Systematic Review: Experience of International Nursing Students

This systematic review evaluates the experience of international nursing students during their studies abroad. The review aims to identify negative and positive experiences of nurses related to studying in foreign countries and assess the challenges or facilitators of pursuing nursing programs or courses abroad.

Running head: SYSTEMATIC REVIEW
Systematic review
Name of the student:
Name of the University:
Author’s note

1SYSTEMATIC REVIEW
Table of Contents
Chapter 3: Methodology..................................................................................................................2
Aim and objectives:.........................................................................................................................2
Inclusion and exclusion:..................................................................................................................2
Search strategy:................................................................................................................................3
Data extraction:................................................................................................................................7
Data analysis and synthesis:..........................................................................................................23
Risk of bias assessment:................................................................................................................23
Summary:.......................................................................................................................................26
Reference:......................................................................................................................................27
Appendix:......................................................................................................................................30

2SYSTEMATIC REVIEW
Chapter 3: Methodology
Aim and objectives:
The main aim of the systematic review is to evaluate the experience of international
nursing students during their studies in abroad. The main objectives of the systematic review are
as follows:
 The examine the live experiences of international nursing students of studying abroad
 To identify negative and positive experiences of nurses related to studying in foreign
countries
 To assess the challenges or facilitators of pursuing nursing program or courses abroad.
Inclusion and exclusion:
To get relevant articles that can meet the key aim and objectives of the review, the search
process was guided by the following inclusion criteria:
Type of research articles: As the main aim is to evaluate experience of international nurse, all
types of qualitative studies, systematic reviews and quantitative studies should be included for
the review.
Type of publication: Only those research articles need to be included in the review which is
published within the year 2010 to 2018.
Type of participants: The main sample of interest for all studies should be nursing students.

3SYSTEMATIC REVIEW
Intervention studied: The main intervention should be exposure to a foreign country for nursing
education.
Language used in the study: Only those articles need to be taken in the review which are
published in English Language.
Type of outcomes evaluated: The main focus of all the included studies should be to evaluate the
experiences of nurses studying in international countries. The main outcome of interest can be
the quality of experience, satisfaction with the experience and quality of life.
There were certain exclusion criteria for the studies too. The studies were excluded if:
 The participants for the research were registered or other nurses apart from the student
nurses
 Those studies would be excluded where study or experience were evaluated in home
countries of nursing students and not in foreign countries
 Research articles published before 2010 were excluded
 Research studies published in other languages were excluded
Search strategy:
The search strategy is guided by the use of PRISMA checklist where all relevant
information sources or database has been used to retrieve relevant articles related to the study
topic. Full electronic search strategy for the database has been presented with the use of specific
data collection and data abstraction process. The advantage of the use of PRISMA while writing
the systematic review is that the PRISMA checklist has all the items deemed necessary for
transparent reporting of a systematic review. The PRISMA flow diagram is an effective process

4SYSTEMATIC REVIEW
to review and segregate articles for analysis and systematic review. The different phases of
systematic review such as identification, screening, eligibility and inclusion provide a good
overview of the search process. Use of the checklist ensures transparent and complete reporting
of systematic reviews (Liberati et al. 2009). The discussions mentioned below gives an overview
about database used, key search term, number of hits achieved and a summary of the search
process by going through the four phases of systematic review.
Search methods:
A comprehensive search process was used to select all research articles that are related to
the topic of the systematic review. The databases that were searched to select research articles for
the systematic review included CINAHL, ProQuest and PsychINFO. The rationale for selecting
the above database is that all of them published peer-review research literature in the field of
biomedical and health care and there are high chances to get maximum number of hits from these
databases. With the availability of peer-reviewed research studies in thee databases, the
reliability of the work can be high. The search process in all the databases were limited by setting
the publication date from 2010 to the current data. Other limits used during the search process
include age and language. For example, as the main population of interest were nursing students,
the age limits of participants that were necessary for all research articles were 19-44 years.
English was used as one of limits to narrow down the search process.
Several keywords and other terms were used in various combinations to retrieve high
quality and suitable research articles for the review. Boolean operator ‘AND’ was applied in
along with several groups of similar search terms to retrieve research articles. The key search
terms included ‘experience’ or ‘attitudes’, international’ or ‘foreign’ or ‘overseas’, ‘nursing

