- Email: [email protected]
International student nurses’ experiences of clinical practice in the Finnish health care system
Nurse Education in Practice 10 (2010) 153–157
Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
International student nurses’ experiences of clinical practice in the Finnish health care system Lea-Riitta Mattila *, Marianne Pitkäjärvi, Elina Eriksson Faculty of Nursing and Health Care, Helsinki Metropolia University of Applied Sciences, P.O. Box 4030, FIN 00079, Metropolia, Finland
a r t i c l e
i n f o
Article history: Accepted 26 May 2009
Keywords: International student nurse Clinical practice Positive and negative experiences
s u m m a r y The purpose of this qualitative study was to describe international student nurses’ experiences of their clinical practice in the Finnish health care system. The data were collected by semi-structured interviews. Fourteen international student nurses of African and Asian origin were interviewed, and the data were then analysed by qualitative content analysis. The results indicated that appreciative orientation, sense of belonging to the team, enhancing independent working, growing towards professionalism and working as a member of the team were descriptions of positive experiences. Descriptions of negative experiences were related to restricted learning and compromised human dignity, which lead to negative feelings of being an outsider, decreased self-esteem, sense of giving up and anticipation of difficulties. Despite the small sample size, the results indicate a need to develop clinical practice arrangements when the language of the learning environment is other than that of the student nurse. As the number of international students has increased in the Finnish health care sector and in nursing education, it is important to recognise the factors related to positive and negative experiences in clinical practice. Ó 2009 Elsevier Ltd. All rights reserved.
Introduction Nursing education in Finland is implemented in degree-level programmes at universities of applied sciences. They are part of the national and international higher education community responsible for educating experts for the workplace and its development. Furthermore, universities of applied sciences carry out research and development relevant to their teaching in close collaboration with the working environment (Ministry of Education, 2001). Twenty-one universities of applied sciences (out of 29) offer degree programmes in nursing in the country. In addition to bilingual education, eight institutions also provide nursing programmes in English. This is a manifestation of the globalisation of the higher education market throughout the world (Speziale and Jacobson, 2005; Bosworth et al., 2006; Statistics Finland, 2006). According to Statistics Finland (2008) the number of international students within higher education has increased from 2% in 1998 to 4% in 2008 of the student population, which reflects the change in population demographics also in broader sense. Nursing education in Finland is a 3.5-year programme, consisting of 210 ECTS credits (European Credit Transfer System). This includes 90 credits of clinical practice meeting the criteria laid down * Corresponding author. Tel.: +358 9 310 81 665; fax: +358 9 310 81 790. E-mail addresses: lea-riitta.mattila@metropolia.fi (L.-R. Mattila), marianne.pitkajarvi@metropolia.fi (M. Pitkäjärvi), elina.eriksson@metropolia.fi (E. Eriksson). 1471-5953/$ - see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.nepr.2009.05.009
in the European Union Council Directives for nursing education and defines the required clinical settings (European Union Council Directive 77/452/EU). The purpose of clinical practice is to provide students with supervised orientation to their future profession in de facto circumstances. The average length of a clinical practice period is 5 weeks (7.5 crore) and it is carried out in clinics belonging to the university – and other teaching hospitals. No theoretical instruction is arranged during this period. Supervision of students’ clinical practice may be carried out in many different manners. It always involves clinical staff and a faculty member, each having differing roles and responsibilities. Most often, students work as pairs with nurses, their clinical instructors, whose role involves supervision of students’ performance. The faculty member’s role may vary, but, it always involves acting as a link between the institution and the clinical practice placement as well as a support person for the clinical instructor and a facilitator of learning for students. Gillespie (2002) has reported of a similar role for the teacher. Meetings involving all three parties are arranged on a regular basis throughout the clinical practice period. The focus of these meetings is on students’ individual objectives. A number of researchers (Löfmark and Wikblad, 2001; Saarikoski, 2002; Andrews et al., 2005) have previously explored the prerequisites of a successful learning experience in the clinical setting. According to their findings, the core elements of positive experiences are related to students’ own motivation to learn, students’ acceptance, positive atmosphere among the caregivers, managers’ supportive attitude as well as distinctive characteristics
154
L.-R. Mattila et al. / Nurse Education in Practice 10 (2010) 153–157
of the interaction between clinical instructors and students. During clinical practice, the most significant factor is the interaction between the clinical instructor and student (Saarikoski, 2002). To explore what is known about international students’ clinical practice experiences, a literature search was carried out by using Ovid-Cinahl and ERIC databases. The period of the search was limited to 2000–2008, and ‘clinical practice’, ‘international student nurse’ and ‘international exchange’ were used as key words. In recent years, a number of studies focusing on international exchange experiences have been published (Walsh and DeJoseph, 2003; Robinson et al., 2006; Bosworth et al., 2006; Koskinen and Tossavainen, 2003) and many of these have involved a clinical element. As stipulated by Rogan et al. (2006), non-native speakers’ experiences of clinical settings involve unique challenges for students, such as wanting to belong but feeling excluded and lack