What Experiences Do International Nursing Students Face When They Go Abroad To Study?
The initial screening phase involved reading the title and the abstract of the shortlisted studies, followed by a decision regarding their inclusion and exclusion. The procedure for selecting studies that can be included in a systematic review is quite complex. Following a thorough read of the abstracts and the titles, a quality assessment was conducted for the studies. The aim of this systematic review was to identify the experiences that are faced by international nursing students, while they study abroad. For the aforementioned purpose, the following research question was asked:
What experiences do international nursing students face when they go abroad to study?
The full text of the articles were critically appraised and each study was selected on the basis of the following criteria:
This question was answered with the help of a systematic review. If the answers to any of the above given questions were ‘no’, the articles were further read and excluded if they did not meet the criteria.
The characteristics of the articles were based on the following inclusion criteria:
Some of the exclusion criteria formulated for the article selection were as follows:
The integrity of the process that involved study selection at the outset was evaluated by piloting these inclusion and exclusion criteria on some subset of studies that were selected from a bibliography composed of the candidate studies. Furthermore, the reliability of the studies were also tested before deriving themes from them. The inclusion and exclusion criteria were subject to modifications for better identifying the relevant studies. The abstracts that were found in the journal databases of the selected articles typically included statement of the problem, a clear description of the participants recruited in the study, and thorough specifications for the experimental design.
This was followed by thematic analysis, the most common analysis employed in qualitative research that emphasised on the examination and record of themes or patterns within the retrieved data. The themes were identified as patterns across the available dataset that was essential for the description of the phenomenon being studied, which in turn was specifically associated to the research question. The themes contained descriptions and ideas that helped in explaining statements, causal events and morals.
A study conducted by Kent-Wilkinson et al. (2015) tried to explore the factors that might play an important role in influencing the decisions of nursing students to study abroad. An estimated 84% nursing students indicated that their international experiences of studying abroad were primarily characterised by high interest, which in turn was associated with a range of perceived benefits. They also reported an increased interest in rural clinical experiences. Students in another study also stated that CALD programs fostered a sense of belonging, and helped the students to develop cherished friendships, thereby making them feel important and valued (Boughton, Halliday and Brown 2010). Another study reported that Chinese international students most commonly faced acculturative stress that most often resulted in their failure to share experiences (He, Lopez and Leigh 2012). Significant differences were also found in the ASSIS scores between the 2nd and 3rd year nursing students. Similar findings were presented by another article where the nursing students emphasised on having complex experiences upon meeting the family members of deceased patients (Arieli 2013).
They elaborated on the fact that emotional difficulties were commonly faced by them, followed by a dilemma between their professional duty and the need of providing support to the family members. Other accounts of emotional challenges were also presented by the students where they encountered situations that were emotionally draining where they had to take efforts to maintain emotional distancing from the patients or their relatives. Lived experiences of nursing students were illustrated in another study where all the international nursing students were found to gain the capability of recognising their self and ethnocentrism, on the basis of cultural experiences. Culture shock was greatly associated with low self-confidence and made the students redefine their nursing objectives. Furthermore, it resulted in open-mindedness and helped them to emphasis on their sense of sight. They were a witness to diverse and sensory experiences. In addition, they also considered themselves as intruders in the new environment and began adapting to the situation (Edmonds 2010).
Some of the most common challenges faced by the nursing students were being looked at mysteriously owing to their accent of speaking, dress, and the behaviour manifested (Edmonds 2010). This was a major form of discrimination. Another article reported that the orientation of international students to mainstream culture played an important role in mediating the relationship between their destination loyalty intention and the discrimination perceived by them (Jamaludin et al. 2018). International nursing students also gave less number of positive responses regarding the fact that classroom experiences assisted them in initiating comfortable interactions with people belonging to diverse cultures (Carpenter and Garcia 2012). Findings from another study elaborated on the fact that the lack of transcultural nursing among the international students was a major barrier owing to the fact that the nurses failed to demonstrate an idea on the definition of the concept. Thus, the absence of adequate emphasis on the concept of transcultural care in nursing education curriculum was an alleged obstacle.
