Discuss about the Literature Review for International Nursing Students.
Nursing students face clinical as well as academic stress which contributes to psychological and physical problems (Shaban et al., 2012; Hamaideh et al., 2016; Yildirim et al., 2017). However, Mitchell (2017), He, Lopez & Leigh (2012), and Hansen &Sygeplejersken (2010) indicate that limited research are currently available to provide information about the experiences of international nursing students with stress and coping strategies. As a result, it is crucial that qualitative research be conducted to explore international nursing students’ stress and coping mechanisms. An in-depth analysis of causes of stress is vital to mitigating the intercultural challenges so as to promote an international educational culture (Shaban et al. 2012). There is a little attempt made to conduct research addressing International nursing students. This study aimed to fill the gaps in the literature related to international education so as to provide insight into areas that need more emphasis in future researches.
Following a search of the databases, a total of 47 research studies were included in this review. Searches were separately done for each area with keywords Stress, International students, nursing students, and coping strategies. The 47 research studies that met the inclusion criteria were taken from CINAHL, Psych info, ERIC and PubMed after the database search. The articles considered for inclusion included peer reviewed articles published in English language between 2008 and 2018. The participants in this study comprised a range of international nursing students and students from other educational programs (Inclusion and exclusion criteria have been attached in Appendix). The findings from the literature review were categorised into four principal areas: stress experienced by international students, stress experienced by international nursing students, stress coping strategies used by international students and stress coping strategies used by international nursing students.
Advancement in science and technology created emerging economies in many countries which made a direct prompt for young people to study abroad and broaden their opportunities globally (Hansen &Sygeplejersken, 2010). Furthermore, the European Higher Education Area (2012) found that International studies provide better career opportunities and economic stability for students, mainly for students from healthcare backgrounds. Nursing students who enrol in international programmes can improve their skills and knowledge for tackling global problems. Similarly, Best Healthcare Degrees and Health Programs (2018) revealed that European countries and the USA promote international nursing students to get better job opportunities in these countries after they graduate.
Ismail et al. (2016), Redfern (2015), Bai (2016), Yakunina et al. (2011), Hamamura et al (2016), and Wong et al (2014) identified higher level of stress prevalence among international students than native students. In addition, a survey conducted by University Kebangsaan Malaysia Medical Centre (UKMMC) in 2013 stated that 58% of International students suffer from stress-related mental health issues. Furthermore, Wong & Paul (2013) reported that there is higher level of suicidal rates in college students who came from diverse cultural background. All the above studies had identified some common stress factors such as lack of communication skills, cultural differences and academic pressure as predictors of stress. Specifically, studying in a second language hinders the students from expressing their thoughts in class. In addition, students who are brought up in countries where academic excellence is a cultural value experience academic stress as they seek meeting cultural expectations.
Although students benefit from international studies, they also face several adjustment problems. Boafo&Arthur (2014), Nasirudeen (2018), Akhtar&Kröner-Herwig (2015), Lee et al. (2014), Koyama (2018), Tavakoli et al. (2009), Wei et al. (2008), and Liu et al. (2016) reported that international students experience acculturative stress while they pursue academic studies abroad. Lueck & Wilson (2011) defined acculturation as a stress response of immigrants to acculturation. Akhtar &Kröner-Herwig (2015) assessed 652 international students. Data was collected by online survey comprised of Acculturative stress scale. Findings indicated that proficiency of the foreign language and previous travelling experience predicted a low level of acculturative stress in foreign students. Further, Lueck & Wilson (2011) and Yu et al. (2014) indicated that International students face acculturative problems as a result of language barrier. In particular, studying in a second language hinders the students’ from expressing their thoughts in class. Furthermore, financial insecurity especially from students from low income families results in stress. Similarly, cultural differences, changes in academic modules, and detachment from the family lead to stress. Yakunina et al. (2018), Lowinger (2018), Nilsson et al. (2008), and Myers-Walls et.al (2011) qualitatively studied the effects of stress on international studies. The results indicated that stress results in poor performance in exams and consequently longer stays in schools. In turn, students suffer from poor personal development and professional growth.
Turner and McCarthy (2017) showed that nursing students experience a different academic experience than their peer groups, which contributes to an increased level of depression. On the other hand, Hansen &Sygeplejersken (2010) revealed that international students face intercultural competencies while migrating to new country. In particular, He, Lopez and Leigh (2012) indicated that nursing students from eastern countries such as China have different norms and social beliefs such as low attendance to hospitals which create an unfamiliar background for them to practice in clinical settings.
Nasirudeen et al. (2014), Akhtar &Kröner-Herwig (2015), Paulakis et al. (2017), Han et al. (2017), Khoshlessan et al. (2015), and Chavajay et al. (2008) showed that international students experience stress due to social interactions, language barriers, financial crisis, cultural concerns, and study anxiety. Moreover, Nasirudeen et al. (2014), Lee et al. (2014), Mahmood et al. (2018), Redfern et al. (2016), and Yan et al. (2011) qualitatively studied the level of acculturative stress among international students and peer groups. The results indicated that international students experience a higher amount of stress than the peer group. On the other hand, Mahmood et al. (2018), Hansen et al. (2018), Chun et al. (2009), Choi & Chung (2014), Hansen &Sygeplejersken (2010), and Wang et al. (2017) examined the impacts of culture on stress. The results reported that changes in culture can create conflict, frustration, and stress in students who adopt a new culture.