of suitable coping strategies. Besides Koskinen and Tossavainen’s study on British exchange students in Finland, there is a shortage of studies about international students’ experiences of clinical practice in Finland. Despite offering English degree programmes in nursing for over ten years, universities of applied sciences seem not to have provided national or international research about international students’ unique situation during their clinical practice. The multilingual circumstances are evoked because students’ native language, the language of theoretical instruction and the language used by caregivers and patients during clinical practice are all different. Evidence suggests that ethnic students do encounter prejudice, discrimination or racism in their nursing education (Yoder, 1996; Jalili-Grenier and Chase, 1997; Malu and Figlear, 1998; Dickerson et al., 2000; Andrews et al., 2005). Furthermore, previous literature has discussed the difficulties experienced by international students when it comes to active participation whether in class or in clinical practice (Ramsay et al., 1999; Robertson et al., 2000; Grant and McKenna, 2003). The purpose of this qualitative study was to describe international student nurses’ experiences of their clinical practice in the Finnish health care system. The research question was: What kind of experiences do international student nurses describe as positive and negative? The aim was to consolidate body of knowledge necessary to ensure positive experiences in clinical practice in cases when students’ primary language is other than that of patients or clinical instructors.
Methods Data collection Because of shortage of studies about international students’ clinical practice experiences in the Finnish health care system, data were collected by semi-structured interviews. In particular, this method enables the interviewee to express sensitive and difficult experiences. The two themes were based on the results of earlier studies (Yoder, 1996; Jalili-Grenier and Chase, 1997; Malu and Figlear, 1998), consisting of descriptions of positive and negative experiences when attending clinical practice. Two students piloted the interview themes. Since the themes appeared relevant and flexible enough to catch the individual experiences, they remained unchanged. These pilot interviews were not, however, included in the data. Three graduating student nurses conducted the interviews. These student nurses were chosen because we assumed international students would share their experiences more openly with peers than with researchers and might reveal feelings and private doubts that contradict student expectations (Rew et al., 1993; Miller and Glassner, 2004). In addition, as fellow students, the interviewers
could identify with the interviews and were able to understand the language in which the experiences were described. Interviewers were from different group than interviewees and they were coached by the authors for interviewing techniques during several meetings. Coaching included themes such as the progress of an interview, the role of the interviewer and the transcription process. Ethical issues relating to conducting interviews were clarified and reflected on. Moreover, interviewers were encouraged to consult the authors in case of possible problems throughout the process. Because of the small amount of potential interviewees, and because we wanted to capture the variation of experiences, the data were collected in two phases. Prior to the interview, those students (n = 17) who had studied a minimum of 2.5 years were inquired about their willingness to participate in the study. The 2.5-year requirement was based on the assumption that by this time students had gained enough experience on clinical practice and various nursing environments. Fourteen international students agreed to be interviewed whilst two potential interviewees refused. All interviewees were of African and Asian origin. Their age varied from 23 to 30 and they had been studying for 2.5–3.5 years. The interviewers and interviewees agreed the time and place of the interviews and to ensure privacy, they were carried out in peaceful surroundings at the institution. The interviews were recorded and their duration varied from 25 to 35 min. The director of the Faculty of Health Care and Social Services gave the permission to conduct the study. The interviewers distributed researchers’ letter to the students. It included an invitation to participate in the study and the information necessary for their consent. The interviewers began the interviews by confirming voluntary participation, confidentiality and anonymity. It was important that the interviewees felt free to speak. The interviewers destroyed the tapes after completion of the transcription process and distributed the transcribed interviews to the authors in sealed envelopes. Data analysis The data were analysed by inductive content analysis based on two themes: positive and negative experiences (Graneheim and Lundman, 2004) which helped the conceptualisation process of students’ descriptions of their experiences. The aim of this was to provide a compact and yet general description of the phenomenon under investigation. The prerequisite of the analysis was an understanding of the interviewees’ social world (Miller and Glassner, 2004). In this study, the social world referred to the clinical practice environment. The interviews were read through several times to gain a comprehensive view of the subject matter. The unit of analysis was a combination of words or a phrase. Students’ descriptions were formed into simplified expressions based on the same terms they had used and they were transformed into plain lists. Those expressions that bore a similar meaning were combined into the same group and were given a name, which indicated their content (subcategory). The subcategories were combined to create categories. The formation of categories was based on students’ expressions and the qualitative content of their meaning. The tentative categories were discussed and revised. Hence, the main categories comprised positive and negative experiences. Results Descriptions of positive experiences Students’ descriptions of positive experiences consisted of diverse staff activities as well as students’ feelings and behaviour.