5SYSTEMATIC REVIEW
students’ or ‘student nurse’ or ‘undergraduate nurse’, ‘academics or education’ and ‘In Abroad’.
The eligibility criteria for selection of articles were determined by comparison with inclusion and
exclusion criteria. The number of hits achieved for each databases, specific key terms used and
details of key resources and action has been provided in Table 1 in appendix.
Research summary:
The process of identifying articles from database search and the number of articles
excluded or included with rational has been provided by the PRISMA flow diagram. It gives
clear idea about the identification stage by giving details on the records identified through data
base search and other articles retrieved from other sources. The screening of articles has been
done by removing duplicate. This section gives an overview of the screening stage of the
systematic review. The number of articles assesses for eligibility and the final selection of
articles based on the eligibility criteria has been provided in the form of PRISMA flow Diagram
below:

6
Records identified through
database searching
(n = 50 )
Additional records identified
through other sources
(n =10 )
Records after duplicates removed
(n = 20 )
Records screened
(n = 30 )
Records excluded
(n =10 )
Full-text articles assessed for
eligibility
(n = 25 )
Studies included in
systematic review
(n =10 )
Full-text articles
excluded, with
reasons
(n = 15)
SYSTEMATIC REVIEW
Figure 1: PRISMA flow diagram for the selection of research articles.

7SYSTEMATIC REVIEW
Data extraction:
The studies selected on the basis of eligibility criteria were extracted and summarized
according to the following data extraction table.
Table 2: Summary of included studies
Author,
year &
Countr
y of
study
Research
question
or study
aim
Research
design
Data
collection
including
research
instrumen
ts
Sample
details
Key
findings
and
conclusi
on
Limitation
s
Comments
on quality
&
significanc
e of study
to your
review
Cruz et
al.
(2018),
Saudi
Arabia
To assess
cultural
competenc
e among
nursing
students
from nine
countries
Descriptive
cross
sectional
study
design was
used to
collect data
from nine
countries
like India,
Chile,
Africa,
Iraq, Saudi
Arabia,
Phillipines,
Sudan and
Turkey
Self-
administe
red
questionn
aire
survey
method
was used
to collect
data from
participan
ts. The
tool was
used in
two parts.
The first
part of the
survey
collected
data
related to
participan
t’s
characteri
The
sample
for the
study
include
d
particip
ants
from
nursing
school
in all
the nine
countrie
s. The
criteria
for
selectio
n was
that the
sample
for the
study
should
The
overall
analysis
revealed
moderat
e range
of
cultural
compete
nce
among
students
. The
compete
nce
level
differed
based
on
country
of
residenc
e, age,
gender,
The
sample
size for
the study
was too
large and
recruitmen
t from
very few
institution
s limited
the quality
of the
study.
The study
is of
moderate
quality and
the
relevance
of the
article to
this study
is that
gives idea
about
experience
of nurse
related to
cultural
competenc
e
developed
as part of
nursing
education.

8SYSTEMATIC REVIEW
stics and
cultural
related
experienc
e. The
part 2 of
the survey
used 20-
item
Cultural
capacity
scale to
rate the
response
of
participan
ts
be full
time
BSN
student
in the
second
to
fourth
year
level
and
voluntar
y
indicati
on to
particip
ate.
year of
study
and
attendan
ce at
culture
related
training
Long
(2014),
United
States
The main
aim of the
study was
to analyse
the
influence
of two
week
medical
service
learning
experience
on cultural
competenc
e, self-
efficacy
and
learning
experience
of student
nurses
travelling
abroad to
The
research
used mixed
method
study
design to
first expose
the
participants
to the
intervention
and then
collect data
related to
experience
and self-
efficacy.
Pre-
interventi
on survey
tools were
used to
collect
data
related to
previous
cultural
diversity
training,
foreign
language
training
and
internatio
nal travel
experienc
e. After
interventi
on,
quantitati
The
particip
ants for
the
study
include
sixteen
student
nurse
from
the
College
of
Nevada
who
particip
ated in
a 14-
day
internati
onal
service
learning
The
results
from the
study
gave the
idea that
experien
ce of
nursing
students
varied.
The
themes
related
to the
experien
ce
included
culture
shock,
increase
d self-
awarene
The
limitation
of the
study
included
lack of
considerati
on
regarding
the
blinding to
eliminate
risk of
bias.
The
research is
of
moderate
quality
evidence.
It gives
implicatio
n
regarding
the need
for cultural
competenc
e training
of
educators.
The
relevance
of the
study is
that it
provides
insight

