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International nursing students: a phenomenological perspective
Article
International nursing students: a phenomenological perspective Elizabeth Pross
Colleges and universities are faced with the challenge of how to create learning environments relevant to the internationalization of society and culture. International learning experiences, the focus of this article, may be one effective tool for internationalizing nursing curricula. Baccalaureate nursing students with international education experiences who were residing in a rural USA state were invited to participate in a qualitative descriptive study informed by phenomenology. Sixteen nursing students participated in mail surveys and eleven in interviews. Participants were mainly female, Caucasian, university seniors with an average age of 31 years. Thematic statements were isolated into nine experiential structures and four essential themes. Themes were identified as preparing, adjusting, caring, and transforming and were found to be influenced by culture, values, and ethics. A descriptive diagram was created summarizing the structure of meaning. Significance of this nursing study was the identification of plausible descriptive insights that may be useful to educators who assist students with international education experiences. ª 2003 Elsevier Science Ltd. All rights reserved.
Phenomenon of focus
Elizabeth Pross RN, PhD, Associate Professor, Department of Nursing, Minot State University, 500 University Ave West, Minot, ND 58707, USA Tel.: 1-701-858-4306; Fax: 1-701-858-4309; E-mail: pross@ minotstateu.edu
(Requests for offprints to EP) Manuscript accepted: 16 April 2003
Preservation and advancement of human care internationally is a central issue for certain nurses and nurse educators. Changes in the world such as rapidly advancing technology, complex bureaucracies, difficulties sustaining human caring ideology, increasing ethnic diversity, and the emerging recognition of nursing as a vital international resource implies a need for a variety of curricula opportunities. International nursing student experiences, the focus of this article, may be one effective tool or opportunity for internationalizing curricula. International nursing student experiences appear to be emerging despite a lack of financial and administrative support from colleges and universities and a paucity of nursing research. Funding in the United States (US) is primarily supported by individual
396 Nurse Education Today (2003) 23, 396–403
faculty or students and usually not through the administrators of universities or schools (Fenton, 1994; Wright et al. 1998). According to Wilson (2002), financial support for overseas study is limited and usually given to nurses holding senior positions or nurses who have demonstrated academic excellence. Furthermore, many nursing programs exist within university environments of continually shrinking financial support indicating an urgent need to identify outcomes of international experiences to justify their existence.
Literature review The review of literature found a considerable, recent, and growing interest in international health among schools of nursing. Numerous anecdotal and subjective descriptions have
0260-6917/$ - see front matter ª 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0260-6917(03)00066-2
International nursing students: a phenomenological perspective
been published while only a few published outcomes studies exist. Reported outcomes in nursing studies consistently support those of international education experiences of general studies’ students (Carlson et al. 1991; Kauffmann et al. 1992). Interestingly, noted outcomes were found to be similar even though nursing students spend one week to several months internationally whereas general studies students spend one semester to an academic year abroad. Outcomes were reported in three broad areas: knowledge development, increased global understanding, and increased personal development (Frisch 1990; Haloburdo & Thompson 1998; Inglis et al. 2000; Kirkpatrick & Brown 1999; Zorn 1996; Zorn et al. 1995). Intellectual outcomes were identified as improved language skills and academic knowledge. Increased global understanding was defined as knowledge acquisition and behavioral changes. Personal development was reported as increased interpersonal skills and value development. Overall outcomes were reportedly influenced by the degree of environmental diversity, the length of the experience, and student age and education level. Increases in cognitive development were identified through two different studies; one where students traveled to Mexico for three weeks (Frisch 1990) and one where students traveled to the UK for three months (Zorn et al. 1995). Researchers reported significant increases in cognitive development despite the different degrees of cultural diversity, poverty, and length of experience. It is important to note that increases were reported even though the Mexican experience was shorter (six weeks) than England (three months). Long term outcomes were studied with 27 alumni who had participated one to five years previously (Zorn 1996). Outcomes were identified as increases in empirical or measurable knowledge, increases in international perspectives, increases in environmental awareness, and personal and professional development. Longer experiences were positively associated with more significant (p < :05) long term outcomes. A nursing student’s age at the time of their experience was positively correlated (p < :05)
ª 2003 Elsevier Science Ltd. All rights reserved.
with personal development suggesting personal development was greater with older students.
Study design The purpose of this study was to explore the nature and meaning of international education experiences from a nursing student perspective. The research design was a qualitative descriptive study informed by phenomenology as described by van Manen (1990). Methods that guided this study were investigating experience, reflecting on essential themes, writing and rewriting, maintaining a focus on the phenomenon, and balancing parts and whole. This study was approved by the University of Colorado Health Sciences Center and Minot State University Institutional Review Boards. Identifying details about participants were changed for this article. The setting was the rural state of North Dakota (ND), USA which is located next to the Canadian border with a population of 650,000 and has seven baccalaureate nursing programs. ND was unique in that it was the only state in the USA that required a baccalaureate degree as the minimum education preparation for entry into professional nursing practice. Participants who were ND residents were recruited during 1999. Data was collected through mail surveys and interviews and analyzed utilizing descriptive statistics and thematic analysis. Sixteen nursing students participated in a two page mail survey and 11 participated in phenomenological interviews. Data were analyzed by the researcher through reflection – a review process of the written text conducted by alternating reviews of specific statements, then as whole, and then again as groups or categories of themes. Through a process of bracketing, the researcher’s bias and prior knowledge were made explicit, which enabled them to be held in abeyance. A researcher’s attempt to understand phenomenon by bracketing or looking at it as if for the very first time contributes to the credibility of the findings. According to Ray (1990), credibility is achieved when the people who have had the experience being studied recognize and acknowledge the researcher’s
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International nursing students: a phenomenological perspective
presentation of the experience. Participants in this student were given an opportunity to review, recognize, and acknowledge written presentation, thereby confirming and validating the findings. Additionally, two nursing students with international education experience who were not participants validated content and interpretations of data through verbal discussions. Limitations inherent in this study are related to the qualitative methods and a homogeneous small sample. As with all qualitative studies, findings should not be generalized to other nursing students.