L.-R. Mattila et al. / Nurse Education in Practice 10 (2010) 153–157
This category was called appreciative orientation. From the beginning, students felt that orientation on the ward reflected appreciation towards them. They described how the clinical environment and its facilities, staff members, patients and daily routines were introduced to them. From this introduction, they also understood how they could become involved with the nursing activities. Thus, students knew what was expected of them as student nurses. Students were made feel welcome by supporting them to join the team. Positive attitude towards students manifested itself in allowing them to be included in planning and decision-making of patient care as well as in staff members’ willingness to help and teach. Students did not feel like outsiders and both English and Finnish were used in a flexible manner. Also, dictionaries were employed, whenever appropriate, and written material in English was distributed to students. All students experienced enhancing their possibilities to work independently positive. The name of this category was enhancing independent working. Clinical instructors encouraged critical thinking and reflection on theory before, during and after being exposed to nursing activities. In addition, students appreciated continuous feedback from instructors. In concrete terms, this meant that as the clinical practice progressed, clinical instructors and students reflected on a regular basis. Furthermore, students’ positive experience was reinforced, if clinical instructors shared their good impressions of students with other staff members. Students’ positive experiences and the staff members’ positive attitude towards them were bridged together. This category was called sense of belonging. Students felt they were accepted and welcomed to join the team and work in it as an equal member, holistically caring for their own patients. ‘‘I saw myself as one of them, as one of the working team, because they included me in their planning and decision making . . .” They felt comfortable in the social environment and they felt at ease. These types of experiences allowed students to self-actualise, which further lead to feelings of profound satisfaction. The category named growing towards professionalism included experiences of being empowered and awareness of own potential. Students’ descriptions included feelings of being appreciated, having energy and an increasing amount of motivation as well as feeling of overcoming any difficulties. Students reported to have felt like professionals. Moreover, they felt they were growing up and maturing, which further made them see themselves as members of the larger community. The data included numerous descriptions of happiness, confidence, encouragement and awareness of one’s own abilities. The last category was called working as a member of the team. Students considered this opportunity positive. On one hand, experiences of having worked independently increased their self-confidence, which, in turn, reinforced similar behaviour in future clinical practice placements. ‘‘...when my tutor gave me that chance to just work on my own and consult her once in a while when I needed something, it just made me feel comfortable and accepted. . .” On the other hand, being a team member facilitated displaying initiative and willingness to try hard and to learn more. Descriptions of negative experiences The category named restricted learning included language-related problems, preventing students from meaningful learning, ignoring students and arousing suspicion. Students felt that there were contradictory language expectations. Some students’ poor Finnish was not accepted, nor were they encouraged to use the limited language skills they had. Students also felt their poor Finnish caused anger in some nurses. In these situations, students were asked to use English instead. Some students were not allowed to use English either. In terms of the level of students’ involvement
155
with nursing practice, conflicting demands existed as students were expected to be active, and yet, they did not know how to get involved with nursing activities because of lack of common language. Furthermore, students expressed concern they were prevented from participating in meaningful learning experiences. This took forms of withholding information concerning patients, not being given own patients, and not allowing students to give oral reports. ‘‘I was never given that chance to give a report in Finnish so it affected me in the sense that I never feel so confident. . .” Some students were even forced to wait for foreign patients, whereas some were guided towards task-orientation as opposed to a more holistic caring approach to nursing. Some students had to concentrate on providing basic nursing care instead of administering medications. Some students felt the staff was ignoring them. This manifested itself in leaving students alone and outside the social environment. Nurses were not aware of students’ learning needs, the student – clinical instructor