9SYSTEMATIC REVIEW
Belize,
Central
America.
ve data
related to
cultural
efficacy
was
collected
from
Cultural
Efficacy
Self scale.
Quantitati
ve data
evaluated
self-
reflective
journals
of
research
participan
t.
health
trip
with a
non-
profit
organiz
ation
called
Internat
ional
Service
Learnin
g to the
Central
Americ
an
country
Belize
ss,
gratitud
e and
feelings
for the
people
they
worked
with.
about
experience
of student
nurses
related to
travel
abroad for
study or
training.
Gillilan
d et al.
(2016)
The
purpose of
the study is
to get an
insight into
the
learning
experience
of nursing
and
pharmacy
students
during
internation
al travel to
learn about
the
country,
people and
Mixed
method
study
design by
experiment
al approach
was used to
collect data
from
research
particioants
.
Self-
administe
red
instrumen
ts like
Clinical
Cultural
Competen
cy
Questionn
aire and
the
researcher
-designed
demograp
hic
questionn
aire was
used to
Nursing
students
enrolee
in the
travel to
China
and
travel to
India
were
include
d in the
study
The
exposur
e to
internati
onal
travel
improve
d
knowled
ge
related
to
culture
and
cultural
practice
significa
ntly.
Small
sample
size and
lack of
randomiza
tion were
some
limitation
of this
research.
The study
is of
moderate
quality and
its
relevance
with
current
research
topic is
that the
main
emphasis
of the
study is on
nursing
student’s
experience
of

10SYSTEMATIC REVIEW
the health
care.
collect
data
related to
cultural
competen
ce and
demograp
hics
respective
ly.
Qualitativ
e data
were
obtained
from
demograp
hic
questionn
aire.
travelling
abroad.
Sealey
and
Hathor
n 2014.
The aim of
the study
was to
examine
the lived
experience
of US
nursing
students
while
collaborati
ng with
Honduran
nursing
during a
study
Qualitative
research
design was
used with t
use of
transcenden
tal
phenomeno
logy
approach.
Data was
collected
from
participan
ts by the
use of
audio-
recorded
semi-
structured
interview
method.
Interview
questions
covered
details on
learning
experienc
e, self-
examinati
on of
The
particip
ants for
the
study
include
d
Hondur
an and
Americ
an
nursing
students
Six
themes
related
to
commu
nication,
cultural
environ
ment
and
sharing
and
learning
emerged
.
Evaluati
on of
particip
ant’s
respons
e
As the
sample for
the study
were taken
only from
two
universitie
s, it
influenced
the
generaliza
bility of
research.
The
findings
cannot be
applicable
for other
setting.
The
research is
of high
quality as
it gives in-
depth idea
regarding
student
nurse
experience
. The
study is
also
relevant to
the
systematic
review
topic as it
highlights
internation
al travel

