Investigating Malaysian Nurses' perspectives of intercultural teaching in transnational higher education learning environments

Accepted Manuscript Investigating Malaysian Nurses' perspectives of intercultural teaching in transnational higher education learning environments

Nirmala Devi Arunasalam, Robert Burton PII: DOI: Reference:

S0260-6917(18)30300-9 doi:10.1016/j.nedt.2018.07.011 YNEDT 3922

To appear in:

Nurse Education Today

Received date: Revised date: Accepted date:

13 December 2017 13 June 2018 19 July 2018

Please cite this article as: Nirmala Devi Arunasalam, Robert Burton , Investigating Malaysian Nurses' perspectives of intercultural teaching in transnational higher education learning environments. Ynedt (2018), doi:10.1016/j.nedt.2018.07.011

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ACCEPTED MANUSCRIPT Investigating Malaysian Nurses’ Perspectives of Intercultural Teaching In Transnational Higher Education Learning Environments Type of paper: Research paper 1.Dr Nirmala Devi Arunasalam, EdD, SFHEA, PGDip, MSc, BSc, DipHE in Nursing, RN 2.Associate Professor Robert Burton, EdD, RNLD, FHEA, CMI, MBA, MEd, BSc (Hons)

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1.School of Nursing and Midwifery, University of Plymouth, United Kingdom 2.School of Nursing and Midwifery, Griffiths University: Singapore

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Correspondence address: Dr Arunasalam: 104, 3 Portland Villas, University of Plymouth, Drake Circus, Plymouth, PL4 8AA. Email address: [email protected]

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Word count: 5471

ACCEPTED MANUSCRIPT Abstract Background: In recent years, many ASEAN countries, including Malaysia have embraced Transnational Higher Education (TNHE) post-registration top-up nursing degree programmes. These are bridging programmes that allow registered nurses to upgrade their diploma qualifications to a degree level. Purpose: To investigate the teaching and learning experiences of Malaysian nurses on Transnational Higher Education post-registration top-up degree programmes in Malaysia.

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Design: Hermeneutic phenomenology and the ethnographic principle of cultural interpretation were used to explore the views of eighteen Malaysian nurses from two UK and one Australian TNHE universities (determined by convenience and snowball sampling methods) to ensure data saturation. Semi-structured interviews were conducted in English and Bahasa Malaysia (Malaysian language) to enable nurses' voices to define, describe and evaluate their TNHE classroom experiences. Data Analysis: Data was analysed using thematic analysis.

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Findings: The nurses' experiences within the short one or two weeks TNHE intercultural teaching and learning environment identified four categories: language and teaching and learning issues; TNHE degree requirements, guidance and support; shock and coping strategies and acclimatisation. They suggest there was a conflict between the assumptions and expectations of the TNHE 'flying faculty' and nurses' about the programme of study. There were also mismatches between Western and Malaysian pedagogical preferences, guidance and support, and professional values.

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Implications for Education / Practice: There is a need for TNHE 'flying faculty' to internationalise the theoretical knowledge to reduce cultural incongruities and dissimilarities. Cultural immersion will stimulate intercultural views and knowledge to equip nurses for promotional and/or global opportunities whilst enabling the 'flying faculty' to create new learning environments. The research provides insights to inform TNHE provider institutions to improve teaching and learning to enable nurses to make the theory-practice connection.

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Background The globalisation-internationalisation nexus in Higher Education (HE) has led to the internationalisation of HE, ‘… Internationalization is definitely past the “new flavor of the month” stage. It is firmly embedded in institutional mission statements, policies, and strategies as well as national policy frameworks. This signals that internationalization has come of age and is a legitimate area of policy, practice, and research in higher education’ (Knight, 2011:14). The fundamental focus of Western Higher Education Institutions (HEIs) is towards market expansion, global recognition and raising their international profile. This is driven by political, economic, educational, social and technological advances (O’Mahony, 2014). Ziguras & McBurnie (2015) and Leshchenko and Avshenyuk (2015) suggest that this globalisation of education has emerged as a result of differing standards and levels of educational systems becoming evident (due to globalisation), exposure to distance and virtual education, and leading to the emergence of transnational providers.