relationship was weak, and the role of the student was unclear. Negative experiences were also related to suspicion against students, which took the form of frequent check-ups with students’ activities, thus, forcing them to learn mainly by observation. Students were not believed to have the required knowledge and skills to participate in nursing. Consequently, patients did not trust students either. The next negative category was named compromised human dignity. Students were called names and remarks were made about their skin colour and ethnic background. Some patients refused to shake hands with some of the students, and some refused to be nursed by them. However, no staff member showed any interest in these experiences, nor tried to support the student. Therefore, the data indicated numerous descriptions of having felt sad, bad, or low, which resulted in unwillingness to begin a new day in the clinical practice placement. These feelings, however, were kept hidden from nurses, patients and teachers. Instead, students tried to act as if everything was fine. Furthermore, students ended up trying to demonstrate their competence and anticipating difficulties. Students described feelings of being intimidated – no matter what good they were trying to do. They felt scared, stupid and humiliated. There were a number of descriptions of feeling unaccepted, being an outsider and not a member of the social environment. This category was named feelings of being an outsider. Students worked and stayed alone, as no one showed positive attention to them. Some students began to think that nursing was a wrong career for them and reported having considered abandoning it and pursuing a career not involving interaction with others. The next category, decreased self-esteem, included students’ descriptions of gradual loss of courage and confidence, and finally, inability to learn. Feelings of inferiority and feeling nothing of oneself were common. ‘‘. . .they oversee you, they don’t always see that you are there. . . and you just feel. . .nothing of yourself”. The data clearly indicated that negative experiences lead to lack of motivation to learn. When experiencing negativity, students either gave up or became more determined to succeed. In the category called giving up, students described withdrawal and distance from the group. Alternatively, they would follow and observe what staff members were doing, as staff did not encourage student participation. Instead, their activities consisted of irrelevant tasks. One of the students called this method ‘‘learning by watching”. Some students stayed in the placement only to earn the credits. Since some patients did not accept care provision from an international student, students learned to approach patients carefully and to interpret their non-verbal cues. This category was called anticipation of difficulties. This manifested itself in avoiding negative responses from patients. In relation to staff, students felt they
156
L.-R. Mattila et al. / Nurse Education in Practice 10 (2010) 153–157
had to prove their competence on continuous basis and with considerable persistence.
Discussion The positive experiences enhanced professional growth, which included sense of awareness of own potential and empowerment. Earlier studies have shown that positive experiences of approval, pleasant atmosphere and support are central to students’ learning (Saarikoski, 2002; Andrews et al., 2005). The students’ negative experiences created feelings of being left out and weakened their self-esteem. According to previous research, ethnic students encounter prejudice, discrimination or racism in their nursing education (Malu and Figlear, 1998; Dickerson et al., 2000; Andrews et al., 2005). As most of the interviewees came from cultures emphasising collectivism as opposed to individuality, they felt disturbed by a taskoriented, non-caring approach to nursing, which seemed to be prominent in some units. Therefore, it seems that staff should use international students’ different ways of interacting with patients and their significant others to a greater degree. The data revealed emotionally sensitive experiences, which the participants had not talked about with their teachers. Based on the transcriptions, some of the interviewees seemed to be in agony whereas some seemed to be relieved when sharing the experiences. Teachers should be aware of the possibility of students’ emotionally sensitive experiences, which they might be reluctant to bring up on their own. The lack of orientation and constant hurry of staff members resulted in students’ feelings of not being welcome to their placement. Instead of focusing on learning, students used their energy in anticipating difficulties and persistently trying to prove their competence. For this reason, it is suggested that more attention should be paid to preparing and supporting the staff to receive an international student. This finding is consistent with previous studies (Gillespie, 2002; Grant and McKenna, 2003). Teachers and clinical instructors should encourage students to