11SYSTEMATIC REVIEW
abroad
program in
Honduras
beliefs
and
values,
personal
developm
ent and
internatio
nal
experienc
e
revealed
benefits
of
internati
onal
program
in
developi
ng
cultural
compete
nce of
nursing
students
.
experience
of nursing
students.
Charles
et al.
(2014)
The aim of
the study
was to
examine
the lived
experience
of third
year
undergradu
ate
Australian
nursing
students
regarding
participatio
n in a 5
week
cultural
immersion
program in
India
Qualitative
descriptive
research
design was
used to
evaluate
participant’
s response
Reflective
journal
were used
to collect
data for
the study.
The
particip
ants for
the
study
include
Australi
an
nursing
students
taking
part in
cultural
immersi
on
progra
m in
Tamil
Nadu
The
result
gave
rise to
five
theme
of Focus
on self,
focus on
differen
ce,
recognit
ion of
validity
of
different
system,
working
within
the
cultural
infrastru
cture,
and
applicati
The study
is limited
by its
small
sample
size.
The study
is of
moderate
quality as
it gives
inconsiste
nt result
related to
learning
experience
of nursing
students.
As it
evaluates
an
internation
al travel
experience
of nursing
students, it
is relevant
to the
systematic
review

12SYSTEMATIC REVIEW
on and
transfer
ability.
Overall,
the
study
undersc
ored the
importa
nce of
internati
onal
travel
experien
ce in
cultural
compete
nce
develop
ment
among
nursing
students
topic.
De
Natale,
M.L.
and
Waltz,
C.L.,
2015
Americ
a
The aim of
the
research is
to analyse
the planned
learning
experience
of the
internation
al nursing
students
(California
) in Ireland
where they
participate
d three-
week
Qualitative:
thematic
analysis of
the open
ended
questionnai
re directed
towards the
internationa
l students
Qualitativ
e data
collection
approach.
The
themes
were
generated
from the
personal
reflection
of the
internatio
nal
nursing g
students
15
master
degree
nursing
students
from
the
Univers
ity of
Californ
ia were
include
d in a
intervie
w of
three
open
The
findings
of the
study
suggeste
d that
the three
week
summer
immersi
on
program
helped
the
nursing
students
to
The
interview
questionna
ire
avoided
questions
like the
what are
the
challenges
if any that
were
experience
d by them
during
their
course of
This study
will help
to analyse
the
positive
aspect of
the
obtaining
study in
abroad by
the
internation
al nursing
students

13SYSTEMATIC REVIEW
summer
immersion
training
program
ended
questio
nnaire.
The
reflectio
n was
collecte
d after
two
years
generate
cultural
awarene
ss and
increase
knowled
ge about
the
healthca
re
system
training in
Ireland
Poor
sample
size
Maltby
et al.
(2016)
The aim of
the
research
was to
evaluate
the
experience
of
American
nursing
students
who
completed
a study
abroad trip
to a low
income
country
Banglades
h and
Netherland
Quantitativ
e research
by the use
of
hermeneuti
c or
interpretive
phenomeno
logy
approach
The lived
experienc
es of
participan
ts were
collected
by the use
of
reflective
journals.
The
journals
were
analysed
using the
g
Lindseth
and
Norberg's
(2004)
phenomen
ological
hermeneu
tical
methodol
ogy of
text
interpretat
ion
The
particip
ants for
the
study
include
d 45
undergr
aduate
nursing
students
who
particip
ated in
study
abroad
progra
m for
four
years in
Banglad
esh and
Netherl
and
The
findings
of the
study
revealed
that
student’
s
cultural
conciou
sness
increase
d after
the
travel
experien
ce and
this was
indepen
dent of
the
place
visited.
The
conclusi
on from
the
study
The
limitation
found in
the study
is the use
of small
sample
size
The
significanc
e of the
study is
that it
highlights
the fact
that
perception
of all
nursing
students
change
whether
they travel
to high
income or
low
income
country. It
suggested
the need to
enhance
cultural
consciousn
ess by
encouragin
g nursing
students to