Findings The age of the mail survey participants ranged from age 18 to 46 years with a mean of 31 years. Participants were mostly female Caucasian university senior nursing students who had an international education experience less than one year ago. Most experiences were facilitated by nursing faculty in collaboration with others. Eleven described their international experience to be organized by nursing faculty with an international mission group or ministries. Two described nursing faculty as organizing the experience in collaboration with an international colleague or friend. Two identified themselves as the organizer and one described the USA military as being responsible for their experience. Participants were asked to list two or three reasons for participating. Motivating factors were described as: nine wanted to help others; eight wanted to enhance nursing education; five were encouraged by friends; four wanted to travel and learn about another culture; three sought spiritual growth; two described motivating factors as parents and the way they were raised; and one was motivated through a government obligation. Activities. In this study, a variety of activities were described by nursing students in numerous nations. International experiences ranged from 7 days to 2 months in Mexico, Guatemala, Norway, Russia, Honduras, China, West Africa, New Zealand, and the Mediterranean. A variety of nursing activities were described. Within Mexico, nursing students performed nursing assessments for
398 Nurse Education Today (2003) 23, 396–403
children in nutritional programs and adults for diabetes and hypertension, provided visits for the home bound older adults, and health teaching for new mothers. In China, basic physical therapy and hygienic skills were taught to an orphanage staff and developmental assessments were completed on children for a US adoption agency. In Russia, nursing students presented a growth and development course to physicians and nurses based on a teaching module that they had developed and published. In Guatemala, one nursing student described assisting in clinics and administering medications, vitamins, and providing health teaching while another described providing primary care or care not qualified to provide. In West Africa, another also described providing primary care or care such as treatment and diagnosis of diseases. In Honduras and the Mediterranean, nursing students visited health professionals and toured health facilities and did not provide nursing. Several nursing students described activities not related to nursing. For instance, during the Norway experience, nursing students studied the language only. Others described constructing schools, homes, hospitals; participating in church activities; and teaching English language courses in addition to nursing activities.
Themes Themes evolved through analysis of the open-ended mail survey questions and tape-recorded interviews. Three hundred and three thematic statements were isolated and arranged into fifty groups with similar meaning. Then nine experiential structures and 4 essential themes were identified. Themes of preparing, adjusting, caring, and transforming were identified as essential themes or themes that formed the experiential structure.
Preparing Once in a lifetime experience. Preparing began before nursing students ever left home and was described as excitement and planning. Excitement usually was
ª 2003 Elsevier Science Ltd. All rights reserved.
International nursing students: a phenomenological perspective
accompanied by a sense of adventure and anticipation ‘‘I knew it would be a once in a lifetime experience. I was so excited to be going. I could hardly wait.’’ Nursing students in this study began planning anywhere from one week to a year prior to departure. Specific activities included researching culture, language development, fund raising, and preparing educational materials. Advanced planning may have contributed to adjustment. For instance, a nursing student explained how she spent a year preparing by ‘‘cruising’’ the internet, joining discussion groups, and researching her host nation. She described how she was able to navigate the metro, a large transit system, independently while others could not. It also seemed that lack of adequate preparation may have contributed to frustration and adjustment difficulties. A nursing student found out she would be participating in an experience four days before she departed. She described feelings of excitement and anticipation until she arrived in her host nation: Well I kind of came into the group at the end. I didn’t know what they knew. The first day I bawled the whole day cuz I was so. . . I don’t know if those guys were more prepared or not. It’s not like I thought I would be staying and working at the Ritz. But driving in, I just did not realize, I mean even when we started working with the people, I sat there with my mouth down and bawled cuz I couldn’t believe I was there. It was so horrible. Other nursing students who had been involved in group preparations for six months prior to departure, did not have the overwhelming experience described by this participant.
Adjusting Feelings of comfort after experiences of shock. The human experience of adjusting was described as occurring when patterns of excitement diminished after immersion in the new nation. Adjusting was described through detailed experiences of shock, coping, and
ª 2003 Elsevier Science Ltd. All rights reserved.
appreciation. For example, shock was described as: You can’t imagine it. You look at pictures but you can’t imagine the vastness of the poverty because you just don’t ever see it here. There is no way to prepare for this. Another described: I never saw anyone get shot but I heard shots at night. There were armed soldiers at every store. You had to be careful with your money. I was afraid of being attacked or abducted. I was aware that something could happen. I was always afraid. After the initial shocking experiences, all the nursing students interviewed described some adjustment to their host nation. Described by a student who spent nine months in a developing country: I just didn’t want to change my life style and I knew that I couldn’t fear them or I would be unhappy. If things are going to happen then they’re going to happen whether I’m there or here. Several described how they began to adjust rather quickly: I think it was like our second day and we had come back from the other mission and we were like ‘Wow I’m home.’ Even others said it was weird. I felt so comfortable. I felt at home. The first day you were so shocked and didn’t want to be there and you’re thinking how do I get out of this place. By the second day you are thinking this is wonderful, this is a really really nice place to be. Not everyone seemed to adjust to different environments in the same way. I was just so embarrassed with them and disappointed. Even on the way home, they were so insulting and rude to our waitress because she did not have the American beer they wanted. I was so upset with them. I told them to be quit complaining. I would not sit with them because they embarrassed me. It was not the US and they could not cope with that.
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International nursing students: a phenomenological perspective
Appreciation seemed to result from a nursing student’s genuine adjustment and their acceptance of the new nation as just another way of living. ‘‘They have so much less than we do but they really seem much happier.’’ Nursing students might or might not have always approved of the new nation but they described understanding differences as they were able to appreciate the rich layers of the nation and the people in it.