ACCEPTED MANUSCRIPT Internationalisation via partnerships with western countries developed quickly in South East Asia. These partnerships include international activities such as student and faculty mobility programmes, research partnerships, international academic programmes, as well as international campuses, franchises and a variety of face to face or distance delivery modes (Bovill, Jordan & Watters, 2015, Choudada, 2013, and Mercado & Gibson, 2013). Ahmad and Buchanan (2016) suggest the term ‘glocal’ describes a generation of students with global ambitions yet prefer to stay in their own region for education. Collaborative partnerships make this possible. Malaysia is one country seen to have deliberately positioned itself as an educational hub for such transnational developments (Sidhu and Christie, 2015).

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Some university Nurse Education providers in the UK and Australia developed collaborative links with Malaysian organisations to provide Transnational Higher Education (TNHE) part-time top-up nursing degree programmes delivered by ‘flying-faculty’. With these ‘flying faculty’ models of TNHE programme delivery, western academics ‘fly in’ from their country for delivery of teaching. These academics then ‘fly back’ to their country on completion of the teaching period (Smith, 2014). Most courses are delivered over two years, with blocks of one or two weeks teaching delivered in each semester by the ‘flying faculty’. Following these block periods, only email contact and online support is available to the students studying on these courses. Such post-registration top-up nursing degree programmes are bridging programmes that allow Diploma qualified nurses the opportunity to upgrade their existing qualifications to degree level.

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The Malaysian Nursing Board allows private HEIs connected with public universities and private colleges allied to private hospitals to make collaborative links with UK and Australian HEIs, to heighten the status of nurses and to develop nurses’ mind-sets to enhance patient care. Qualified and registered Malaysian nurses are motivated to upgrade their diploma to a TNHE degree level (due to the status attached to the western degrees), and meet the Malaysian Nursing Board (2008) enforced Continuous Professional Education criterion for annual re-license. A previous Chief Nurse of Malaysia influential in this development, suggested that,

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“Shifting demands and the technological advances in healthcare have also created challenges for the Malaysian nursing profession. Nurses must therefore conquer these challenges by becoming more knowledgeable about their profession. The continuous education of Malaysian nurses would promote greater accountability, knowledge and personal commitment in providing healthcare to individuals throughout their lifespan.” (Florina Abdullah, 2009: 2). In order to access these courses, nurses must be registered with the Malaysian Nursing Board and hold the Diploma in Nursing or equivalent. The course structures, teaching and learning, assessment, qualifications and quality standards vary between the universities delivering TNHE nursing degree programmes in Malaysia. Furthermore, only some of these universities have the Malaysian Quality Agency (MQA) approval or accreditation. Malaysian nurses who complete the TNHE degree programme attain an academic award from the institution that developed the programme. The UK Nursing and Midwifery Council (NMC) however does not permit their registration to practice in UK as a result of these awards, neither does the Australian Nursing and Midwifery Council (ANMC) allow nurses to practise in Australia. This is due to the programme content being 100% theory based and not requiring clinical practice experience and assessment.

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Research Question: The purpose of this study was to investigate the experiences of the Malaysian nurses undertaking such TNHE courses. The main research question was to ascertain ‘to what extent have Malaysian nurses applied theoretical knowledge taught in TNHE post registration top up nursing degree programmes in clinical settings?’. This question was underpinned by 4 objectives for exploration in answering the question. These were to consider the nurses’ perspectives on personal development, professional transformation, implementation of nurse led changes and acceptance of nurse led changes. This paper focuses on issues related to the nurses’ perspectives of their experiences within the TNHE intercultural teaching and learning environment.

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The findings will be presented under four categories: language and teaching and learning issues; TNHE degree requirements, guidance and support; shock and coping strategies and acclimatisation.

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Design This was a qualitative study based on a hermeneutic phenomenological approach. Hermeneutic Phenomenology is informed by the work of Max van Manen (2014). It was chosen as it required participants to re-visit, reflect and describe their lived experiences and the meanings forthcoming from this. It does not attempt to create a theoretical standpoint only to provide understanding of those experiences in context whilst also recognising the researcher’s role in the process (Dowling, 2007).

