Needs Analysis: The Primary Step in Designing English Instructional Materials for Nursing Students

This research intended to analyze and identify the needs of English instructional materials (ESP) for nursing students. English in higher education in non-English major is only as a General Basic Subject and the material provided is only general English. Whereas ideally English material taught should be adjusted to their major. So, needs analysis was required to find out the need for English teaching materials on the nursing department so that students could get the appropriate materials they really need to support their future careers to be professional nurses. This study design was a descriptive qualitative with subjects were 81 nursing students, heads of nursing study programs, 3 ESP lecturers, 2 Indonesian nurses, 2 Indonesian nurses who work in overseas hospital. The research instrument used a questionnaire and interviews. The results showed that in general, students' English skills were still low. From the 4 language skills, speaking become the main priority to provide them fulfilling their profession’s demands in accordance with the job market, namely being able to communicate in English well. They also expected ESP English teaching materials that are relevant to nursing major to support their professional careers. 86% students believed if English materials related to nursing major will improve their interest in learning. Besides that, there are also 12 nursing topics that students need to support their world of work later. This research results will be guidance in making appropriate syllabus and developing English for nursing textbook.


Introduction
English in higher education is taught as a general subject in non-English majors and must be followed by all students, including at STIKES Banyuwangi. But it seems that the English subject in non-English major is only as a General Basic Subject and the material provided is only general English. Whereas English materials in every major needed by students in their future profession are not the same. Ideally English material taught should be adjusted to the major and should talk about a specific English according to the major or usually known as ESP for example, the economic major should teach English for economics, the midwifery major should teach English for Midwifery, the hotel and restaurant major should teach English for hotel and restaurant, the law major should teach English for law, and the nursing major should teach English for nursing. Learning English is crucial for university students to response many defiance in an increasingly competitive world of work. Someone who mastered English well will have more opportunities to get brighter job, so having English skills is something that is very needed by the community especially for those who will be in the world of work.
So, the students' needs in mastering English are dare for university to prepare learners with sufficient skills in English so that they are capable to take part in the 4.0 industrial revolution era. Teaching English with the right material for nursing students according to their needs is badly needed to support their career. So, of course the lecturers' roles are essential in order to assist the students in obtaining suffice English ability. This English course must focus on the skill development in comprehending material which is customized to a particular professional context. At STIKES Banyuwangi, English subject must be taught by students from first to fourth semester for bachelor of nursing students and from fourth to fifth semester for D3 of nursing students. The English nursing material provided by lecturers is still not able to meet the standards and needs of students in technical aspects, content, and practice.
The material used so far does not meet technical aspects; such as there is no link between the materials taught from the previous to the next semester which result in (1) overlapping of some materials being taught, (2) repetition of materials delivered by previous lecturers in different semesters due to the lack of conformity and similarity of the materials being taught, (3) there is material discrepancy in certain semester, and (4) The students have difficulty in understanding the material being taught because the material that was not supposed to be taught in the semester instead was given by the lecturer and vice versa, the lecturer delivered the material that had been conveyed in the previous semester. Beside that some references used still do not meet the standards for a language material used for non-English students, in this case nursing students. The context of the existing content is still less relevant to the disciplines that students are engaged in. From the practical aspect, each skill in each section or unit lacks a relationship with one another, such as the reading aspect that must be related to vocabulary, grammar with speaking and writing.
English in the field of nursing has terms that are more complex than general English as they are correlated with medical terms which are not familiar for many people. The variations and meanings of English in nursing terms are more troublesome and require particular concepts and understanding since they are associated with the practice in the world of work. Placing student needs should be used as the approach focus which leads to ESP where learners and their needs are the major concern in establishing the direction and learning process so as the teaching goals' achievement is able to work as effective as possible. Regarding the English lecturers who teach in non-English major, they are expected to build up syllabus and materials for teaching based on the learners' needs. They must meet the demands of students' real world of work effectively. However, the problem occurs is that many English lecturers who teach in non-English major find difficulties to design teaching materials and syllabus for their study programs because of the minimum number of specific English books for non-English major at the bookstore. So all this time English materials provided are more related to English in general which is certainly not in accordance with the English language competence that is expected to be mastered by nursing students. Moreover, ready to use English teaching materials available in various bookstores have not been able to provide students' needs in ESP and are commonly not in accordance with students' conditions, needs, and their characteristics. Hence, the students' need analysis can be an appropriate option to resolve the existing problems.
