linguistic complexity in
the stem or options; lack of clarity or consistency in the wording; and errors in
grammar, punctuation, and spelling (Bosher, 2009, p. 266). One type of linguistic/structural bias is embedded and reduced clauses, which require students to read
and reread the question to understand what is being asked. In the following
example, Bosher uses brackets to indicate two clauses embedded in the main
clause:

courses, because
of difficulties
instructors have
writing valid and
reliable test items?

Original: An inappropriate reaction by the immune system [in which antibodies form against self-antigens] [mistaken as foreign] best describes:
Revision: In the immune system, self-antigens are sometimes mistaken
as foreign to the body. When this happens, antibodies form against the
self-antigens. Which statement describes this inappropriate reaction by the
immune system? (Bosher, 2009, p. 266)
When each clause is stated in its own sentence, the intent of the question is
clearer.
Another type of linguistic/structural bias is unclear wording. In the following example, high index of suspicion is not common terminology. It is
also an example of unnecessary nominalization, in which the noun form of
a word (suspicion) is used instead of the verb form (suspect) (Bosher, 2009,
p. 267).
Original: In which of the following situations should the nurse have a high
index of suspicion for water intoxication?
Revision: In which situation does the nurse suspect water intoxication?
CULTURAL BIAS
The third challenge for EAL students is cultural bias, or the use of cultural content
that is not equally available to all cultural groups (Mohan, 1986, as cited in
Linguistic Bias in Multiple-Choice Test Questions

65

Use of the term

pint, a measure
of volume used
almost exclusively
in the United
States, rather
than the more
commonly
understood term
cup, is
an example of
cultural bias.

Bosher, 2009, p. 267). Once alerted to this issue, we discovered several examples
in the tests we were administering. The previously mentioned question from the
publisher asking about measurable loss of height is an example of unnecessary
use of an unfamiliar term. Another example is the use of the term pint, a measure of volume used almost exclusively in the United States, rather than the more
commonly understood term cup.
We reviewed 73 test questions from the textbook publishers test bank and
found that all were in completion format. Seven asked for a priority choice without highlighting or bolding the word best, and 14 included embedded clauses.
We changed completion format questions into two sentences (a statement and
a question); used bolding, italics, and capitalization in questions that required
choosing a priority rather than one correct answer; and changed uncommon
terms to more easily understood terms. We again consulted with the four EAL
students, who confirmed that the revisions made the questions easier to understand.
Some nursing faculty may believe that test content and purpose are diluted when test questions are revised as suggested by Bosher and Bowles. This
concern is addressed in Boshers and Bowles article, The Eects of Linguistic
Modification on ESL Students Comprehension of Nursing Course Test Items
(2008). They describe a collaborative process in which a panel of faculty worked
with the researcher to use linguistic modification techniques to increase comprehensibility of test items. Bosher and Bowles state, To the students who
participated in this study, it was clear that the content of the revised or modified
test items was essentially the same as the original versions (2008, p. 171). Bosher
and Bowles suggests that faculty members engage . . . in a group process,
where language and nursing experts work together, cooperatively and respectfully (p. 171) to study test questions. They ask, What are the ethical implications of students failing poorly worded multiple-choice tests, and possibly
courses, because of diculties instructors have writing valid and reliable test
items? (Bosher & Bowles, 2008, p. 171)

CONCLUSION
Publishers test bank questions require careful review for language choice and
question construction. In order to create a more level playing field for EAL
students, nursing educators need to learn more about the impact of language
and linguistic modification on EAL nursing students comprehension of test
items.

REFERENCES
Case, S. M., & Swanson, D. B. (1985). Constructing wrien test questions for the basic and clinical sciences. Philadelphia: National Board of Medical Examiners.
Bosher, S. (2009). Removing language as a barrier to success on multiple-choice nursing
exams. In M. D. Pharris & S. Bosher (Eds.), Transforming nursing education: The culturally
inclusive environment. New York: Springer Publishing.
Bosher, S., & Bowles, M. (2008). The eects of linguistic modification on ESL students
comprehension of nursing course test items. Nursing Education Perspectives, 29(3),
165172.
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Lampe and Tsaouse

Klisch, M. L. (1994). Guidelines for reducing bias in nursing examinations. Nurse Educator,
19(2), 3539.
Lewis, S., Heitkemper, M., Dirksen, S., OBrien, P., & Bucher, L. (2007) Medicalsurgical nursing assessment and management of clinical problems. Philadelphia: Mosby
Elsevier.

Correspondence regarding this article should be directed to Susan Lampe, MS, RN, at sslampe@avvidonline.net
or Bess Tsaouse at btsaouse@yahoo.com

Linguistic Bias in Multiple-Choice Test Questions

67

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