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Although ethnography was not employed as an approach, the ethnographic principle of cultural interpretation (Geertz, 1973) was used. This enabled the researcher as an insider, to connect with the nurses’ experiences to reveal rationales and meanings (emic) that will enable outsiders to understand the phenomena (etic) (Pike, 1967).

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Participants The participants in this study were Malaysian nurses who had completed their TNHE nursing top up degree programme within the previous six months. This was to ensure they would be able to reflect clearly on their recent experiences. It also allowed them to provide their views without any fear of repercussions or negative consequences. Initially, 10 participants were recruited via email by convenience sampling from the only UK University that consented to participate in this study. However, when contact details were requested to arrange interviews, only six participants responded. There were no further responses to the emails that were sent on three separate occasions. In Malaysia, during data collection, interest was shown by five nurses who had studied with other TNHE universities. These additional nurses were accepted, and were asked to further introduce others who had studied in similar programmes. This method of recruiting participants is known as snowball sampling (Merriam, 2009). In total, 18 Malaysian nurses participated in the study, drawn from one Australian and two UK TNHE universities. Settings This data collection was undertaken in a room in the nurses’ own clinical settings in Malaysia. It was not the kind of quiet environment recommended for conducting research interviews (Polit and Beck, 2017), however, this was the preferable option for the participants who had opted to be interviewed there during breaks or after their shifts for convenience. Methods

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Qualitative methodology was chosen as it would allow the researcher to hear Malaysian nurses’ voices and probe further to encourage and understand their outlook. Interviewing, was considered ideal to gain, develop, validate and ascertain in-depth understanding as Dempsey, Dowling, Larking and Murphy (2016) suggest it is an approach that yields rich and meaningful data (in this case nurses’ experiences and the researchers’ quest for insight into these). In addition, it ensures the participants remain safe in light of sharing sensitive information. Interviews allow participants to be more confident and relaxed to express their personal views about a topic (Hammond and Wellington, 2013) or when available evidence is limited (Locke, Silverman & Spirduso, 2010) which they might be reluctant to discuss in a group (Ting & Ting, 2013).

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Data Collection Semi-structured interviews were conducted to allow a conversational way of using the same questions to enable participants to reflect, identify and describe experiences (Green and Thorogood, 2014; Saks and Allsop, 2013; and Zohrabi, 2013). An eight-question interview guide was developed from the review of the literature, personal insights and experiences, and employing principles related to developing interview questions put forward by Merriam and Tisdell (2016) for targeted data collection. The interview guide was pre-pilot and pilot tested. The interviews were conducted in both English and Bahasa Malaysia (Malaysian language) to encourage the 18 Malaysian nurses to describe their experiences within the intercultural teaching and learning environment and programme to ensure data saturation. The 60-90 minute interviews were digitally voice recorded and on completion of the interviews, field notes were written.

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The interview data were collected, transcribed, analysed and interpreted from the original languages used in the interviews by the researcher who speaks both languages as they. Wordby-word translation was not used although it would provide a true representation due to idiomatic words and phrases (Kamler & Threadgold, 2003). The researcher’s knowledge and understanding of the history and culture of Malaysian society meant it was used in a precise context to outline Malaysian nurses experiences in English as these can differ when translated from one language or cultural context to another. To ensure the original meaning was not lost, back translation was used. Initially, similarities were identified through the translation of words from Bahasa Malaysia to English. This was followed by an independent translation of these back into Bahasa Malaysia. Finally, both accounts in Bahasa Malaysia were compared to clarify the meaning, (Birbili, 2000). Two Malaysian nurses (not part of the study) and four western academics from three UK university schools of nursing checked the translations and interpretations following analysis. A UK university researcher checked the transcripts with the analysis of the findings. In presenting the findings of the research, the interview extracts chosen were shown in italics and were left in their authentic state, or as close to their original state for extracts that needed translation into English. Hence, where both English and Bahasa Malaysia were used in data collection, only the Bahasa Malaysia part of the interview was translated. This means despite the fluency of the participants during data collection, some extracts appeared disjointed. In addition, the researcher changed the structure of certain extracts by inserting the missing parts of the statement to provide clarity for readers.