Needs analysis is a technique in gathering information as an important source in designing syllabus and developing instructional materials that is relevant to the students' needs (Ali & Salih, 2013). The importance of conducting an ESP needs analysis is to ensure that the language being taught is truthfully the language required according to the field that the students are engaged in. Like the English learning activities for nursing students at STIKES Banyuwangi, so far, English has been a compulsory subject for all students majoring in nursing and the provision of material tends to be more directed at the discretion of the English lecturers. So the teaching material is General English, not in accordance with the field of science being studied.
Consequently, students' motivation in learning English decrease, they consider English subject only as complementary because it does not support the development of their interests or scientific fields. Needs analysis is very crucial to plan many programs, particularly language and we cannot override the students' needs, wants and interests in designing teaching materials because if we ignore it then the purpose of teaching and learning will not be achieved (Irmawati et al., 2016). Previous research has shown the importance of carrying out an ESP needs analysis to obtain the materials needed and teaching methods that truly suitable with the real student needs (Ali & Salih, 2013). Making needs analysis is the basis for writing ESP materials and it is an important factor in the successful of ESP materials development. Another study concluded that conducting needs analysis may assist educators in finding out if only the material provided is proper with the learners' goals in learning a language and is more oriented to the learners' needs (Boroujeni & Fard, 2013). Furthermore it also assists the educators to evaluate the existing materials and if the weaknesses found, it may help out to decide the students' need and modify the materials based on the students' need. Then another research conducted by Syukur & Nugraha (2019) about English needs analysis on students in nursing study program with the result Nursing students' needs for ESP English course is varied, which means that the nursing students learn English not only for their recent needs, but also for their professional careers in the future. So, it is suggested for ESP lecturers can accommodate the students' need and perform needs analysis periodically as the ESP learners' need are constantly altering.
Another research by Ramani & Thiruvengadam (2015) perceived that how important to conceive how the learners see their English needs by recognizing their background as constructive information in developing learning curriculum. While Sulistyani (2018) mentioned that needs analysis is the initial act in designing course with the aim to know the language skills needed by students to support their careers such as midwife, nurse, tour guide, or others. Besides, need analysis is also important to determine whether existing materials adequately meet student needs. More specifically Haque (2014) argues if need analysis has a vital role in foreign and second language learning because the educators are able to set learning goals, lead to select the content of teaching, make adjustments to the syllabus, strategy, approach, and learning methods.
Needs analysis is the basis in constructing the curriculum, teaching methods and materials which may raise students' enthusiasm and their achievement. So, lecturers should have the materials for teaching which are closely connected with the students' background and their experience. The availability of pertinent teaching material may significantly assist ESP lecturers of the nursing major as a guide in teaching English as needed (Gultom, 2016). With the appropriate materials, the teaching learning process runs more motivating and exciting to enhance students' enthusiasm in learning English because material takes a crucial part in teaching. Good and proper material will have a positive effect on the student learning process.
Based on the above literatures, needs analysis has a crucial part in teaching due to the educators, learners, teaching materials and procedures could be linked harmoniously to make the learning process better. For that reason, researchers are inspired to explore the students' needs of English subject for nursing students at STIKES Banyuwangi. This research intended to describe the nursing students' need in learning English. This study is the primary phase from many processes of future study in designing, constructing, and assessing the English instructional materials for nursing department. This study is necessary to ease the lecturers in developing teaching materials and help students in accessing certain languages they require to be able to communicate properly according to students' demand in the world of work.

Research questions
What are the English Instructional Materials needed by nursing students in learning English?

