International nursing students bring important cultural and economic opportunities to universities, and support and diversify the professional nursing workforce.1 They contribute to the promotion of international higher-education programs, student mobility globally, and the growth of international research collaborations, furthering opportunities for students to study in Western and non-Western settings.2 Extending student mobility globally has been acknowledged as having an important role and responsibility in helping reduce global health inequality through access to global health care education, practice, and research collaboration.3 International students make substantial social and financial investments to study in another country and it is important that their learning experiences are positive, supportive, and satisfying.2 Currently, research examining international nursing students’ experiences with, or perceptions of, their learning environment during their studies suggests factors such as satisfaction,4 confidence,5-8 and competence9 can enhance or detract from a positive experience. There does not appear to be agreed-upon outcomes to ensure students’ experiences are being captured. Further research is required to provide a sound evidence base to improve the students’ experiences while studying overseas.
Debate continues about what a learning environment entails.10 A broad definition encompassing the education continuum describes it as “an environment in which any person who has the opportunity to influence the care of a patient learns.”11(p.1) Learning for clinical practice as a registered nurse requires understanding, integration, and application of theoretical knowledge.2 The definition of learning environment in this study refers to all learning settings included in international nursing undergraduate studies, including the classroom, tutorial, laboratory, simulation, and clinical placements. While the definition by Chappell11 is broad, it is inclusive of theoretical, clinical, and practical learning environments that make up undergraduate nursing education.1 The learning environment is explained by Nordquist and colleagues12 as including diverse, digital, educational, socio-cultural, and psychological elements of learning. Edgecombe1 indicates that the experiences of international nursing students’ learning require consideration of the academic, clinical, and social contexts. Further, Chappell11 suggests that creating a safe health care learning environment across all settings is a critical responsibility of tertiary and health service leaders.
International students are defined differently in each country, however, most definitions specify that the student is not a citizen of the country where they are studying.13 The length of time they have resided in the country where they are studying may vary, such as in the case of those with refugee status; however, the majority of international or foreign students travel to the country for the purpose of the program of study. In this review, international nursing students are those who are enrolled in a higher-education institution to gain registration as a registered nurse in a country other than their normal place of residence.1 Research has focused on ways to improve international nursing students’ learning outcomes. Several studies report the experiences of the facilitators who support the international students,8,14 while others measure the impact educational interventions, such as peer-mentoring14 and simulation,10 have on international students’ demonstrated knowledge and skills. Diversity of health care systems and practices was identified, by both students and clinical facilitators, as a challenge to learning. This challenge was associated with reduced satisfaction and confidence with clinical learning among international nursing students.4 Demonstrated confidence with communication skills during simulation learning has been linked to improved skill acquisition and satisfaction among international health care students, including nursing students.10,8 In addition, much emphasis is placed on English as a second language, where problems responding to the cultural needs of patients in a second language have been reported.1,14,15 This is not surprising given that most of the research is conducted in English-speaking settings where issues with language are considered problematic.1 It is not clear how these challenges can influence international nursing students’ experiences during their clinical learning across a range of settings.15
A systematic review, conducted almost a decade ago, examined the experiences of international nursing students.16 The review highlighted cultural and communication barriers, which amplified their experiences of exclusion and isolation during the international students’ studies.14,15,17,18 The review also emphasized the need to recognize and value difference in the clinical learning, academic, and social context, and to provide better support and encouragement to international students to enhance their experience. However, the review was not limited to undergraduate students and also included experiences of graduate and postgraduate international nursing students.9,19 More recently, experiences of isolation and inadequate support were reported by nursing students in a qualitative study by Jeong and colleagues.4 In a follow-up discursive paper, factors that impacted psychological well-being experienced by the students included increased stress, exposure to discrimination, social isolation, and reduced quality of life and self-care.19
Primary quantitative research examining international nursing students’ perspectives and experiences in their learning environments focuses on interventions such as mentorship,14,8 simulation activities,10 communication skills,7 and supervision.20 Further, measures and concepts to evaluate such interventions vary. They include satisfaction,5 skills, confidence,6,10 and competence.20,21 Given the contribution by international nursing students to the education sector, professional workforce, and the economy, it is essential to understand and respond effectively to their clinical learning needs.1,15,16 It is equally important that their learning environment is positive and for higher-education opportunities to continue to be attractive.5,22
To guide primary research on this topic, it is necessary to scope the interventions already studied, and the experiential outcomes for international nursing students within their learning environment. The results will inform primary research by identifying possible interventions and outcome measures to provide a synthesis of findings on which to draw and compare.
A preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews, JBI Evidence Synthesis, and Open Science Framework was conducted and no current or in-progress systematic or scoping reviews on the topic were identified. A systematic review conducted in 2012 by Terwijn and colleagues16 examined international nursing students’ experiences during their studies in English-speaking universities. This scoping review will include both qualitative and quantitative studies, will not be limited to English-speaking universities, and will include a further eight years of research.16 A recent scoping review exploring the psychological well-being of international students in the health professions was also found; however, it included all international health science students.21 This scoping review aims to investigate the factors that influence international undergraduate nursing students’ experiences and perceptions of their learning environments to guide and inform primary research in this area.
- What factors enhance international nursing students’ experiences or perceptions of their learning environment?
- What factors detract from international nursing students’ positive experiences or perceptions of their learning environment?
- What concepts are used to describe and explore international nursing students’ experiences or perceptions of their learning environment?
The review will consider studies that include undergraduate international nursing students. For this review, international nursing students are defined as those enrolled in a nursing program in a higher-education institution in a country that is not their own.1 As the definition of international student varies between countries,13 studies reporting on foreign students and those who have not been granted permanent residency of the country where they are studying will be included. Nursing students who are refugees may also be included within some participant samples, however, they will not be sought separately. To be included, the international students will have to be studying onshore. Students whose educational preparation is vocational or leads to registration to work under the supervision of registered nurses will be excluded; this includes courses to become an enrolled nurse, associated degrees in nursing, licensed practical nurses, and licensed vocational nurses. Studies of exchange students and those undertaking an international placement during their program will be excluded.
In line with the review questions, the two concepts are as follows.
Concept 1: The factors reported by international nursing students that positively or negatively influenced their perceptions or experiences of the learning environment. Factors that influenced their experiences may include, but are not limited to, peer support, language programs, communication skills, mentorship, preceptorship, and learning strategies, such as simulation.
Concept 2: Concepts used to measure or describe the international nursing students’ experiences or perceptions will also be scoped and may include, but are not limited to, satisfaction, confidence, attitude, and self-reported views of competence. Within quantitative studies, these concepts may be measured by instruments such as the motivated strategies for learning questionnaire,10 the satisfaction with life scale,23 the job satisfaction scale,24 the Clinical Learning Environment Inventory (CLEI),25 and attitudinal scales about skill acquisition.10 Only instruments with proven reliability and validity will be included. Any perceptions or experiences reported by educators, mentors, or clinical facilitators who support international nursing students, will be excluded.
The learning environment will include any environment where clinical learning occurs as part of a nursing program within the higher-education sector.11 This will include, but is not limited to, learning that has occurred in the classroom (large and small groups), lecture theater, laboratories, self-directed learning such as online learning activities, and during clinical placement in any health care setting. Studies from any country will be considered for inclusion.
Types of sources
This scoping review will consider peer-reviewed primary research of both quantitative and qualitative designs. Experimental and quasi-experimental study designs, including randomized controlled trials, non-randomized controlled trials, before and after studies, and interrupted time-series studies, will be considered. In addition, analytical observational studies, including prospective and retrospective cohort studies, case-control studies, and analytical cross-sectional studies will be considered for inclusion. The review will also consider descriptive observational study designs, including case series, individual case reports, and descriptive cross-sectional studies.
Qualitative studies to be considered include, but are not limited to, designs such as phenomenology, grounded theory, ethnography, qualitative description, action research, and feminist research. In addition, mixed methods studies that meet the inclusion criteria will also be considered. Reviews and conference abstracts will be excluded.
The proposed review will be conducted in accordance with the JBI methodology for scoping reviews.26
The search strategy will aim to locate both published and unpublished primary studies. An initial limited search of MEDLINE (Ovid) and CINAHL (EBSCO) was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles, were used to develop a full search strategy for MEDLINE (Ovid; see Appendix I). This search strategy has been peer reviewed by the PRESS Forum and includes suggested amendments. This peer-reviewed search strategy, including all identified keywords and index terms, will be adapted for each included information source. The reference lists of all studies selected for inclusion will be screened for additional studies.