Furthermore, cultural diversities were also experienced around language (37%) and pronunciation differences (53.4%) were also some of the challenges encountered (Ayaz, Bilgili and Ak?n 2010). Poor facilities encountered by the students in the nursing schools, stark differences between the public and private health facilities and the stratified levels of health care were some of the most common encounters that nursing students with experiences of studying abroad were found to report (Gilliland et al. 2016). Lack of cultural competency was found to act as major challenges in nursing education and this called for the need of bringing about an increase in the preparedness of the international nurses in the related field. 71% students identified lack of funding as a major barrier of pursuing education abroad. Job obligations (23%), commitment towards relationships (19%), and family responsibilities (30%) were other perceived barriers in the process of gaining education abroad (Kent-Wilkinson et al. 2015). Owing to differences in the education system abroad and their previous learning experiences, students found their expectations to be confounded within the first few weeks of reaching a different country. Lack of expertise in online learning and research, in addition to differences in academic roles were other supposed barriers that prevented them from approaching their lecturers. The nursing students also reported a failure in striking balance between their academics and family life (Clerehan et al. 2012).
Living with the expectations to cope up with the presenting problems were a major positive experience encountered by the nursing students. Although the nursing students most often reported difficulties in not being able to share their feelings or experiences, they showed an interest in adopting coping strategies that would help them get rid of their failures and would facilitate adaptation to the new environment. Furthermore, they also emphasised on the fact that in spite of the emotional turmoil, they were most often driven by their personal ambitions that made them recognise the need of doing something to overcome their difficulties (Harvey, Robinson and Welch 2017). Findings from a study also illustrated the fact that the nursing students reported an increase in their cultural self-efficacy and subsequent cultural competence while pursuing higher education abroad. Therefore, an increase in cultural competence and their associated skills were considered by the nurses as a major positive impact of their education abroad (Kohlbry 2016).
Other studies also provided evidence for an increase in cultural awareness and understanding among the students. This helped them to get rid of the myths and stereotype opinions that they initially has about particular cultures. The stay abroad allowed the students to gain a sound understanding of the local culture and also facilitated the process of adapting to it. Other students also stated that one positive impact was related to their increase in respect for the cultural difference and appreciation for the cultural uniqueness. Significant increase in language proficiency of the new country was another benefits of studying abroad (Carpenter and Garcia 2012). Similar findings were reported by another study that indicated that cultural differences led to a positive impact on the students by allowing them recognise the necessity of taking into consideration the major cultural differences, thereby utilising the opportunity to learn about the cultures and develop effective interpersonal relationships (Ayaz, Bilgili and Ak?n 2010). Speaking at least one language that was different to the native language of the students was perceived as another advantage. This helped them better interact with patients belonging to different cultural backgrounds (Repo et al. 2017).
Cultural differences were also found to have negative impacts on the students by resulting in difficulties that arose from communication with CALD patients. Due to the fact that the patients abroad spoke different language or their pronunciation were not easy to decipher, the students often failed in delivery quality care (Ayaz, Bilgili and Ak?n 2010). A sense of coherence and acculturative stress encountered by the international nursing students were regarded as the foremost negative effects of studying abroad. This made their learning journey stressful and resulted in barriers in the enhancement of their overall well-being (He, Lopez and Leigh 2012).
Resentment and disgust were also reported by several nursing students in another research where they stated that clinical placements abroad resulted in their exposure to unpleasant smells and sights, which in turn often made the students perceive nursing as a profession that encompasses dirty tasks. Crisis regarding career choices were also encountered by many where their stay in different countries made them question the motivation and capacity to become a nursing professional. Poor relations with clinical instructor were also considered as a negative effect (Arieli 2013). Other articles elaborated on presence of chaotic driving, stereotypic attitudes, unsanitary bathrooms and differences in food as undesirable (Gilliland et al. 2016). Cultural differences were also though to greatly contribute on the low competencies of the students in collecting information on the health, illness, beliefs, or behaviours of the culturally diverse service users, thereby affecting their overall cultural competence (Cruz et al. 2018).