Significance of the study
It is hoped that the result of formulation can be utilized to arrange and build up appropriate English materials according to nursing competence and their instructional strategic such as textbooks, modules, methods, techniques, and others to assist the educators in teaching and learning process. Then, the result of this development is supposed to be a reference and guidance for arranging the teaching materials, modules, or textbooks for nursing students particularly at STIKES Banyuwangi and generally for nursing students in Indonesia. This study is hopefully useful for English lecturers who teach in nursing majors as references to build up English materials that are closely interrelated with nursing major to improve the teaching and learning quality. For students this is useful to provide learning resources, especially in learning English for nursing and support their careers in the future.

Research Design
Hossain (2013) declared that every situation for needs analysis in teaching English is not always the same. The method selection used by each researcher depends on the time and resources available, and then the procedure used also depends on the researcher's accessibility to the research sample. The researchers used a descriptive qualitative in this study which described needs analysis to explore the needs, shortcomings, gaps, and desires in learning English in order to be able to make a good syllabus, lesson plan, and appropriate English instructional materials for nursing students. The technique in analyzing the data used descriptive analysis in the form of numbers and percentages.

Samples/Participants
This study was conducted at Sekolah Tinggi Ilmu Kesehatan (STIKES Banyuwangi) with the research subjects were 65 students of bachelor in nursing, 16 students of Diploma Three in nursing who were taking English subject in the 2021/2022 academic year at STIKES Banyuwangi, 2 heads of nursing study programs each from bachelor in nursing and diploma three in nursing, 3 ESP lecturers, 2 Indonesian nurses, 2 Indonesian nurses who work in overseas hospital.

Instruments
The instruments used to gather the data were questionnaire and interview about the needs of ESP learners due to its easiness to use and more practical. A closed-ended questionnaire was chosen, questions that have some answer options where the respondents can directly choose their options. The questionnaire consisted of 12 main questions to be answered by students. The structured interviews were conducted with heads of study program in nursing department, ESP lecturers, nurse practitioners who work in Indonesia and overseas hospital and some nursing students to collect information related to the materials needed by nursing students which can support the nurse career in the future. Then, class observations and studying relevant book sources and literature were conducted to support the data needed. After collecting needed information, a questionnaire of the students' needs was made, and then distributed to get the real data about the nursing students' needs.

Data analysis
The research results were analyzed descriptively. In analyzing data, researchers used the process of reduction from Miles & Huberman(1994). Data reduction is a means of concluding data, then sorting the data in the units of certain concepts, themes, and categories (Rijali, 2018).
It is hoped that the data from needs analysis would be a proper base for developing the product in the form of syllabus and English for nursing textbook.

Findings
Researchers had distributed a questionnaire which consisted of some close ended questions to get the results of students' needs analysis in learning English. Here are the results:

Figure 1. Students' Interest in Learning English
The figure 1 was about students' interest in learning English. 68% students stated that they were very interested to learn English in class, and 32% students were not interested to learn English because they think English is difficult subject and they do not really need English when they work, especially only working in local hospitals.

Figure 2. Students' English Learning Needs related to Nursing Major
Then the second question was whether the students need to learn English which is related to nursing major which was shown in figure 2. Most of respondents as many as 74 (82%) students declared agree, they need English materials which are related to nursing major in order to support their future career. The third question about students' level of language proficiency indicated that from four language skills, most of students (85%) assume that they were poor in speaking, followed by listening (78%) as many as 63 students. They feel better in reading and writing skill.  Table 2 showed that speaking ability is the most important language skills to be developed (79%) to meet the students' careers. Actually listening comprehension, speaking ability, reading skill, and writing are equally important because these four language skills must be taught in integrated way. Related to the students' goals in learning English were very diverse. Most of them learn English for working overseas (69%), supporting their future career (64%), continuing study (60%), getting better and brighter job (57%), communicating with friends and foreigners (48%), understanding reading text and articles (33%), for their success in the future (28%), and visiting other countries (26%).    In connection with the selection of materials that are appropriate with the students' major, the data was obtained that all 12 topics related to nursing field they considered important to be learnt.