Caring Awakened a feeling of caring that required nothing in return. Caring was described through structural experiences identified as doing and being. Experiences of doing allowed nursing students to have first hand experience with diseases and culture aspects in clinical sites that were unlike any education they had received before. These experiences were often described as profound and transforming. A nursing student who spent nine months in a host nation described an expanded nursing role as: I did so many things I was not prepared for like suturing and splinting. I was all they had many times. Sometimes in the morning a kid would show up at my door who had been running all night to come and get me. All he would say is ‘bleeding.’ Many times I never knew what was bleeding. Was it an artery or vein? They could never answer me even though I spoke Spanish. So I would just go. I’d wash my hands and grab my duffle bag and follow them. It might take us all day to get there. Several described newly gained confidence as: I thought this was the greatest thing that had ever happened to me. Cause I went over there and I felt like I totally didn’t know anything. I felt I’m going to graduate and I still am not sure what I know. I realize now that I know a lot more than I thought I did. It was a real confidence builder for me. Not all experiences were described positively:
400 Nurse Education Today (2003) 23, 396–403
As far as the nursing experience, I felt stupid and unprepared. Although it was a great experience in so many ways, we could not offer proper care or treatment for the clients in need. All treatment was deferred most of the time. It should have been a team with doctors and medical supplies. Many mothers came wanting their children better. We did little. I felt frustration. The experience of being seemed to be an attitude: Here nurses work with machines and not the patient and there it was different. What I really learned was how to care for people whereas here nurses learn how to run machines. Several described: The experience made me remember why I went into nursing. I know I want to continue doing this throughout my nursing career. I think it keeps you in check with the caring part of nursing. I recognized that the art of nursing is universal and people want to be cared for and (they) recognize when nurses are kind and compassionate regardless of the language spoken. I came away from this experience more determined than ever to be a compassionate nurse. Another described awakening as: The caring part of it just opened up. This is why I’m a nurse. Everyone should go at least once a year to bring themselves back, back to caring. Another described: I realized that humans are the same everywhere regardless of socioeconomic status. Everyone needs and deserves safety, love, respect, kindness, and human touch. The caring touched both, them and me.
Transforming Changes are here inside of me. Nursing students seemed transformed as they were challenged to examine their world view
ª 2003 Elsevier Science Ltd. All rights reserved.
International nursing students: a phenomenological perspective
and empathy through questioning and searching to decide which values and beliefs to make their own and which to discard. Five of eleven nursing students interviewed stated they are now more empathetic. One explained that by being in another country where she did not know the language, made her realize how it must be for her Spanish speaking and hearing impaired patients and she now spends extra time with them trying to understand. Another explained that she felt she really was not more caring but more empathetic in the way she tried to understand her patients from different cultures ‘‘I really try to understand their needs instead of forcing my beliefs onto them.’’ Another described empathy as ‘‘This experience enabled me to see past the poverty and filth and see the strength of the human spirit. It awakened an understanding I had never known before.’’ Another described her experience as ‘‘It opened my eyes to cultural differences and similarities and finding ways to communicate and connect.’’ Transforming world views meant asking questions. Questions raised related to experiences of different cultures, values, and ethics including religion. The world view of realizing own values and beliefs was described by a nursing student as: It was the first time I realized what I value and believe in, what is important to me. It was the first time I really examined my thinking. I believe my main duty as a nurse is to care for my patient, no matter what country I’m in, and not judge but help people manage their health in their own way. The world view of examining nursing’s universalities was described by several: I feel strongly that all human life should be valued. I also recognized that the art of nursing is universal and people want to be cared for no matter where they live. Each individual is ultimately in control of their health care and we need to acknowledge that. Others suggested ethnocentrism ‘‘I realized that we (nurses) live in a vacuum in the US. We have no idea what the rest of the world is up to.’’ Nursing student participants in this study
ª 2003 Elsevier Science Ltd. All rights reserved.
seemed to cross over into another nation and begin to have an expanded world view and empathetic understanding for its people. Empathy seemed to represent a relativity high level of sensitivity. The change toward a multicultural world view took place with the integration of new perspectives into old values and views that may have been transforming. Integration that allows for ethical choice and actions in a profoundly relativistic world has the potential to be transforming. Described by one participant as ‘‘By going over there I realize that I can do a little bit more here. The changes are here, inside me.’’
Essential themes diagram Themes make up the universe of meaning people live through. Four essential themes identified in this study were preparing, adjusting, caring, and transforming. Fig. 1 illustrates the descriptive diagram generated from data grounded in descriptions of meanings. All themes appeared relational in nature and seemed to occur simultaneously or impact one another continuously. For example, a nursing student may be participating in an international education experience preparing to provide nursing activities while adjusting to unfamiliar practice environments while being present and caring in relationship with coworkers from a Colonia. The processes of the four essential themes appeared to be influenced by culture, values, and ethics. The specific structures and relationships were not explored. Essential themes are not objects or generalizations. Metaphorically, they are more like knots in the webs of our experiences, around which certain lived experiences are spun and thus lived through as meaningful wholes (van Manen 1990). Through
Fig. 1 International education diagram.
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International nursing students: a phenomenological perspective
experiential processes of preparing, adjusting, and caring nursing students were transformed as they found a broader existential view of life.