ACCEPTED MANUSCRIPT The transcripts were returned to all 18 interviewees to read, amend and verify the accuracy of the dialogue of the interview. It enabled them to confirm the conversation during the interview. This ensured rigour by establishing the reliability and validity of the interview data (Polit & Beck, 2017). However, only 10 participants responded despite three emails. Some personal email addresses were no longer operational, as notification of failed delivery returned whilst others simply failed to respond. All 10 confirmed the accuracy of the record and none of them asked for any additions, amendments or removing any details. Another bilingual Malaysian researcher listened to the audio recordings, verified the transcriptions of the dialogue, and checked translations, interpretations and analysis of the findings.

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Ethical Considerations Cohen, Manion and Morrison (2018) believe that the researcher has a moral and intellectual responsibility to ensure their research is sound and trustworthy. Approval was given by the researcher’s University Research Ethics Committee. The British Education Research Association (BERA, 2011) key principles about ethics were also acknowledged. The participants were informed that this research was being conducted by a Malaysian researcher for her professional doctorate and that she had previously been an international student in the UK. Consent for interviews to be held in the identified local hospitals was also obtained prior to data collection.

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Data Analysis The interviews were analysed using thematic analysis developed from Benner’s (1994) hermeneutic analysis that identified three key steps of (a) isolating paradigm cases, (b) identifying repetitious themes from within and between cases and finally (c) selecting quotes to illustrate themes. This is an approach to recognise and organise patterns in content and meaning, including inconsistencies (Willig, 2013). It involved reading and re-reading the data or information numerous times, then coding the information, and identifying substantive and theoretical themes that relate to the aims of the research (Polit and Beck, 2017) to capture descriptions and meanings of the nurses’ experiences.

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Results All eighteen participants were female, from private hospitals and their age ranged between 21 to 50 years with two thirds of the interviewees aged between 31- 40 years (n=12/18). These interviewees had 5 or more years’ experience and held senior positions including the one member of staff under the category ‘Other’ (role not stated to ensure anonymity), (n=17/18). There were no restrictions on the number of choices participants could select as their reasons for attending the TNHE degree programme. Their main motives cited were to update themselves i.e. interest (n=14/18), career development (n=12/18) and improving practice (n=11/18). The participants’ three year pre-registration nurse training appeared to be underpinned by the principles of: teachers and books being authoritative knowledge sources; didactic teaching; information in books as reliable; bilingualism is used even if English is the approved language of instruction; rote or repetitive learning by memorisation for assessments in the classroom and clinical settings; all material required for assessments is provided; effortful and respectful learning were used, and assessment methods of written exams, closed-book examination, multiple choice questions, group presentations, short answer questions and Objective Structured Clinical Examinations are used. It appears that these did not require

ACCEPTED MANUSCRIPT students to demonstrate decision making or critical thinking about the taught knowledge and procedures or skills.

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In contrast, their post-basic journey centred on practice in specialised areas. Taught knowledge was in-depth to enable justification of care provision as they observed, practised and gained competency with essential practices and skills in specialised settings. Senior nurses supported them to use deep-level thinking for integrating relevant theory to nursing practices and skills. It appears that reasoning skills were developed during their post-basic education to enable them to rationalise the management of patient care in specialised settings. Kirby, Lanyon, Cronin and Sinclair (2003) identify these as the salient features of deep learning styles. According to Chin and Brown (2000), a deep method to learning can also be attained by using memorisation as a tool.

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Language and Teaching & Learning Issues

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The participants were initially not deterred by the anticipated differences between the eastern and western educational traditions. Instead, all indicated they were mainly positive despite mixed feelings of anxiety, fear and lack of confidence in their English Language skills and western academic practices. Interviewee 014: “I scared lah but want western degree, more standard.” Interviewee 009: I know different, I think can lah, can do lah.