14SYSTEMATIC REVIEW
was to
revise
nursing
curricul
a so that
nurses
can
develop
their
cultural
compete
nce
engage in
reflective
journaling
Philips,
L.,
Bloom,
T.,
Gainey,
T. and
Chiocc
a, E.,
2017
The aim of
the study
was to
elucidate
the
importance
of the very
short study
abroad
programs
among the
under
graduate
nursing
students.
Qualitative
study via
the
instrument
of interview
questions
The
narratives
of the
students
were
recorded
as per the
pre and
post travel
semi-
structured
yet open-
ended
prompts
dealing
with the
expectatio
ns and the
subsequen
t
perceptio
ns of the
culture,
happiness
and
healthy.
The data
analysis
The
focus
group:
62
senior
baccala
ureate
nursing
students
who
travelle
d for 2
weeks
to the
Cape
Coast,
Ghana
in
between
their
semeste
rs for a
special
faculty-
led
commu
nity
health
The key
findings
of the
study
indicate
d that
the
student
percepti
ons of
culture
demonst
rated a
progress
ion
through
the
numero
us
stages
of the
cultural
compete
nce. The
analysis
of the
themes
like
The main
limitation
of the
study is, it
mainly
highlighte
d the
themes
from the
response
of the
African
American
students
(n=3).
Since the
sample
size is
low, the
generated
themes
may lead
to the
generation
of biased
results.
The
significanc
e of the
study is, it
helped to
identify
the
importanc
e of short
aboard
study
among the
internation
al students
towards
building
the
cultural
sensitivity
along with
a special
focus on
the
importanc
e of
adaptabilit
y of the
internation

15SYSTEMATIC REVIEW
was done
on the
basis of
qualitativ
e
descriptiv
e style
approach.
clinical
experie
nce.
culture,
relations
hips
with the
commu
nity and
proper
definitio
n of the
health
and
happine
ss lead
to the
elucidati
on of
the fact
that the
training
or study
in
aboard
help to
increase
the
overall
adaptabi
lity
from
different
cultural
backgro
und.
Even
under
the short
term
study,
the
adaptabi
al nursing
students
on the
exposure
of the
aboard
training

16SYSTEMATIC REVIEW
lity
quotient
was
high
Gower,
S.,
Duggan
, R.,
Dantas,
J.A.
and
Boldy,
D.,
2017
Australi
a
nursing
student
s
To study
the level of
understand
ings of the
prevailing
global
health
issues
among the
nursing
students
after they
have taken
active
participatio
n in an
internation
al clinical
placement
during the
tenure of
their pre-
registration
university
level
nursing
education
A
retrospectiv
e cross-
sectional
design.
This
particular
design was
employed
via using an
exploratory,
descriptive
style
qualitative
approach
Data
collection
was done
via the
use of the
individual
ised semi-
structured
interview
questions.
The
responden
ts mainly
recorded
their lived
experienc
e. Data
analysis
was done
via
thematic
data
analysis
25 pre-
registrat
ion
nursing
students
from
Western
Australi
an
universi
ties who
underto
ok their
clinical
placeme
nt
across
five
differen
ce
countrie
s.
The key
findings
of the
study
indicate
d
students
who
underwe
nt
clinical
placeme
nts
abroad
during
2014
develop
ed new
understa
ndings
about
their
health
care
systems
includin
g the
concept
of
fragility
of the
resource
access,
differen
ces
about
The main
limitation
of the
study is its
poor
sample
size that
may lead
to the
generation
of biased
results
The
challenges
and the
benefits
which are
experience
by the
internation
al nursing
students
will help
the
researcher
to develop
a critical
analysis of
the
internation
al training
of the
nursing
students

17SYSTEMATIC REVIEW
their
clinical
practise
methods
and
variance
s in
their
respecti
ve
nursing
roles in
different
settings.
The
study
conclud
ed that
the
internati
onal
clinical
placeme
nts can
help to
develop
greater
awarene
ss and
help to
the
nursing
students
in the
domain
of the
realistic
strategie

18SYSTEMATIC REVIEW
s via
employi
ng their
global
nursing
skills
obtained
through
the
internati
onal
training.
The
study
also
highligh
ted that
the pre-
placeme
nt
training
in the
domain
of
cultural
awarene
ss and
in the
health
system
realities
plus
strong
supervis
ory
support
is
importa
nt for
the