Studies published since 1995 will be included. This period will capture the increased international student mobility that commenced at that time and became an important part of the global higher-education landscape.13 Studies published in languages other than English that can be translated using translation software will be considered.
The databases to be searched include CINAHL (EBSCO), MEDLINE (Ovid), Embase (Ovid), Emcare (Ovid), PsycINFO (Ovid), Web of Science Core Collection, Scopus, and ScienceDirect.
The search for unpublished studies and gray literature will include Google Scholar, ProQuest Dissertations and Theses, CORE, and BASE.
Following the search, all identified citations will be collated and uploaded into EndNote v.X9.3.1 (Clarivate Analytics, PA, USA) and duplicates removed using Bramar's method.27 Titles and abstracts will then be imported into Rayyan (Qatar Computing Research Institute, Doha, Qatar) and screened by two independent reviewers for assessment against the inclusion criteria. Potentially relevant studies will be retrieved in full and their citation details imported into Rayyan. The full text of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of full-text studies that do not meet the inclusion criteria will be recorded and reported in the scoping review. Any disagreements that arise between the reviewers at each stage of the study selection process will be resolved through discussion or with a third reviewer. The results of the search will be reported in full in the final scoping review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) flow diagram.28
Data will be extracted from each paper included in the scoping review by one reviewer and will be checked by a second reviewer independently. A data extraction tool developed by the reviewers will be used (see Appendix II). The data extracted will include specific details about the population, concepts, context, study methods, and key findings relevant to the review objective. The draft data extraction tool will be piloted, modified, and revised as necessary during the process of extracting data from each included study. Modifications will be detailed in the full scoping review report. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required.
Data analysis and presentation
The extracted data will be presented in diagrammatic or tabular form in a manner that aligns with the objective of this scoping review. Descriptive characteristics including year of publication, country of origin, the population, methods used, and the concepts addressed will be tabulated. Findings extracted from qualitative studies will undergo descriptive content analysis. In combination with findings from quantitative studies, they will be organized and presented in the form of mind maps where concepts will be named and illustrated according to their frequencies. The findings may be classified and named appropriately under conceptual groups, such as learning strategies or communication strategies, and associations between concepts will be shown. A narrative summary will accompany the tabulated characteristics and mind maps to describe how the results relate to the review's objective.
This scoping review forms part of a research study that is supported by a Faculty of Health Sciences Innovation and Scholarship of Learning and Teaching (iSOLT) grant awarded by the School of Nursing Midwifery and Paramedicine at Curtin University, Western Australia. This funding does not in any way influence the research findings or reporting of this review.
Appendix I: Search strategy
1946 to October 9, 2020
Date searched: October 12, 2020
Appendix II: Data extraction instrument
1. Edgecombe K, Jennings M, Bowden M. International nursing students and what impacts their clinical learning: literature review. Nurse Educ Today 2013;33 (2):138–142.
2. Mikkonen K, Elo S, Tuomikoski A, Kaariainen M. Mentor experiences of international health care students’ learning in a clinical environment: a systematic review. Nurs Educ Today 2016;40:87–94.
3. Frenk J, Chen L, Bhutto Z, Cohen J, Crisp N, Evans T, et al. Health professional for a new century: transforming education to strengthen health systems in an interdependent world. Lancet 2010;376:1923–1958.
4. Jeong SY, Hickey N, Levett-Jones T, Pitt V, Hoffman K, Norton CA, et al. Understanding and enhancing the learning experiences of culturally and linguistically diverse nursing students in an Australian bachelor of nursing program. Nurse Educ Today 2011;31 (3):238–244.
5. Papastavrou E, Dimitriadou M, Tsangari H, Andreou C. Nursing students’ satisfaction of the clinical learning environment: a research study. BMC Nurs 2016;15 (44):1–10.
6. Mikkonen K, Merilainen M, Tomietto M. Empirical model of clinical learning environment and mentoring of culturally and linguistically diverse nursing students. J Clin Nurs 2020;29 (3/4):653–661.
7. Mikkonen K, Elo S, Miettunen J, Saarikoski M, Kääriäinen M. Development and testing of the CALDs and CLES+T scales for international nursing students’ clinical learning environments. J Adv Nurs 2017;73 (8):1997–2011.