Figure 7. Students' Perception on the Improvement of Their Interest in Learning English
Based on the research result in figure 7 revealed that approximately 70 students (86%) agreed that the application of appropriate English instructional materials related to nursing science as their major can improve their interest in learning English significantly.

Figure 8. Students' Preference in Learning/ Learning Style
The results of students' preference in learning English showed through lecturing (20 students), group work (16 students), work in pairs (11 students), small group discussion/SGD (10 students), using book reference (9 students), self learning (8 students), and reading journal articles (7 students).

Discussion
The figure 1 was about students' interest in learning English, 68% students stated that they were very interested to learn English in class, and 32% students were not interested to learn English because they think English is difficult subject and they do not really need English when they work, especially only working in local hospitals. Then the second question was whether the students need to learn English which is related to nursing major which was shown in figure 2.
Most of respondents as many as 74 (82%) students declared agree, they need English materials which are related to nursing major in order to support their future career. Some students claimed that the lecturers taught some materials only about the general English that had been taught in senior high school, so it was boring for some students.
Then the result of questionnaire about students' level of language proficiency indicated that from four language skills, most of students assume that they were poor in speaking because it requires good English skills. Speaking is a productive skill which is considered able to show the extent of someone's English proficiency level. Teaching speaking in ESP is indeed quite difficult. It is in line with (Megawati, 2016) who stated that creating a perfect ESP language class is not as simple as we think due to lack of practice frequency and the total of students' number in the classroom is overload. The second position was listening. During listening to English audios or videos, students experience difficulty as they cannot follow the fast rhythm of the native speakers while speaking.
In table 2 showed that speaking ability is the most important language skills to be developed to meet their careers, especially to communicate with patients from abroad and for those who aspire to work in overseas hospitals. It is in line with the research result from (Saragih, 2014) that most of students were more interested to increase speaking activity (70% students) during ESP learning followed by listening (50% students), and writing (38% students).
So the collage should facilitate them to increase their motivation in learning English. Like what stated by (Chovancová, 2014) if the educational institutions must examine their students' need according to their wishes to raise their enthusiasm and able to fulfill the need of their career. It proved that the student's eagerness to improve their speaking is in line with the job market need that demands the English communication skills well. However, actually listening comprehension, speaking ability, reading skill, and writing are equally important because these four language skills are taught integratedly. So that ESP lecturers must decide the teaching skill that become a focus and need more in-depth handling.
Related to the students' goals in learning English were very diverse starting from supporting their career, getting better and brighter job, communicating with friends and foreigners, working overseas, visiting other countries, continuing study, understanding reading texts and journal articles, and for the success of present education. In this question students could choose more than one options. Most of students learn English for working overseas (69%), supporting their future career (64%), and continuing study (60%). Some students also had other reasons in learning English such as they want to have tourist couple, to meet their idol abroad, make them easier to understand English films without having to read subtitles, access to various unique cultures in the World, and can be accepted at the reputable university.
In addition, from four figures (figure 3 to 6) above indicated that students expected an integrated and varied English instructional materials which are closely related to the nursing department which contain audio and video related to nursing on listening materials, dialogues related to nursing context for speaking practice, reading texts in the context of nursing science, and basic grammar and vocabularies about nursing terms as the basis for students to be able to communicate and write nursing care reports in English well. In connection with the selection of materials that are appropriate with the students' major, the data was obtained that all 12 topics related to nursing field they considered important to be learnt. There were 12 topics offered in the questionnaire according to consultation and interview results with 2 heads of nursing study programs each from bachelor in nursing and diploma three in nursing at STIKES Banyuwangi, 3 ESP lecturers, 2 Indonesian nurses, 2 Indonesian nurses who work in overseas hospital. These materials will be very useful in preparing students to face job competition. Based on the research result in figure 7 revealed that approximately 70 students (86%) agreed that the application of appropriate English instructional materials related to nursing science as their major can improve their interest in learning English significantly. It is correlated with the result of study (Puluhulawa et al., 2021) that 90% students declared if English materials related to nursing context can increase the level of interest in learning.
Besides, for the learning styles and activities some students had different tendencies, some students really like lecturing methods in which they listen the explanation from lecturers and do the assignments. On the other hands some students prefer self learning by using book reference, reading journal articles, pair works, group works, and small group discussion. Here are the results of students' preference in learning English through lecturing (20 students), group work (16 students), work in pairs (11 students), small group discussion/SGD (10 students), using book reference (9 students), self learning (8 students), and reading journal articles (7 students). It could be said that learners wish meaningful learning activities that appropriate with their learning styles. They expected clear explanations from lecturers, and relevant reference books and journal articles to support their study. Then related to the learning activities in the classroom will be combined and varied to represent the students' opinions. Talking about meaningful learning and the quality of teaching learning process in the classroom cannot be separated from the lecturers' roles.
Based on the interviews results with the head of bachelor in nursing and diploma three in nursing study programs, the outcomes expected by the nursing department are to create professional and qualified nurses who are able to be globally competitive. To meet the goals and demands of being able to be globally competitive, students must be equipped with sufficient English skills to supply their profession demands in the future. It is in line with the study conducted by Riwasanti et al., (2021)  The interview results of interviews with 2 nurses who work in Indonesia hospitals argued that they rarely used English in their every day work unless there were foreign patients because the majority of patients come from within the country so they do not need special skills in English. On the contrary, 2 Indonesian nurses who work in overseas hospitals stated that English is absolutely important because it is used to daily communication with patients, colleagues and superiors. In addition, we also asked for the English skills required by nurses in the workplace.
According to them, they serve foreign patients every day. Dialogues with patients are commonly related to nursing care in general, such as patients' admission, asking patients' condition, health problems, and past ill history, signs and symptoms, giving advice and instruction, health education, medical procedures, and regular examination. So that ESP English materials related to nursing is very necessary for students' future career development. It supported the study from (Irmawati et al., 2016) that 53% of graduates students that English related to nursing major could support their career as professional nurses.
Interview results with several nursing students about their difficulties in learning English, they mentioned that they lack of vocabulary and grammatical knowledge, difficulty in memorizing English vocabularies, it is quite difficult to pronounce the English words since it is extremely dissimilar with Indonesian, less confidence, they are afraid of producing errors or mistakes during speaking English, and afraid of being ridiculed by their friends. In listening context students were difficult to catch the point in the audio due to different accent and the speed of native speakers' voice. Students expect innovative, interactive, and varied activities in English teaching such as quizzes, assignments, and various fun activities, interesting games in order not to get bored.