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Interviewee 007:

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“Before I start, I happy lah. I know [this] course [is] different, here [we] use dwi Bahasa but degree [western lecturers will speak] only English. If I know everything like this [teaching, learning, assessment and support], I won’t take [study on TNHE programme].”

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The participants outlined that even though they were familiar with English, they had difficulty coping with English as the medium of instruction during the classroom teaching. Interviewee 016 stated:

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“I found it difficult to the language, I trying to figure one word, she has finished sentence. She said ‘one die’ [accent], I thought Oh dear! Who has died? Then I realise she actually meant ‘one day’!” In using the emic perspective, it is acknowledged that English is not the students’ first language but a second or third language for some. In addition, their spoken Malaysian English freely incorporates a mix of words or code-switching from the languages of diverse ethnic groups and mother tongues. Ee and Hashim (2012) explain that Malaysian English follows standard English grammar to a certain degree only then includes a combination of local words, phrases and descriptions from all ethnic groups. “At Malaysia we not speaking English only, we mix everything, all mixed language” (Interviewee:009). The etic view identifies that ‘flying faculty’ only spoke in western English and there are variations in the pronunciations, accent and expression that made their spoken presentation appear like a new language to the students. The nurses demonstrated silent classroom behaviour and the western academics questioned them about this “You all very quiet, never ask anything. ... we understand or don’t

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understand we keep quiet only” (Interviewee: 006). A combination of reasons contributed to their behaviour: a) deference to authority (Abdullah & Koh, 2009): “We cannot be open, we have our national style, hierarchy, very, very obvious!” (Interviewee: 013); b) culture of listening to learn or save face of teacher (Hofstede & Hofstede, 2005): “We give respect, we don’t criticise or argue or give opinions” (Interviewee: 010) (Amir, 2009); c) potential for repercussions: “We have to accept, if we argue, they will say ‘You are a bad student’. Then they will aim you and cut your marks” (Interviewee: 006); d) miscommunication: “... when we ask question they explaining but we cannot catch what they are telling. Lastly, we give up” (Interviewee: 002); e) lack of comprehension: “If we don’t understand anything we don’t know what to ask, right” (Interviewee: 017); f) student saving face: “If we ask then lecturer and others will think ‘she is stupid lah to ask this question!’ You don’t want everyone to think you stupid so you keep quiet” (Interviewee: 006), and g) feelings of inequality with western academics: Interviewee 004 expressed “We have English person coming to teach, we feel inferiority complex.”

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The literature identifies differences between Malaysian and western learners in the classroom (Ryan and Carroll, 2005; Abdullah, 2010; Bovill, Jordan & Watters, 2013; Yamat, Fisher and Rich, 2013; Biggs, 2014). It typifies Malaysian learners as passive, linguistically incapable class fellows, rote learners, plagiarisers and uncritical thinkers. The researcher’s Malaysian emic view clarifies that students apply respectful listening and attention when the teacher speaks. There is also an accepted assumption and a sense of security among Malaysians that not being active in the classroom does not mean lack of academic ability. Likewise, participating does not indicate academic prowess. Nurses were behaving exactly as they would in a Malaysian classroom. Their polite, silent behaviour (Amir, 2009; Gill, 2009) suggests that the interviewees’ reluctance to participate could be due to classroom etiquette as desired and defined by their home cultures rather than their approach to learning or abilities. Leask and Carroll (2011) stress that recognition of these cultural rules by TNHE academics is vital. Race (2011) and Burton and Kirshbaum (2012) believe that attention needs to be directed to identifying and working with cultural differences. The researcher’s etic academic view is that these hidden narratives influence the nurses’ experiences in the TNHE teaching and learning environment.

Theoretical knowledge and assessment The participants expressed that teaching content within the modules was very UK or Australia centric rather than having an international focus, as interviewee 007 commented: “I thought, why they don’t give Malaysian examples, it’s good we can know their ways but all from their practice. But here, we didn’t see that, we don’t know.” In using the etic academic view the researcher points out the importance to relate the TNHE theoretical knowledge by providing both western (UK or Australia) and eastern (Malaysia) examples to demonstrate the similarity and differences that will enable the widening of knowledge. The researcher’s emic perspective, identifies that even if Malaysian nurses have knowledge of certain aspects they will not be able to relate it as the meaning is different and also because they are not practising it.