19SYSTEMATIC REVIEW
overall
success
of the
nursing
students
.
Hilde,
C.,
Marion,
W. and
Marian
ne, N.,
2018
The main
aim of the
study is to
critically
explore the
lived
experience
of the
Flemish
midwifery
students
who are
undertakin
g an
internship
in the
Suriname.
Qualitative
research
design via
Hermeneuti
c
phenomeno
logical
method
Qualitativ
e data
collection.
All the
interviews
were
audio-
taped and
then
transcribe
d
verbatim
and then
they were
analyzed
thematical
ly
Seven
midwife
ry
nursing
students
from
one
Univers
ity
College
were
selected
purpose
fully for
an in-
depth
intervie
w
during
the
course
of their
abroad
internsh
ip from
October
to
Novem
ber
2014.
The key
findings
of the
study
indicate
d
students
who
underwe
nt
clinical
placeme
nts
abroad
during
2014
develop
ed new
understa
ndings
about
their
health
care
systems
includin
g the
concept
of
fragility
of the
resource
access,
differen
The main
limitation
of the
study is its
poor
sample
size that
may lead
to the
generation
of biased
results
The
challenges
and the
benefits
which are
experience
by the
internation
al nursing
students
will help
the
researcher
to develop
a critical
analysis of
the
internation
al training
of the
nursing
students

20SYSTEMATIC REVIEW
ces
about
their
clinical
practise
methods
and
variance
s in
their
respecti
ve
nursing
roles in
different
settings.
The
study
conclud
ed that
the
internati
onal
clinical
placeme
nts can
help to
develop
greater
awarene
ss and
help to
the
nursing
students
in the
domain
of the

21SYSTEMATIC REVIEW
realistic
strategie
s via
employi
ng their
global
nursing
skills
obtained
through
the
internati
onal
training.
The
study
also
highligh
ted that
the pre-
placeme
nt
training
in the
domain
of
cultural
awarene
ss and
in the
health
system
realities
plus
strong
supervis
ory
support
is
importa

22SYSTEMATIC REVIEW
nt for
the
overall
success
of the
nursing
Data analysis and synthesis:
The initial number of studies that were selected via the search of the keywords from the
databases was screened for the removal of the duplicate. The selected unique studies were then
screened on the basis of their tiles. The shortlisted articles which have qualified on the basis of
their titles were then screened via study of the abstract. The detailed of the study of the abstract
of the short listed articles lead to exclusion of the some articles. The articles which were selected
after the short listing of the abstract are then analysed in a standard tabular format. The Data
from the selected studies were systematically extracted via the use of the standard tabulated
format (as discussed in table: 4). In order to stringently address the aims and the objectives of
the research, the data were extracted on the basis of the aim of the selected study, the research
design, the process employed for the purpose of the data collection, the sample details (focus
group selected), the key findings of the research, the associated research limitations and the
interlinkage of the chosen study with the aims and objectives of the research (Miles, Huberman,
and Saldana 2013). The finally selected articles were then passed through the quality appraisal
tool, AMSTAR.
Quality appraisal:

23SYSTEMATIC REVIEW
The criteria used for accessing the finally selected study were mainly based on the
AMSTAR quality appraisal tool. According to Harrison et al. (2016), the quality in the research
included two main aspects that is methodological and reporting quality. Here quality is not
associated with the importance of the topic or enjoys ability of the research but the term
“quality” is associated with the values of the research. The methodological quality of the
research is associated the research design and the manner in which the entire research is
conducted and how the fundamental understandings of the results relates with the level of
confidence in the findings of the research (Harrison et al. 2016). So in order to critically analyse
the quality of the research, the researcher here will use AMSTAR critical appraisal tool.
According to Shea et al. (2007), AMSTAR critical appraisal tool is a measurement tool that is
used to assess the methodological quality of the systematic reviews. AMSTAR is an abbreviated
from of assessment of multiple systematic reviews. This tool consists of 11 items that provides
good face along with proper content validity for measuring the overall methodological quality of
the systematic reviews. Proper analysis of the systematic reviews via the critical appraisal tools
help in the quality assessment of the research papers based on the research design and the
methodology used. This quality assessment helped the researcher to select quality rich paper that
will help to stringently address the research aims and objectives.
Risk of bias assessment:
Apart from analysis of research findings and results, evaluation of methodological quality
of research article is also essential to understand the reliability and transferability of the research
work. Bias is a systematic error found in results or other stages of research that can lead to
underestimation of overestimation of the true intervention effect. Consideration of risk of bias in
each study and differences in risk of bias may help to understand variation in the studies included