Conclusion
Needs analysis is an effort to analyze and recognize the learners' needs in learning ESP.
Each learners has different reason in learning English depends on the major they take so it is believed that need analysis is crucial in ESP context due to enable lecturers, teachers, educators, practitioners, and writers to discover the real needs of learners. Needs analysis is badly needed to know the students' need in learning English. The research findings showed that nursing students need learning English materials (topics) which are related to their major and they believed that it could increase their learning motivation because it supports their future job. Thus, learning English for nursing students must consider students requirements in order that the compliace of their competence can be reached. By means of appropriate and integrated teaching methods, lecturers are able to present an precise learning environment for ESP students build upon their necessity and the learning goals that have been set. Needs analysis is not only the initial process on the ESP development, but also it may be used to evalute the on going process.

Suggestions
The researcher suggests that ESP lecturers teach English based on students' needs. They must make the content and theme/topic being taught based on the student's major because the topics that are in accordance with students' competence and performance will contribute to motivate students in order to participate more actively and feel comfortable in the learning process because they have a stronger connection with the material being studied and are expected to be more interested and motivated in learning. Researchers hope that this research can give impact on education and this research result can be developed and applied in curriculum design for nursing departments. Needs analysis is a continuous process as the students' necessity on ESP is constantly altering that also must be given to the study program so that the data obtained reflects the actual needs. In addition, the study about the problems faced by lecturers in implementing ESP learning is also important so that English learning can provide benefits for all parties.