Discussions and conclusions According to the literature review, many nursing schools are making progress in launching students into the international world through a variety of strategies. However, provision for internationally competent human care continues to be a major challenge facing professional nursing and nurse educators. According to Leininger (1994) there is a long standing deficit in nursing education in preparing knowledgeable, competent, and responsible nurses for serving those with multicultural needs. Others have suggested nursing education in general be altered to support more global awareness of cultures, world views, and ethnic diversity (Andrews 1992; Arnold et al. 1998; Davidhizar et al. 1998; Freda 1998). According to Watson (1999) nursing theory, research, and education needs to provide nurses with appropriate fundamental preparation and knowledge to practice human care universally for the preservation of humanity. Shock was experienced by all the participants in this study. What was not clear was if experiences of shock were related to culture or poverty. The vastness of poverty seemed ‘difficult to take’ as described by several participants in a variety of ways, more so than cultural differences. Sparse living conditions, unkempt environments, and many times large families without adequate resources were noted as difficult. Further inquiry is suggested to explore issues of shock as related to poverty. Several participants described ethical dilemmas related to poverty-stricken large families, issues surrounding appropriate levels of cleanliness, life and death issues surrounding the disabled, and treatment of female infants. Whose beliefs are right? Of course each person believes their own beliefs are true implying a need for nursing students to have sound ethical principles and arguments for the justification and consideration of truth. Several participants stated they felt inadequate or possibly could have
402 Nurse Education Today (2003) 23, 396–403
accomplished more if they had knowledge of the language of the host nation. One explained that she could not communicate with the people she was assessing and that did not seem right on a human level. Only seven out of sixteen (44%) mail survey participants in this study identified personal knowledge of a foreign language. Obviously, if language barriers are present, it is difficult to communicate. It is possible to use interpreters, which was described by several nursing students in this study, however, it was not described as the best situation as it placed a burden on interpreters who sometimes had other agendas. Every college graduate should have the ability to communicate in at least one foreign language. Through a foreign language, one may gain entry to a previously unknown culture in a way that will enhance ones understanding of humans, their beliefs about health an illness, and their use of words to express values, feelings, and needs. Nursing knowledge that deals with women of different cultures may also be beneficial. Several participants in this study described how frustrating it was to accept the oppression of women and patriarchal families in certain nations. It may be helpful for international nursing students to explore the role, social status and position of nursing in the occupational and social structure of host nations. Additional research with other qualitative and quantitative methodologies could be emphasized to advance descriptions discovered in this study. Participants were described as homogenous, mostly Caucasian females educated in a rural Midwestern state. It would be valuable to replicate this study with others from diverse backgrounds, ethnic groups, socioeconomic backgrounds, and nations as they may experience international education differently. Research designed to follow students longitudinally may also be beneficial to determine how transformations change over time. Also, when compared to general education study aboard students, nursing students are unique. They appear to spend less time internationally, adjust rather quickly, and practice in an advanced role (one not trained for) implying a need for further comparative investigations.
ª 2003 Elsevier Science Ltd. All rights reserved.
International nursing students: a phenomenological perspective
Through this inquiry, descriptions and meanings of phenomena related to nursing students’ international education experiences were discovered. The qualitative design helped illuminate themes that would have been obscured in a quantitative study if predetermined questions were used. The significance of this nursing study was the identification of plausible descriptive insights that may be useful to educators who assist students with international education experiences that potentially could benefit nursing students, nursing, and humanity. Acknowledgements Drs. Sally Phillips and Marlaine Smith, University of Colorado Health Sciences Center, Denver, Colorado, USA, Donna Marsland, Campus Ministries, Minot, ND, USA, and North Dakota nursing students. References Andrews M 1992 Cultural perspectives on nursing in the 21st century. Journal of Professional Nursing 8(1): 7–15 Arnold L, Bakhtarina I, Brooks AM, Coulter S, Hurt L, Lewis C, Weinstein S, Younger J 1998 Nursing in the newly independent states of the former Soviet Union: An international partnership for nursing development. Journal of Obstetric, Gynecologic, and Neonatal Nursing 27(2): 203–208 Carlson JS, Burn BB, Useem J, Yachimowicz D 1991 Study abroad: The experience of American undergraduates in western Europe and in the United States. Greenwood, Westport, CT Davidhizar R, Dowd SB, Giger JN 1998 Educating the culturally diverse healthcare student. Nurse Educator 23(2): 38–42 Fenton M 1994 Development of models of international exchange to upgrade nursing education. In: McClosky
ª 2003 Elsevier Science Ltd. All rights reserved.
JC, Grace HK (eds). Current Issues in Nursing, 4th edn. Mosby, St Louis, MO, pp. 202–206 Freda MC 1998 International nursing and world health: Essential knowledge for the 21st century nurse. The Journal of Maternal Child Nursing 23(6): 329–332 Frisch N 1990 An international nursing student exchange program: An education experience that enhanced student cognitive development. Journal of Nursing Education 29(1): 10–12 Haloburdo E, Thompson M 1998 A comparison of international learning experiences for baccalaureate nursing students: Developed and developing countries. Journal of Nursing Education 37(1): 13–21 Inglis A, Rolls C, Kristy S 2000 The impact on attitudes towards cultural difference of participation in a health focused study abroad program 9(3–4): 246–255 Kauffmann N, Martin J, Weaver H 1992 Students abroad: Strangers at home. Intercultural Press, Yarmouth, ME Kirkpatrick M, Brown S 1999 Efficacy of an international exchange via the internet. Journal of Nursing Education 38(6): 278–281 Leininger MM 1994 Transcultural nursing education: A worldwide imperative. Nursing and Health Care 15(5): 254–259 Ray MA 1990 Phenomenological method for nursing research. In: Chaska NL (ed). The Nursing Profession: Turning Points. Mosby, St Louis, MO, pp. 173–179 van Manen M 1990 Researching lived experience: A human science for an action sensitive pedagogy. State University of New York Press, New York Watson J 1999 Postmodern Nursing and Beyond. Churchill Livingston, New York Wilson M 2002 Transnational nursing programs: Models, advantages and challenges 22(5): 417–426 Wright M, Godue C, Manfredi M, Korniewicz D 1998 Nursing education and international health in the United States, Latin America, and the Caribbean. Image: Journal of Nursing Scholarship 30(1): 31–36 Zorn C 1996 The long-term impact on nursing students of participating in international education. Journal of Professional Nursing 12(2): 106–110 Zorn C, Ponick D, Peck S 1995 An analysis of the impact of participation in an international study program on the cognitive development of senior baccalaureate nursing students. Journal of Nursing Education 34(2): 67–70
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International nursing students: a phenomenological perspective Elizabeth Pross
Colleges and universities are faced with the challenge of how to create learning environments relevant to the internationalization of society and culture. International learning experiences, the focus of this article, may be one effective tool for internationalizing nursing curricula. Baccalaureate nursing students with international education experiences who were residing in a rural USA state were invited to participate in a qualitative descriptive study informed by phenomenology. Sixteen nursing students participated in mail surveys and eleven in interviews. Participants were mainly female, Caucasian, university seniors with an average age of 31 years. Thematic statements were isolated into nine experiential structures and four essential themes. Themes were identified as preparing, adjusting, caring, and transforming and were found to be influenced by culture, values, and ethics. A descriptive diagram was created summarizing the structure of meaning. Significance of this nursing study was the identification of plausible descriptive insights that may be useful to educators who assist students with international education experiences. ª 2003 Elsevier Science Ltd. All rights reserved.