ACCEPTED MANUSCRIPT Fourteen of the nurses found western critical analysis skills, to criticise others’ work, to discern the value of evidence found, be convinced or remain unconvinced by the evidence and to reason logically were difficult concepts to understand and master within the short teaching period. In Malaysia, the notion of critical thinking and analysis is absent from the language and cultural frames of Malaysian society. As previously mentioned, teachers and books are considered authoritative sources in imparting knowledge (Hassan, 2010; Hassan & Jamaluddin, 2010). In addition, information in books is accepted as reliable and undisputable as they are assumed to have been tested in practice. The student’s purpose is merely to explicate, refine and support taught knowledge (c.f. Li, 2016).

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Questioning to make sense or justify knowledge was done mentally which is evidenced by interviewee 006’s statement:

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“She spoke about Indian patients in UK, but our nation, we used to Malays wear Malay clothes, Chinese, Cheong Sam and Indians, sari, they wear their traditional clothes. The lecturer said, ‘Oh! No, let them wear their own traditional clothes’. I thought ‘Why the big fuss about their clothing’? In Malaysia we have already done it.”

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On the TNHE programmes, the assessment was mainly assignments. The assessment criteria were given on the first day of the teaching period which led to anxiety, uncertainty and stress as they were not used to writing assignments such as those expected:

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“You know our English standard here, speaking and writing how we will be writing our essays. 500 words also we will be struggling to write in English. In diploma we answering a,b,c,d - that’s what we learn; suddenly to do essay style 2500, 3000, 5000 words is quite hard. You know to make up a word, to make up a sentence, to make it longer, we find is very difficult” (Interviewee: 018).

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The researcher’s emic UK academic outlook recognised that the Malaysian nurses’ teaching and learning experiences should have been identified prior to delivery of teaching to enable academic and critical writing support to be provided. Ryan (2011); Trahar and Hyland (2011); Jin and Cortazzi (2013b) emphasise that education should consider the cultural dimensions of teaching and learning instead of primarily adapting to existing academic standards and profit generation. Also, what TNHE academics considered as appropriate language, methods and evidence to support critical thinking and analysis skills were western in nature and different to the reasoning skills that are fundamental to management of care provision. Leask & Carroll (2011) believe that their learning experiences need to be supported by an international awareness and competence curriculum. Further, Jin and Cortazzi’s (2013a, b) emphasise the importance of promoting culturally open attitudes and communication between educators and international students to develop meta-cultural sensitivity (i.e. to reflect on their own culture and other cultures (Ryan and Carroll, 2005). Guidance and support The participants found the assessment criteria was difficult to decipher. Further, for fourteen of the nurses, this was their first time to write an assignment as the education and nurse education system in Malaysia does not require them to do so. They experienced feelings of fear, insecurity and inadequacy by the need to search for relevant information and literature and use enquiry skills to undertake a critical discussion of their thought processes. This could be because their former styles of learning e.g. memorisation to pass exams had been replaced

ACCEPTED MANUSCRIPT by a diversity of teaching and learning styles (Ibrahim, Nik Yusoff & Kamarudin, 2016). In addition, the lack of face-to-face guidance and support for their assessments led to challenges in completing their assessments. The TNHE ‘flying facultys’’ lack of intercultural awareness also contributed to difficulties in communication, interpretation and understanding in the classroom, on-line forums and email exchanges.