Wei et al (2008) examined the stress caused by perceived discrimination of Asian international students from China, India, Korea, Taiwan and Hong Kong. Data was collected using online survey. Findings indicated that minority immigrants such as Asian students experience excess stress when they immigrate to European countries. In a similar study, Chun & Poole (2009) indicated that Asian international students have different cultural norms which creates unfamiliar environment while they pursue study in western countries. Furthermore, Myers-Walls (2010) qualitatively studied the effect of environment on stress among Asian international graduate students. The findings indicated that unfamiliar environment as a major stress factor among the participants. On the other hand, Huang et al (2016) indicated that maladaptive perfectionism results in increased risk of stress-related psychological problems in international students.
Further, Wong et al (2014) qualitatively explored 160 male university students to determine the effects of masculine identity on stress. The results of the study indicated that male international students with high masculine experience higher levels of stress than those with less masculine identities. Similarly, Boafo-Arthur (2013) indicated that Black –African students are more prone to the issues of racial discrimination which can lead to stress and depression.
Lazarus & Folkman (1984) proposed the cognitive-relational theory of stress and coping. However, the only studies that effectively concluded personal coping strategies in terms of acculturation were Ismail et al (2016), Wei et al. (2012), Chun et al. (2006), and Szabo et al (2011). The studies indicated that personal coping strategies were effective means of coping with stress. Lazarus and Folkman (1980) indicated that coping strategies play an important role in a person who exchanges his culture and lifestyle. In addition, the study revealed necessity of investigations in relation to stress and coping strategies. On the contrary, Ward, Bochner, &Furnham (2001) indicated that less is known about stress coping, especially in the context of International nursing students.
International students experience stress as a result of second language anxiety. Firstly, He, Lopez & Leigh, (2012) indicated that overseas nursing students are reported with moderate level of stress and sense of coherence in University schools of nursing in Australia. In addition, Phakiti et al. (2013) showed that a high prevalence of academic stressors is caused by second language difficulty in international nursing students. Further, Khawaja (2017) conducted a hierarchical regression analysis to determine the relationship between second language anxiety and academic related stress in international nursing students. The findings revealed that second language anxiety is directly related to academic stress.
International students employ a variety of coping strategies mechanisms to deal will academic related stresses (Poulakis, 2017). First and foremost, Han et al (2017) indicated that parental professor attachment can be functioning against acculturative stress since the parental professor can effectively orientate the student to adapt to the new culture. Particularly, Poulakis (2017) and Tung (2011) indicated that most students adapt this coping strategy to reduce the impact of stress caused by cultural transaction. On the other hand, Choi & Chung (2016), Akhtar et al. (2017), Law et al. (2016), and Lee et al. (2014) reported socio-cultural adaptation through community participation, social support and collectivism were reported as common coping strategies adopted by a significant number of international students. Specifically, adaptation has five subscales namely interpersonal communication, academic performance, ecology adaptation, community involvement, and language proficiency.
Yan et al (2011) conducted an examination of individual level factors in stress and coping. The results indicated that individual coping strategies are effective in reducing stress. Elsewhere, Kwadzo& Moses (2014), Michelle et al. (2013), and Wei et al. (2012) indicated that International students in higher education participated in leisure activities and spiritual activities as a way to effectively reduce stress. On the other hand, Law et al. (2012) showed that coping strategy of accepting responsibility for the cause of stress was found to be a positive reliever of stress in overseas students. Tavakoli et al. (2009) conducted a randomized trial to assess the effectiveness of expressive writing in stress management. The results reported a higher positive effect to cope up with stress through expressive writing. Finally, Yakunina et al (2011) indicated that group counselling is effective for coping with stress in international colleges. Specifically, group counselling assists the students to adapt to the new culture and lessen the home feel factor.
There is limited research on the strategies available to address stress by international nursing students (Khawaja, 2017). In an exploratory descriptive quantitative study, He, Lopez, & Leigh (2012) indicated that second language adaptation is an individual coping strategy for international nursing students’ acculturative stress. Further, Khawaja (2017) recommended the need of second language support in nursing universities so as to cope with English language barrier. On the other hand, Nasirudeen (2018), Akhtar &Kröner-Herwig (2015), Lee et al. (2014), Wong & Paul (2013), Ismail et al. (2016), Phakiti et al. (2013), and Yakunina et al. (2011) indicated that social support and religious coping is employed by some nursing students to decrease the level of stress. These studies showed that religious and social support is a key strategy to managing stress by decreasing stress factors.
Conclusion
Nursing students experience high levels of stress related to different cultures as well as language barrier. Stress being a psychological phenomenon, it affects the level of nursing students’ academic performance and wellbeing. As a result, it is vital that the nursing students develop coping mechanisms to help deal with the challenges arising from stress. Common stress factors include lack of communication skills, cultural differences and academic pressure as predictors of stress. Coping strategies include social support and second language adaptation, and group counselling. It is crucial to prioritize the strategies so that stress is minimised among the international students.
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