Phenomenon of focus
Elizabeth Pross RN, PhD, Associate Professor, Department of Nursing, Minot State University, 500 University Ave West, Minot, ND 58707, USA Tel.: 1-701-858-4306; Fax: 1-701-858-4309; E-mail: pross@ minotstateu.edu
(Requests for offprints to EP) Manuscript accepted: 16 April 2003
Preservation and advancement of human care internationally is a central issue for certain nurses and nurse educators. Changes in the world such as rapidly advancing technology, complex bureaucracies, difficulties sustaining human caring ideology, increasing ethnic diversity, and the emerging recognition of nursing as a vital international resource implies a need for a variety of curricula opportunities. International nursing student experiences, the focus of this article, may be one effective tool or opportunity for internationalizing curricula. International nursing student experiences appear to be emerging despite a lack of financial and administrative support from colleges and universities and a paucity of nursing research. Funding in the United States (US) is primarily supported by individual
396 Nurse Education Today (2003) 23, 396–403
faculty or students and usually not through the administrators of universities or schools (Fenton, 1994; Wright et al. 1998). According to Wilson (2002), financial support for overseas study is limited and usually given to nurses holding senior positions or nurses who have demonstrated academic excellence. Furthermore, many nursing programs exist within university environments of continually shrinking financial support indicating an urgent need to identify outcomes of international experiences to justify their existence.
Literature review The review of literature found a considerable, recent, and growing interest in international health among schools of nursing. Numerous anecdotal and subjective descriptions have
0260-6917/$ - see front matter ª 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0260-6917(03)00066-2
International nursing students: a phenomenological perspective
been published while only a few published outcomes studies exist. Reported outcomes in nursing studies consistently support those of international education experiences of general studies’ students (Carlson et al. 1991; Kauffmann et al. 1992). Interestingly, noted outcomes were found to be similar even though nursing students spend one week to several months internationally whereas general studies students spend one semester to an academic year abroad. Outcomes were reported in three broad areas: knowledge development, increased global understanding, and increased personal development (Frisch 1990; Haloburdo & Thompson 1998; Inglis et al. 2000; Kirkpatrick & Brown 1999; Zorn 1996; Zorn et al. 1995). Intellectual outcomes were identified as improved language skills and academic knowledge. Increased global understanding was defined as knowledge acquisition and behavioral changes. Personal development was reported as increased interpersonal skills and value development. Overall outcomes were reportedly influenced by the degree of environmental diversity, the length of the experience, and student age and education level. Increases in cognitive development were identified through two different studies; one where students traveled to Mexico for three weeks (Frisch 1990) and one where students traveled to the UK for three months (Zorn et al. 1995). Researchers reported significant increases in cognitive development despite the different degrees of cultural diversity, poverty, and length of experience. It is important to note that increases were reported even though the Mexican experience was shorter (six weeks) than England (three months). Long term outcomes were studied with 27 alumni who had participated one to five years previously (Zorn 1996). Outcomes were identified as increases in empirical or measurable knowledge, increases in international perspectives, increases in environmental awareness, and personal and professional development. Longer experiences were positively associated with more significant (p < :05) long term outcomes. A nursing student’s age at the time of their experience was positively correlated (p < :05)
ª 2003 Elsevier Science Ltd. All rights reserved.
with personal development suggesting personal development was greater with older students.
Study design The purpose of this study was to explore the nature and meaning of international education experiences from a nursing student perspective. The research design was a qualitative descriptive study informed by phenomenology as described by van Manen (1990). Methods that guided this study were investigating experience, reflecting on essential themes, writing and rewriting, maintaining a focus on the phenomenon, and balancing parts and whole. This study was approved by the University of Colorado Health Sciences Center and Minot State University Institutional Review Boards. Identifying details about participants were changed for this article. The setting was the rural state of North Dakota (ND), USA which is located next to the Canadian border with a population of 650,000 and has seven baccalaureate nursing programs. ND was unique in that it was the only state in the USA that required a baccalaureate degree as the minimum education preparation for entry into professional nursing practice. Participants who were ND residents were recruited during 1999. Data was collected through mail surveys and interviews and analyzed utilizing descriptive statistics and thematic analysis. Sixteen nursing students participated in a two page mail survey and 11 participated in phenomenological interviews. Data were analyzed by the researcher through reflection – a review process of the written text conducted by alternating reviews of specific statements, then as whole, and then again as groups or categories of themes. Through a process of bracketing, the researcher’s bias and prior knowledge were made explicit, which enabled them to be held in abeyance. A researcher’s attempt to understand phenomenon by bracketing or looking at it as if for the very first time contributes to the credibility of the findings. According to Ray (1990), credibility is achieved when the people who have had the experience being studied recognize and acknowledge the researcher’s
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International nursing students: a phenomenological perspective
presentation of the experience. Participants in this student were given an opportunity to review, recognize, and acknowledge written presentation, thereby confirming and validating the findings. Additionally, two nursing students with international education experience who were not participants validated content and interpretations of data through verbal discussions. Limitations inherent in this study are related to the qualitative methods and a homogeneous small sample. As with all qualitative studies, findings should not be generalized to other nursing students.