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In hindsight, the researcher’s Malaysian experience outlines that the nurses were expecting TNHE academics to give them all the relevant subject information to complete their assessments. For six participants from one UK university, their lack of understanding of the required criteria, assessments and the poor face to face and on-line support, only became evident after submission of their first assignment. When the lecturer realised that none of the students had met the criteria, she arranged to meet with the nurses for three extra days in Malaysia to ensure they met the assessment criteria for their re-submission. They had shocked reactions when informed of their failure to meet western academic standards. These standards were the demonstration of a certain level for their English language, adequacy of study skills, critical evaluative thinking in their assignment and certain academic writing skills that had not been taught during the teaching period. This was expressed by all nurses, as verbalised by interviewee 010:

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“Very hard, most of us doesn’t know what we doing, we had to write 5000 words, it’s not medical words but this is totally different. First module we all didn’t meet criteria, so all had to do it again. Only then knew our English not good. She said be more critical, not descriptive – how? Reference list, key point in each paragraph and some other things and plagiarism taught on another extra three days. This was not told in the 2 week teaching period."

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The skills required for academic achievement are generally acquired over a period of time, as identified with the researcher’s emic view as a Malaysian and UK academic stance. As nurses’ previous learning focused on assimilation of information and providing correct answers, they struggled with the new academic literacy skills. These nurses also had to fast track their learning due to the short-time frame allocated to teaching on the module. Further, support to complete their assessments was only conducted by email exchanges.

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From a personal analysis, the brevity of the teaching delivery make these programmes vulnerable to criticisms about academic standards. The UK academic view highlights that the quality of the programme is not assured through following models of knowledge that worked in the UK. Further, the academic standards achievable on such short courses are unlikely to meet those required of degree programmes in the host country. This has implications for both eastern and western academic standards. Shock and coping strategies and acclimatisation. Participants described how the initial excitement of being successful in being accepted and offered a place on the TNHE programme quickly on the first few days gave way to a sense of shock and disorientation that exacerbated their feelings of anxiety, frustration, uncertainty and self-doubts. The experience proved more demanding, compared to their previous class contact hours and pace of teaching delivery, than they had expected. Bartram’s (2008) taxonomy identified three key aspect areas i.e. social, academic and practical where international students require assistance. In this instance, nurses struggled as they were accustomed to a pedagogical approach that was different, thus, they experienced ‘learning

ACCEPTED MANUSCRIPT culture shock’. Teras (2013) argues in taking the cultural aspect into consideration, it does not mean trying to make the learning environment familiar to these students, instead it is to develop an environment that promotes cultural sensitivity, appreciation for diversity and dialogue for all learners.

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Their experience of each module was summed up by all the nurses as similar to using a “remote control” (Interviewee: 010) - “switch on, switch off” (Interviewee: 011). Interviewee 016 clarified this succinct portrayal of the TNHE teaching as “talk, talk, talk, fast, fast, fast then bye-bye”. The “compressed” (Interviewee: 012) or “toooooooooooo short” (Interviewee: 017) teaching time-frame resulted in “everything was like a blur” (Interviewee: 009).

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Kalervo Oberg in 1960 introduced the concept of culture shock and the importance for the ‘honeymoon’ period as it provides time for a gradual adjustment and acclimatisation. These nurses were deprived of this time-frame to adjust to the new thinking, writing and academic practices required for TNHE programmes. After their initial ‘flight’ response they quickly recognise the need to use coping strategies to ‘fight’ to overcome their shock and confront the challenges. The tendency for international students to take flight or fight when confronted with obstacles was acknowledged by Anderson (1994).

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On reflection it clarifies that the students used their effortful and respectful learning to deal with adjustment demands for instrumental ends. The researcher’s UK academic perspective highlights the idealised Western education that these nurses were keen to experience and the western degree qualification that was deemed superior, pressurised them to adjust.

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Main outcomes The findings and lessons learnt identify key aspects to be considered by schools of nursing that intend to, or already provide collaborative TNHE programmes. The data is also relevant to all those engaged in international collaboration and higher education, including other professions, and all TNHE programmes delivered in South East Asian countries. This is because of the effects of strong cultural factors. Hofstede’s (2005) described these as hierarchical with a ‘high power distance’; respect for elders and roles in society, harmony and ‘saving face’.