24SYSTEMATIC REVIEW
in the systematic review. A research article with rigorous methodology are more like to provide
results closer to reality that those with bias in sample selection or analysis method (Moher et al.
2015).
` To conduct risk of bias assessment for the included studies in this systematic review, the
Cochrane Risk of Bias Assessment tool has been used. It is a tool that supports an appraiser to
identify different kinds of bias in research such as performance bias, selection bias, detection
bias, attrition bias and other kinds of bias (Sterne, Higgins and Reeves 2015). The following
criteria have been used to consider an article to have the following biases:
Selection bias: Selection bias can be identified by the presence of systematic differences in
baseline characteristics of research participants. By the use of Cochrane risk of Bias Assessment
tool, two types of bias assessment can be identified. These include random sequence generation
and allocation concealment. Risk of bias in allocation sequence is identified by analysing the
method used to generate allocation sequence. Inadequate generation of randomized sequence
means selection bias is present. Bias in allocation concealment can be identified by reviewing the
method used to conceal the allocation sequence.
Performance bias: Performance bias may arise by identifying differences in the treatment of
intervention and control group apart from the exposure to intervention. Effective blinding is the
process to minimize performance bias. Blinding of participants and study personnel may denote
that the study is free from performance bias.
Attrition bias: Attrition bias can be identified by events like poor follow-up and withdrawal from
clinical trials. This may lead to incomplete data. The Cochrane risk of bias assessment tools

25SYSTEMATIC REVIEW
supports researchers to identify attrition bias by analysing whether attritions and exclusions were
reported in the study or not.
Detection bias: Detection bias relates to identification of differences in groups by the method of
measuring the outcome. Detection bias may arise when assessors have the knowledge about the
allocated intervention.
Other kinds of bias: Apart from the above mentioned sources, other forms of bias identified in
research study may include risk of biasness in design or possibility of bias due to contextual
issues found in clinical setting (Higgins et al. 2011).
The risk of bias assessment will be summarized in the form of following risk assessment
table:
Table 3: Risk of bias assessment table
References Sequence
generation
Allocation
concealmen
t
Blinding of
participants
Blinding of
outcome
assessor
Incomplete
Outcome
date
Other
source of
bias
Author et al.
year
+ + ? - + -
The symbols as mentioned above in the table denote the level of bias found in the studies.
Positive signs in the table will indicate high risk of bias in the assigned section and negative sign
will indicate low risk of bias. In addition, question mark sign indicates unclear risk of bias.

26SYSTEMATIC REVIEW
Summary:
The systematic review gave a summary about the methods used to retrieved articles
related to experience of international nursing students regarding studying abroad. The PRISMA
checklist was followed to report about the systematic review and cover important sections such
as eligibility criteria, search strategy, data analysis and quality appraisal method. This chapter
provides an insight into inclusion and exclusion criteria used to collect research articles. The
search strategy and the process of screening and including research articles have been provided
in the form of PRISMA flow diagram. The analysis of research articles is first done by the
review of title and abstract. The second stage focus on review of full articles. Furthermore, the
quality appraisal of the research article has been done with the use of AMSTAR tool and the
Cochrane Risk of Bias assessment tool. The data extraction table gives an overview of the study
and significance of the research findings.

27SYSTEMATIC REVIEW
Reference:
Charles, L., Maltby, H., Abrams, S., Shea, J., Brand, G. and Nicol, P., 2014. Expanding
worldview: Australian nursing students’ experience of cultural immersion in
India. Contemporary nurse, 48(1), pp.67-75.
Cruz, J. P., Aguinaldo, A. N., Estacio, J. C., Alotaibi, A., Arguvanli, S., Cayaban, A. R. R., ...and
Idemudia, E. S. 2018. A Multicountry Perspective on Cultural Competence Among
Baccalaureate Nursing Students. Journal of Nursing Scholarship, 50(1), 92-101.
De Natale, M.L. and Waltz, C.L., 2015. Reflections of nursing students travel abroad
experiences in Ireland: A global nursing perspective. Nursing Education Perspectives, 36(3),
pp.188-189.
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.
Gower, S., Duggan, R., Dantas, J.A. and Boldy, D., 2017. Something has shifted: Nursing
students’ global perspective following international clinical placements. Journal of advanced
nursing, 73(10), pp.2395-2406.
Harrison, J.K., Reid, J., Quinn, T.J. and Shenkin, S.D., 2016. Using quality assessment tools to
critically appraise ageing research: a guide for clinicians. Age and ageing, 46(3), pp.359-365.