Findings The age of the mail survey participants ranged from age 18 to 46 years with a mean of 31 years. Participants were mostly female Caucasian university senior nursing students who had an international education experience less than one year ago. Most experiences were facilitated by nursing faculty in collaboration with others. Eleven described their international experience to be organized by nursing faculty with an international mission group or ministries. Two described nursing faculty as organizing the experience in collaboration with an international colleague or friend. Two identified themselves as the organizer and one described the USA military as being responsible for their experience. Participants were asked to list two or three reasons for participating. Motivating factors were described as: nine wanted to help others; eight wanted to enhance nursing education; five were encouraged by friends; four wanted to travel and learn about another culture; three sought spiritual growth; two described motivating factors as parents and the way they were raised; and one was motivated through a government obligation. Activities. In this study, a variety of activities were described by nursing students in numerous nations. International experiences ranged from 7 days to 2 months in Mexico, Guatemala, Norway, Russia, Honduras, China, West Africa, New Zealand, and the Mediterranean. A variety of nursing activities were described. Within Mexico, nursing students performed nursing assessments for
398 Nurse Education Today (2003) 23, 396–403
children in nutritional programs and adults for diabetes and hypertension, provided visits for the home bound older adults, and health teaching for new mothers. In China, basic physical therapy and hygienic skills were taught to an orphanage staff and developmental assessments were completed on children for a US adoption agency. In Russia, nursing students presented a growth and development course to physicians and nurses based on a teaching module that they had developed and published. In Guatemala, one nursing student described assisting in clinics and administering medications, vitamins, and providing health teaching while another described providing primary care or care not qualified to provide. In West Africa, another also described providing primary care or care such as treatment and diagnosis of diseases. In Honduras and the Mediterranean, nursing students visited health professionals and toured health facilities and did not provide nursing. Several nursing students described activities not related to nursing. For instance, during the Norway experience, nursing students studied the language only. Others described constructing schools, homes, hospitals; participating in church activities; and teaching English language courses in addition to nursing activities.
Themes Themes evolved through analysis of the open-ended mail survey questions and tape-recorded interviews. Three hundred and three thematic statements were isolated and arranged into fifty groups with similar meaning. Then nine experiential structures and 4 essential themes were identified. Themes of preparing, adjusting, caring, and transforming were identified as essential themes or themes that formed the experiential structure.
Preparing Once in a lifetime experience. Preparing began before nursing students ever left home and was described as excitement and planning. Excitement usually was
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International nursing students: a phenomenological perspective
accompanied by a sense of adventure and anticipation ‘‘I knew it would be a once in a lifetime experience. I was so excited to be going. I could hardly wait.’’ Nursing students in this study began planning anywhere from one week to a year prior to departure. Specific activities included researching culture, language development, fund raising, and preparing educational materials. Advanced planning may have contributed to adjustment. For instance, a nursing student explained how she spent a year preparing by ‘‘cruising’’ the internet, joining discussion groups, and researching her host nation. She described how she was able to navigate the metro, a large transit system, independently while others could not. It also seemed that lack of adequate preparation may have contributed to frustration and adjustment difficulties. A nursing student found out she would be participating in an experience four days before she departed. She described feelings of excitement and anticipation until she arrived in her host nation: Well I kind of came into the group at the end. I didn’t know what they knew. The first day I bawled the whole day cuz I was so. . . I don’t know if those guys were more prepared or not. It’s not like I thought I would be staying and working at the Ritz. But driving in, I just did not realize, I mean even when we started working with the people, I sat there with my mouth down and bawled cuz I couldn’t believe I was there. It was so horrible. Other nursing students who had been involved in group preparations for six months prior to departure, did not have the overwhelming experience described by this participant.
Adjusting Feelings of comfort after experiences of shock. The human experience of adjusting was described as occurring when patterns of excitement diminished after immersion in the new nation. Adjusting was described through detailed experiences of shock, coping, and
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appreciation. For example, shock was described as: You can’t imagine it. You look at pictures but you can’t imagine the vastness of the poverty because you just don’t ever see it here. There is no way to prepare for this. Another described: I never saw anyone get shot but I heard shots at night. There were armed soldiers at every store. You had to be careful with your money. I was afraid of being attacked or abducted. I was aware that something could happen. I was always afraid. After the initial shocking experiences, all the nursing students interviewed described some adjustment to their host nation. Described by a student who spent nine months in a developing country: I just didn’t want to change my life style and I knew that I couldn’t fear them or I would be unhappy. If things are going to happen then they’re going to happen whether I’m there or here. Several described how they began to adjust rather quickly: I think it was like our second day and we had come back from the other mission and we were like ‘Wow I’m home.’ Even others said it was weird. I felt so comfortable. I felt at home. The first day you were so shocked and didn’t want to be there and you’re thinking how do I get out of this place. By the second day you are thinking this is wonderful, this is a really really nice place to be. Not everyone seemed to adjust to different environments in the same way. I was just so embarrassed with them and disappointed. Even on the way home, they were so insulting and rude to our waitress because she did not have the American beer they wanted. I was so upset with them. I told them to be quit complaining. I would not sit with them because they embarrassed me. It was not the US and they could not cope with that.