Adaptation to the differences in experiences was facilitated by CALD programs that helped the students to clarify their doubts and speak out in group sessions. The study experiences abroad also resulted in the development of valued friendships with other CALD students (Boughton, Halliday and Brown 2010). Recognition was found to play an important role in enabling the students to demonstrate a compassionate and patient attitude towards their clients, and subsequently resulted in an increase in self-awareness. Diverse encounters also enhanced the bonding experiences with fellow students belonging to different cultures and also provided an opportunity to explore the surrounding environment. This in turn increased their sense of appreciation for all historical sites that were located in and around the new locality. This helped them to adapt to the new culture by overcoming their cultural shock (Edmonds 2010).
Adaptation to the new land was also facilitated by gaining a sound understanding of the cultural preferences of the service users that made the nursing students uphold their beliefs with patient care. Conducting a thorough observation of health promotion practices were also identified as life-changing experiences that made the students adapt to the situation by holding new thoughts on their life. The students also stated that acquiring new skills and knowledge also facilitate them to deliver high quality patient care (Carpenter and Garcia 2012). Adapting to the environment was facilitated by acknowledging the honour, and religious beliefs of the patients. This provided a basis for gaining a deeper understanding of the behaviour of the people in the new land. Understanding the cultural traditions for the family members of the patients also assisted the process of adaptation to the environment (Ayaz, Bilgili and Ak?n 2010).
References
Arieli, D., 2013. Emotional work and diversity in clinical placements of nursing students. Journal of Nursing Scholarship, 45(2), pp.192-201.
Ayaz, S., Bilgili, N. and Ak?n, B., 2010. The transcultural nursing concept: a study of nursing students in Turkey. International nursing review, 57(4), pp.449-453.
Boughton, M.A., Halliday, L.E. and Brown, L., 2010. A tailored program of support for culturally and linguistically diverse (CALD) nursing students in a graduate entry Masters of Nursing course: a qualitative evaluation of outcomes. Nurse Education in Practice, 10(6), pp.355-360.
Carpenter, L.J. and Garcia, A.A., 2012. Assessing Outcomesof aStudy Abroad Course for nursing students. Nursing Education Perspectives, 33(2), pp.85-89.
Clerehan, R., McCall, L., McKenna, L. and Alshahrani, K., 2012. Saudi Arabian nurses’ experiences of studying Masters degrees in Australia. International nursing review, 59(2), pp.215-221.
Cruz, J.P., Aguinaldo, A.N., Estacio, J.C., Alotaibi, A., Arguvanli, S., Cayaban, A.R.R., Cecily, J., Shaji, H., Machuca Contreras, F.A., Hussein, A. and Idemudia, E.S., 2018. A Multicountry Perspective on Cultural Competence Among Baccalaureate Nursing Students. Journal of Nursing Scholarship, 50(1), pp.92-101.
Edmonds, M.L., 2010. The lived experience of nursing students who study abroad: A qualitative inquiry. Journal of Studies in International Education, 14(5), pp.545-568.
Gilliland, I., Attridge, R.T., Attridge, R.L., Maize, D.F. and McNeill, J., 2016. Building cultural sensitivity and interprofessional collaboration through a study abroad experience. Journal of Nursing Education, 55(1), pp.45-48.
Harvey, T., Robinson, C. and Welch, A., 2017. The Lived Experiences of International Students Who’s Family Remains at Home. Journal of International Students, 7(3), pp.748-763.
He, F.X., Lopez, V. and Leigh, M.C., 2012. Perceived acculturative stress and sense of coherence in Chinese nursing students in Australia. Nurse Education Today, 32(4), pp.345-350.
Jamaludin, N.L., Sam, D.L., Sandal, G.M. and Adam, A.A., 2018. The influence of perceived discrimination, orientation to mainstream culture and life satisfaction on destination loyalty intentions: the case of international students. Current Issues in Tourism, 21(8), pp.934-949.
Kent-Wilkinson, A., Leurer, M.D., Luimes, J., Ferguson, L. and Murray, L., 2015. Studying abroad: Exploring factors influencing nursing students’ decisions to apply for clinical placements in international settings. Nurse education today, 35(8), pp.941-947.
Kohlbry, P.W., 2016. The impact of international service?learning on nursing students’ cultural competency. Journal of Nursing Scholarship, 48(3), pp.303-311.
Repo, H., Vahlberg, T., Salminen, L., Papadopoulos, I. and Leino-Kilpi, H., 2017. The cultural competence of graduating nursing students. Journal of Transcultural Nursing, 28(1), pp.98-107.
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