A Literature Review on Experiences of International Nursing Students

This literature review synthesizes research on the experiences of international nursing students studying abroad, focusing on their transition, educational challenges, and both positive and negative experiences. The review identifies key themes such as acculturative stress, cultural competence development, language barriers, and the impact of cultural differences on patient care. It highlights the role of support programs in helping students adapt and the importance of cultural awareness in nursing education. The reviewed studies reveal that while international students face significant challenges, they also experience personal and professional growth, increased cultural understanding, and enhanced language proficiency. The review also touches upon negative experiences like feelings of resentment, career choice crises, and difficulties in adapting to new healthcare environments.

Running head: MASTERS IN NURSING
Chapter 3
Name of the Student
Name of the University
Author Note

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Study selection
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:
 Do these articles address a clearly focused question?
 Do these articles rely on the application of valid methods for addressing the question?
 Are the results presented in the article valid and important?
 Are the valid results applicable to the population of interest?
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.
Study characteristics
The characteristics of the articles were based on the following inclusion criteria:
 The title or abstract must have explicitly stated that the title of the article that was in
accordance with the research question
 The articles focused on experiences and reports of international nursing students

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 The articles were either journal papers, thesis or reports.
 Articles were published in English
 They were published not prior to 2008.
 The articles were accessible in full-text format
Some of the exclusion criteria formulated for the article selection were as follows:
 Articles were not published in English
 The retrieved documents were an introduction to some form of proceedings or were
an editorial
 The articles were not based on the domain of international nursing student’s
experiences abroad
 The full-text eligibility of the articles could not be assessed
 The articles were some kind of duplicates of texts that already existed in the set.
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

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specifically associated to the research question. The themes contained descriptions and ideas
that helped in explaining statements, causal events and morals.
Thematic analysis
Experiences of international nursing students transitioning to another country
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

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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).
Perceived educational challenges of international nursing students studying abroad
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 Akın 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

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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).
Positive experiences
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).

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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 Akın 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).
Negative experiences
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 Akın 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

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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).
Adapting and adjusting with different experiences
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

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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 Akın 2010).

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