8. Korhonen H, Tuomikoski A-M, Oikarainen A, Kääriäinen M, Elo S, Kingäs H, et al. Culturally and linguistically diverse healthcare students’ experiences of the clinical learning environment and mentoring: a qualitative study. Nurse Educ Pract 2019;41:102637.
9. Amaro DJ, Abriam-Yago K, Yoder M. Perceived barriers for ethnically diverse students in nursing programs. J Nurs Educ 2006;45 (7):247–254.
10. Laschinger S, Medves J, Pulling C, McGraw R, Waytuck B, Harrison, et al. Effectiveness of simulation on health profession students’ knowledge, skills, confidence and satisfaction. JBI Libr Syst Rev 2008;6 (7):265–309.
11. Chappell K. The clinical learning environment: improving the education experience and patient outcomes within Magnet organizations. J Nurs Adm 2016;46 (1):1–3.
12. Nordquist J, Hall J, Caverzagie K, Snell L, Chan MK, Thoma B, Razack S, et al. The clinical learning environment. Med Teach 2019;41 (4):366–372.
13. Figueroa CI, Morales B, Sharma AD. International student mobility: trends in first-time graduate enrollment. J Acad Admin High Ed 2012;8 (2):55.
14. Carragher J, McGaughey J. The effectiveness of peer mentoring in promoting a positive transition to higher education for first-year undergraduate students: a mixed methods systematic review protocol. Syst Rev 2016;5:68.
15. Junious DL, Malecha A, Tart K, Young A. Stress and perceived faculty support among foreign-born baccalaureate nursing students. J Nurs Educ 2010;49 (5):261–270.
16. Terwijn R, Pearce S, Rogers-Clark C. A systematic review of the experiences of undergraduate nursing students choosing to study at an English speaking university outside their homeland. JBI Evid Synth 2012;10 (2):66–186.
17. Deluca EK. Crossing cultures: the lived experience of Jordanian graduate students in nursing: a qualitative study. Int J Nurs Stud 2005;42 (6):657–663.
18. Gardner J. Barriers Influencing the success of racial and ethnic minority students in nursing programs. J Transcult Nurs 2005;16 (2):155–162.
19. McKenna L, Robinson E, Penman J, Hills D. Factors impacting on psychological wellbeing of international students in the health professions: a scoping review. Int J Nurs Stud 2017;74:85–94.
20. Mikkonen K, Elo S, Miettunen J, Saarikoski M, Kääriäinen M. Clinical learning environment and supervision of international nursing students: a cross-sectional study. Nurse Educ Today 2017;52:73–80.
21. Harvey T, Robinson C, Frohman R. Preparing culturally and linguistically diverse nursing students for clinical practice in the health care setting. J Nurs Educ 2013;52 (7):365–370.
22. Rogan F, Miguel CS, Brown D, Kilstoff K. ’You find yourself.’ Perceptions
of nursing students from non-English speaking backgrounds of the effect of an intensive language support program on their oral clinical communication skills. Contemp Nurse 2006;23 (1):72–86.
23. Diener E, Emmons RA, Larsen RJ, Griffin S. The satisfaction with life scale. J Pers Assess 1985;49 (1):71–75.
24. Heritage B, Pollock C, Roberts LD. Confirmatory factor analysis of Warr, Cook, and Wall's (1979) job satisfaction scale. Aust Psych 2015;50 (2):122–129.
25. Chan D. Development of the clinical learning environment inventory: using the theoretical framework of learning environment studies to assess nursing students’ perceptions
of the hospital as a learning environment. J Nurs Educ 2002;41 (2):69–75.
26. Peters MDJ, Godfrey C, McInerney P, Munn Z, Tricco AC, Khalil H. Aromataris E, Munn Z. Chapter 11: Scoping Reviews. JBI, JBI Manual for Evidence Synthesis [internet]. Adelaide:2020.
27. Bramer WM, Guistini D, de Jonge GB, Holland L, Bekhuis T. De-duplication of database search results for systematic reviews in EndNote. J Med Libr Assoc 2016;104 (3):240–243.
28. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. The PRISMA-ScR statement. Ann Intern Med 2018;169 (7):467–473.