28SYSTEMATIC REVIEW
Higgins, J.P., Altman, D.G., Gøtzsche, P.C., Jüni, P., Moher, D., Oxman, A.D., Savović, J.,
Schulz, K.F., Weeks, L. and Sterne, J.A., 2011. The Cochrane Collaboration’s tool for assessing
risk of bias in randomised trials. Bmj, 343, p.d5928.
Hilde, C., Marion, W. and Marianne, N., 2018. The lived experiences of flemish midwifery
students undertaking an internship in Suriname: A phenomenological study. Nurse education in
practice, 30, pp.79-85.
Liberati, A., Altman, D.G., Tetzlaff, J., Mulrow, C., Gøtzsche, P.C., Ioannidis, J.P., Clarke, M.,
Devereaux, P.J., Kleijnen, J. and Moher, D., 2009. The PRISMA statement for reporting
systematic reviews and meta-analyses of studies that evaluate health care interventions:
explanation and elaboration. PLoS medicine, 6(7), p.e1000100.
Long, T., 2014. Influence of international service-learning on nursing student self-efficacy
toward cultural competence. Journal of Nursing Education, 53(8), pp.474-478.
Maltby, H.J., de Vries-Erich, J.M. and Lund, K., 2016. Being the stranger: Comparing study
abroad experiences of nursing students in low and high income countries through hermeneutical
phenomenology. Nurse education today, 45, pp.114-119
Miles, M.B., Huberman, A.M. and Saldana, J., 2013. Qualitative data analysis. Sage.
Moher, D., Shamseer, L., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., Shekelle, P. and
Stewart, L.A., 2015. Preferred reporting items for systematic review and meta-analysis protocols
(PRISMA-P) 2015 statement. Systematic reviews, 4(1), p.1.

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Philips, L., Bloom, T., Gainey, T. and Chiocca, E., 2017. Influence of short-term study abroad
experiences on community health baccalaureate students. Journal of Nursing Education, 56(9),
pp.528-533.
Sealey, L.J. and Hathorn, D., 2014. The lived experience of Honduran and USA nursing students
working together in a study abroad program. The Qualitative Report, 19(48), pp.1-20.
Shea, B.J., Grimshaw, J.M., Wells, G.A., Boers, M., Andersson, N., Hamel, C., Porter, A.C.,
Tugwell, P., Moher, D. and Bouter, L.M., 2007. Development of AMSTAR: a measurement tool
to assess the methodological quality of systematic reviews. BMC medical research
methodology, 7(1), p.10.
Sterne, J.A.C., Higgins, J.P.T. and Reeves, B.C., 2015. on behalf of the development group for
ACROBAT-NRSI. A Cochrane Risk Of Bias Assessment Tool: for non-randomized studies of
interventions (ACROBAT-NRSI), Version 1.0. 0, 24 September 2014. 2014-10-11)[2014-10-21]
http://www. riskofbias. info.

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Appendix:
Table 1: SEARCH STRATEGY TABLE
Date
Research
Topic
Search
Strategy
Key
concepts
Synonyms/alternative
terminology(consider regional variations
here also) – combine using OR
“Experiences” or Attitudes
“International”, or “foreign”
“Nursing students or Student Nurses
Education or nursing programs
Eligibility
criteria
AND
AND
AND
AND

31SYSTEMATIC REVIEW
related to
the topic
(these are
informed by
your knowledge
prior to
conducting the
search)
Research papers published within 2010 to 2018
Table 4: Quality Appraisal tool (AMSTAR)

32SYSTEMATIC REVIEW