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Appreciation seemed to result from a nursing student’s genuine adjustment and their acceptance of the new nation as just another way of living. ‘‘They have so much less than we do but they really seem much happier.’’ Nursing students might or might not have always approved of the new nation but they described understanding differences as they were able to appreciate the rich layers of the nation and the people in it.
Caring Awakened a feeling of caring that required nothing in return. Caring was described through structural experiences identified as doing and being. Experiences of doing allowed nursing students to have first hand experience with diseases and culture aspects in clinical sites that were unlike any education they had received before. These experiences were often described as profound and transforming. A nursing student who spent nine months in a host nation described an expanded nursing role as: I did so many things I was not prepared for like suturing and splinting. I was all they had many times. Sometimes in the morning a kid would show up at my door who had been running all night to come and get me. All he would say is ‘bleeding.’ Many times I never knew what was bleeding. Was it an artery or vein? They could never answer me even though I spoke Spanish. So I would just go. I’d wash my hands and grab my duffle bag and follow them. It might take us all day to get there. Several described newly gained confidence as: I thought this was the greatest thing that had ever happened to me. Cause I went over there and I felt like I totally didn’t know anything. I felt I’m going to graduate and I still am not sure what I know. I realize now that I know a lot more than I thought I did. It was a real confidence builder for me. Not all experiences were described positively:
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As far as the nursing experience, I felt stupid and unprepared. Although it was a great experience in so many ways, we could not offer proper care or treatment for the clients in need. All treatment was deferred most of the time. It should have been a team with doctors and medical supplies. Many mothers came wanting their children better. We did little. I felt frustration. The experience of being seemed to be an attitude: Here nurses work with machines and not the patient and there it was different. What I really learned was how to care for people whereas here nurses learn how to run machines. Several described: The experience made me remember why I went into nursing. I know I want to continue doing this throughout my nursing career. I think it keeps you in check with the caring part of nursing. I recognized that the art of nursing is universal and people want to be cared for and (they) recognize when nurses are kind and compassionate regardless of the language spoken. I came away from this experience more determined than ever to be a compassionate nurse. Another described awakening as: The caring part of it just opened up. This is why I’m a nurse. Everyone should go at least once a year to bring themselves back, back to caring. Another described: I realized that humans are the same everywhere regardless of socioeconomic status. Everyone needs and deserves safety, love, respect, kindness, and human touch. The caring touched both, them and me.
Transforming Changes are here inside of me. Nursing students seemed transformed as they were challenged to examine their world view
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International nursing students: a phenomenological perspective
and empathy through questioning and searching to decide which values and beliefs to make their own and which to discard. Five of eleven nursing students interviewed stated they are now more empathetic. One explained that by being in another country where she did not know the language, made her realize how it must be for her Spanish speaking and hearing impaired patients and she now spends extra time with them trying to understand. Another explained that she felt she really was not more caring but more empathetic in the way she tried to understand her patients from different cultures ‘‘I really try to understand their needs instead of forcing my beliefs onto them.’’ Another described empathy as ‘‘This experience enabled me to see past the poverty and filth and see the strength of the human spirit. It awakened an understanding I had never known before.’’ Another described her experience as ‘‘It opened my eyes to cultural differences and similarities and finding ways to communicate and connect.’’ Transforming world views meant asking questions. Questions raised related to experiences of different cultures, values, and ethics including religion. The world view of realizing own values and beliefs was described by a nursing student as: It was the first time I realized what I value and believe in, what is important to me. It was the first time I really examined my thinking. I believe my main duty as a nurse is to care for my patient, no matter what country I’m in, and not judge but help people manage their health in their own way. The world view of examining nursing’s universalities was described by several: I feel strongly that all human life should be valued. I also recognized that the art of nursing is universal and people want to be cared for no matter where they live. Each individual is ultimately in control of their health care and we need to acknowledge that. Others suggested ethnocentrism ‘‘I realized that we (nurses) live in a vacuum in the US. We have no idea what the rest of the world is up to.’’ Nursing student participants in this study
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seemed to cross over into another nation and begin to have an expanded world view and empathetic understanding for its people. Empathy seemed to represent a relativity high level of sensitivity. The change toward a multicultural world view took place with the integration of new perspectives into old values and views that may have been transforming. Integration that allows for ethical choice and actions in a profoundly relativistic world has the potential to be transforming. Described by one participant as ‘‘By going over there I realize that I can do a little bit more here. The changes are here, inside me.’’
Essential themes diagram Themes make up the universe of meaning people live through. Four essential themes identified in this study were preparing, adjusting, caring, and transforming. Fig. 1 illustrates the descriptive diagram generated from data grounded in descriptions of meanings. All themes appeared relational in nature and seemed to occur simultaneously or impact one another continuously. For example, a nursing student may be participating in an international education experience preparing to provide nursing activities while adjusting to unfamiliar practice environments while being present and caring in relationship with coworkers from a Colonia. The processes of the four essential themes appeared to be influenced by culture, values, and ethics. The specific structures and relationships were not explored. Essential themes are not objects or generalizations. Metaphorically, they are more like knots in the webs of our experiences, around which certain lived experiences are spun and thus lived through as meaningful wholes (van Manen 1990). Through
Fig. 1 International education diagram.
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experiential processes of preparing, adjusting, and caring nursing students were transformed as they found a broader existential view of life.