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Discussion The interview data highlighted that the nurses perceptions were that there appeared to be a conflict between their assumptions and expectations of the TNHE programme and that of the TNHE ‘flying faculty’ (Arunasalam, 2013). According to these nurses, it led to mismatches between western and Malaysian pedagogy, assessment and support. Teaching and learning has cultural dimensions and the ‘flying faculty’ academics and Malaysian nurses in this multicultural context both bring different cultural expectations and social practices. These differences initially led the nurses to experience learning culture shock. In addition, the nurses identified that within the modular framework of TNHE teaching and learning the: a) classroom experiences were short, overwhelming, western centric and assessment focused; b) TNHE academics appeared unaware of nurses’ education systems and reasons for their classroom behaviours; c) academic standards varied but too little explanation on how to meet them was given; d) writing assignments was a new experience for most nurses; e) explicit assessment criteria was desired; f) guidance and face-to-face support was

ACCEPTED MANUSCRIPT required for completing assessments and g) email contact for assessment support needs to be enhanced.

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Based on the data, it appears that TNHE programmes were being delivered within unrealistic time-frames and teaching was not pitched at the students’ level of education. Also, too much subject knowledge for each module was taught within an unrealistically short time-frame, which meant nurses had to fast track their learning. Limited guidance and face-to-face and online support were also provided to complete the assessments. Mainly, it took place against what they understood to be good learning, teaching, assessment, guidance and support practices. Joy & Kolb (2009) and Hénard & Roseveare (2012) agree that it can be difficult to pitch the language and teaching and learning to a suitable level for all students.

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Previously, Ziguras (2008) strongly recommended academics to be familiar with their student’s backgrounds, assumptions and expectations. In fact, Ziguras stressed that academics have a professional responsibility to learn and use this knowledge in teaching. However, Hunter, Leask, and Rumbley (2014) identify the challenges HEIs face within the short time frames and limited resources for TNHE provision. They agree strategies need to be developed to overcome them. This is because students are required to adapt to existing academic standards and social expectations to achieve a western degrees successfully, despite these challenges and difficulties (Montgomery, 2016). Further, the healthcare system in Malaysia also faces unique health-related issues (Birks, Chapman & Francis, 2009). Students do not interact spontaneously with other students who have a different culture, ethnicity, religion or speak a different language (Hyland, Trahar, Anderson and Dickens, 2008 and Volet and Ang, 2012). Caruana and Spurling (2007) and Welikala (2013) maintain meaningful cultural interaction do not easily occur, but must be encouraged. It is important to empower students to become active agents of their own learning (Jin and Cortazzi 2013b). These Malaysian nurses used coping strategies to acclimatise to the western approach in the intercultural teaching and learning environment. However, Djerasimovic (2014) and Hunter, Leask & Rumbley (2014) stress that teaching activities need to consider the similarities and differences between cultures for TNHE programmes. Only then will it be beneficial for both academics and students in their teaching and learning experiences.

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Limitations of Research In this study, only one UK university agreed to participate, thus, it did not allow the researcher to correlate the findings with the module evaluations the nurses provided at the end of a module. This comparison is valuable because of the tendency for Malaysian nurses to provide socially acceptable responses to save face, of self and authority, be perceived with a bad image and being subject to reprisals or repercussions. Interviews provided a degree of security for nurses to reveal their hidden views. The researcher’s insider knowing guided her to slip effortlessly into a Malaysian insider role by using Bahasa Malaysia, colloquial words and humour. It enabled the participants’ to be encouraged or cajoled to disclose more detailed accounts. However, the nurses would have disclosed more confidential experiences to a Malaysian living in Malaysia and from their own ethnic group compared to the researcher’s perceived outsider status as a UK academic. Conclusions This paper has presented participants’ perspectives of their TNHE teaching and learning experiences with an emic and etic interpretation. It is important to listen to the ‘student voice’

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in the current globalisation and marketing of higher education. The cultural perspectives identified need to be considered by those embarking on TNHE top up degrees and the Universities who are being commissioned to lead these programmes. The Malaysian nurses views of their intercultural and TNHE experiences highlights the importance for ‘flying faculty’ academics preparedness and readiness to deliver these programmes by considering the cultural diversity that exists between those offering the programmes and practicing nurses in Malaysia.

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