Discussions and conclusions According to the literature review, many nursing schools are making progress in launching students into the international world through a variety of strategies. However, provision for internationally competent human care continues to be a major challenge facing professional nursing and nurse educators. According to Leininger (1994) there is a long standing deficit in nursing education in preparing knowledgeable, competent, and responsible nurses for serving those with multicultural needs. Others have suggested nursing education in general be altered to support more global awareness of cultures, world views, and ethnic diversity (Andrews 1992; Arnold et al. 1998; Davidhizar et al. 1998; Freda 1998). According to Watson (1999) nursing theory, research, and education needs to provide nurses with appropriate fundamental preparation and knowledge to practice human care universally for the preservation of humanity. Shock was experienced by all the participants in this study. What was not clear was if experiences of shock were related to culture or poverty. The vastness of poverty seemed ‘difficult to take’ as described by several participants in a variety of ways, more so than cultural differences. Sparse living conditions, unkempt environments, and many times large families without adequate resources were noted as difficult. Further inquiry is suggested to explore issues of shock as related to poverty. Several participants described ethical dilemmas related to poverty-stricken large families, issues surrounding appropriate levels of cleanliness, life and death issues surrounding the disabled, and treatment of female infants. Whose beliefs are right? Of course each person believes their own beliefs are true implying a need for nursing students to have sound ethical principles and arguments for the justification and consideration of truth. Several participants stated they felt inadequate or possibly could have
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accomplished more if they had knowledge of the language of the host nation. One explained that she could not communicate with the people she was assessing and that did not seem right on a human level. Only seven out of sixteen (44%) mail survey participants in this study identified personal knowledge of a foreign language. Obviously, if language barriers are present, it is difficult to communicate. It is possible to use interpreters, which was described by several nursing students in this study, however, it was not described as the best situation as it placed a burden on interpreters who sometimes had other agendas. Every college graduate should have the ability to communicate in at least one foreign language. Through a foreign language, one may gain entry to a previously unknown culture in a way that will enhance ones understanding of humans, their beliefs about health an illness, and their use of words to express values, feelings, and needs. Nursing knowledge that deals with women of different cultures may also be beneficial. Several participants in this study described how frustrating it was to accept the oppression of women and patriarchal families in certain nations. It may be helpful for international nursing students to explore the role, social status and position of nursing in the occupational and social structure of host nations. Additional research with other qualitative and quantitative methodologies could be emphasized to advance descriptions discovered in this study. Participants were described as homogenous, mostly Caucasian females educated in a rural Midwestern state. It would be valuable to replicate this study with others from diverse backgrounds, ethnic groups, socioeconomic backgrounds, and nations as they may experience international education differently. Research designed to follow students longitudinally may also be beneficial to determine how transformations change over time. Also, when compared to general education study aboard students, nursing students are unique. They appear to spend less time internationally, adjust rather quickly, and practice in an advanced role (one not trained for) implying a need for further comparative investigations.
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International nursing students: a phenomenological perspective
Through this inquiry, descriptions and meanings of phenomena related to nursing students’ international education experiences were discovered. The qualitative design helped illuminate themes that would have been obscured in a quantitative study if predetermined questions were used. The significance of this nursing study was the identification of plausible descriptive insights that may be useful to educators who assist students with international education experiences that potentially could benefit nursing students, nursing, and humanity. Acknowledgements Drs. Sally Phillips and Marlaine Smith, University of Colorado Health Sciences Center, Denver, Colorado, USA, Donna Marsland, Campus Ministries, Minot, ND, USA, and North Dakota nursing students. References Andrews M 1992 Cultural perspectives on nursing in the 21st century. Journal of Professional Nursing 8(1): 7–15 Arnold L, Bakhtarina I, Brooks AM, Coulter S, Hurt L, Lewis C, Weinstein S, Younger J 1998 Nursing in the newly independent states of the former Soviet Union: An international partnership for nursing development. Journal of Obstetric, Gynecologic, and Neonatal Nursing 27(2): 203–208 Carlson JS, Burn BB, Useem J, Yachimowicz D 1991 Study abroad: The experience of American undergraduates in western Europe and in the United States. Greenwood, Westport, CT Davidhizar R, Dowd SB, Giger JN 1998 Educating the culturally diverse healthcare student. Nurse Educator 23(2): 38–42 Fenton M 1994 Development of models of international exchange to upgrade nursing education. In: McClosky
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JC, Grace HK (eds). Current Issues in Nursing, 4th edn. Mosby, St Louis, MO, pp. 202–206 Freda MC 1998 International nursing and world health: Essential knowledge for the 21st century nurse. The Journal of Maternal Child Nursing 23(6): 329–332 Frisch N 1990 An international nursing student exchange program: An education experience that enhanced student cognitive development. Journal of Nursing Education 29(1): 10–12 Haloburdo E, Thompson M 1998 A comparison of international learning experiences for baccalaureate nursing students: Developed and developing countries. Journal of Nursing Education 37(1): 13–21 Inglis A, Rolls C, Kristy S 2000 The impact on attitudes towards cultural difference of participation in a health focused study abroad program 9(3–4): 246–255 Kauffmann N, Martin J, Weaver H 1992 Students abroad: Strangers at home. Intercultural Press, Yarmouth, ME Kirkpatrick M, Brown S 1999 Efficacy of an international exchange via the internet. Journal of Nursing Education 38(6): 278–281 Leininger MM 1994 Transcultural nursing education: A worldwide imperative. Nursing and Health Care 15(5): 254–259 Ray MA 1990 Phenomenological method for nursing research. In: Chaska NL (ed). The Nursing Profession: Turning Points. Mosby, St Louis, MO, pp. 173–179 van Manen M 1990 Researching lived experience: A human science for an action sensitive pedagogy. State University of New York Press, New York Watson J 1999 Postmodern Nursing and Beyond. Churchill Livingston, New York Wilson M 2002 Transnational nursing programs: Models, advantages and challenges 22(5): 417–426 Wright M, Godue C, Manfredi M, Korniewicz D 1998 Nursing education and international health in the United States, Latin America, and the Caribbean. Image: Journal of Nursing Scholarship 30(1): 31–36 Zorn C 1996 The long-term impact on nursing students of participating in international education. Journal of Professional Nursing 12(2): 106–110 Zorn C, Ponick D, Peck S 1995 An analysis of the impact of participation in an international study program on the cognitive development of senior baccalaureate nursing students. Journal of Nursing Education 34(2): 67–70
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