reflect on their negative experiences because this might empower them to overcome difficulties. In Finland, the number of international nurses and student nurses is smaller than in many other European countries. Interestingly, Grant and McKenna (2003) have explicated that even if the language of the learning environment was the same as students’ mother tongue, they experienced feelings of fear and frustration as well as difficulties in interaction with the staff. In addition, in terms of students’ skin colour and cultural background, more tolerance and broadmindedness is required in interaction with international students. The nursing staff should take more responsibility for introducing international students to patients. Clinical instructors should pay more attention to the orientation of both students and staff. According to Miles and Huberman (1994), qualitative research has five overlapping issues of reliability and validity: credibility, dependability, confirmability, transferability and utilisation of the results. In this study, credibility means that the students openly expressed their views. The researchers did not carry out the interviews, as suggested by Rew et al. (1993). This was a conscious choice. Since the interviewers and participants were peers, it may be assumed that the participants talked truthfully, which did, in fact, turned out to be evident. The criteria of dependability are met once the credibility of findings has been established. The data collected in 2007 supported the previous data collected in 2004. We discussed the formation of categories several times to improve the validity of the analysis process. Confirmability refers to the freedom of bias in the whole process. Discussion of confirmability must take into account the peer
interviewers and the two researchers who were familiar with the students. The identity of the interviewees was unknown to the authors and it facilitated bracketing. Description of the background information and the steps of the research process allow the reader to follow the progress. Transferability refers to the extent to which findings could be transferred to other subjects and contexts. In this study, fourteen students were interviewed. The sample size was small and selective, but the data were rich and revealed sensitive information. It became apparent that the interviewers were successful in posing questions, probing and encouraging. These findings can be used to prepare nurses to assume the role of the supervisor and to help students to reflect on their experiences during clinical practice. Despite the small sample size, the results can be applied to the development of international students’ clinical practice supervision. Conclusions A successful orientation period had a significant role in facilitating positive experiences for students. Accepting students as team members as well as allowing for independence in patient care and expose to challenges enhanced professional growth, including sense of awareness of own potential and empowerment. These experiences lead to students perceiving themselves as full members of health care providers community as well as of the society as a whole. Students’ poor command of Finnish easily lead to negative experiences. In this case, flexible use of both English and Finnish was found helpful. Putting students into a position where they had no role in patient care resulted in experiences of being left out, wanting to give up or using energy to anticipation of difficulties. Students were not necessarily willing to elucidate the most painful experiences with clinical instructors or teachers. Awareness of students’ tendency to hide these experiences will contribute to developing a more supportive clinical learning environment. References Andrews, G.J., Brodie, D.A., Andrews, J.P., Wong, J., Thomas, B.G., 2005. Place(ment) matters: students’ clinical experiences and their preferences for first employers. International Nursing Review 52, 142–153. Bosworth, T., Haloburdo, E., Hetrick, C., Patchett, K., Thompson, M.A., Welch, M., 2006. International partnerships to promote quality care: faculty groundwork, student projects, and outcomes. The Journal of Continuing Education in Nursing 37 (1), 32–38. Dickerson, S., Neary, M., Hyche-Johnson, M., 2000. Native American graduate nursing students’ learning experiences. Journal of Nursing Scholarship 32 (2), 189–196. Gillespie, M., 2002. Student–teacher connection in clinical nursing education. Journal of Advanced Nursing 37 (6), 566–576. Graneheim, U.H., Lundman, B., 2004. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today 24 (2), 105–112. Grant, E., McKenna, L., 2003. International clinical placements for undergraduate students. Journal of Clinical Nursing 12 (4), 529–535. Jalili-Grenier, F., Chase, M., 1997. Retention of nursing students with English as a second language. Journal of Advanced Nursing 25 (1), 199–203. Koskinen, L., Tossavainen, K., 2003. Relationships with undergraduate nursing exchange students–a tutor perspective. Journal of Advanced Nursing 41 (5), 499–508. Löfmark, A., Wikblad, K., 2001. Facilitating and obstructing factors for development of learning in clinical practice: a student perspective. Journal of Advanced Nursing 34 (1), 43–50. Malu, K., Figlear, M., 1998. Enhancing the language development of immigrant ESL nursing students: a case study with recommendations for actions. Nurse Educator 23 (2), 43–46. Miles, M.B., Huberman, A.M., 1994. Qualitative Data Analysis, second ed. Sage Publications, Thousand Oaks. Miller, J., Glassner, B., 2004. The ‘‘inside” and the ‘‘outside” Finding Realities in Interviews. In: Silverman, D. (Ed.), Qualitative Research. Theory, Method and Practice. Sage Publications, London. pp. 125–139. Ministry of Education, 2001. Ammattikorkeakoulusta terveydenhuoltoon. Koulutuksesta valmistuvien ammatillinen osaaminen, opintojen keskeiset
L.-R. Mattila et al. / Nurse Education in Practice 10 (2010) 153–157 sisälöt ja vähimmäisopintoviikkomäärät. Opetusministeriö 7.9.2001. Helsinki. (English Summary). Ramsay, S., Barker, M., Jones, E., 1999. Academic Adjustment and Learning Processes: a comparison of international and local students in first-year university. Higher Education Research and Development 18 (1), 129–144. Rew, L., Bechtel, D., Sapp, A., 1993. Self-as-instrument in qualitative research. Nursing Research 42 (5), 300–301. Robertson, M., Line, M., Jones, S., Thomas, S., 2000. International students, learning environments and perceptions: a case study using the Delphi technique. Higher Education Research and Development 19 (1), 89–102. Robinson, K., Sportsman, S., Eschiti, V., Bradshaw, P., Bol, T., 2006. Preparing faculty and students for an international nursing education experience. The Journal of Continuing Education in Nursing 37 (1), 21–29. Rogan, F., SanMiguel, C., Brown, D., Kilstoff, K., 2006. ‘‘Find yourself” Perceptions of nursing students from non-English speaking backgrounds of the effect of an
157
intensive language support program on their oral clinical communication skills. Contemporary Nurse 23 (1), 72–86. Saarikoski, M., 2002. Clinical learning environment and supervision. Development and Validation of the CLES Evaluation Scale. Dissertation, Annales Universitatis Turkuensis Medica–Odontologica Ser. D, Tom. 525 (University of Turku, Finland) Speziale, H., Jacobson, L., 2005. Trends in registered nurse education program 1998– 2008. Nursing Education Perspectives 26 (4), 230–235. Statistics Finland, 2008. Statistics Finland. www.tilastokeskus.fi/index_en.html (Site visited December 2, 2008). Walsh, L., DeJoseph, J., 2003. ‘‘I Saw it in a Different Light”: international learning experiences in baccalaureate nursing education. Journal of Nursing Education 42 (6), 266–272. Yoder, M., 1996. Instructional responses to ethnically diverse nursing students. Journal of Nursing Education 35 (7), 315–321.
Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
International student nurses’ experiences of clinical practice in the Finnish health care system Lea-Riitta Mattila *, Marianne Pitkäjärvi, Elina Eriksson Faculty of Nursing and Health Care, Helsinki Metropolia University of Applied Sciences, P.O. Box 4030, FIN 00079, Metropolia, Finland
a r t i c l e
i n f o
Article history: Accepted 26 May 2009
Keywords: International student nurse Clinical practice Positive and negative experiences
s u m m a r y The purpose of this qualitative study was to describe international student nurses’ experiences of their clinical practice in the Finnish health care system. The data were collected by semi-structured interviews. Fourteen international student nurses of African and Asian origin were interviewed, and the data were then analysed by qualitative content analysis. The results indicated that appreciative orientation, sense of belonging to the team, enhancing independent working, growing towards professionalism and working as a member of the team were descriptions of positive experiences. Descriptions of negative experiences were related to restricted learning and compromised human dignity, which lead to negative feelings of being an outsider, decreased self-esteem, sense of giving up and anticipation of difficulties. Despite the small sample size, the results indicate a need to develop clinical practice arrangements when the language of the learning environment is other than that of the student nurse. As the number of international students has increased in the Finnish health care sector and in nursing education, it is important to recognise the factors related to positive and negative experiences in clinical practice. Ó 2009 Elsevier Ltd. All rights reserved.
Introduction Nursing education in Finland is implemented in degree-level programmes at universities of applied sciences. They are part of the national and international higher education community responsible for educating experts for the workplace and its development. Furthermore, universities of applied sciences carry out research and development relevant to their teaching in close collaboration with the working environment (Ministry of Education, 2001). Twenty-one universities of applied sciences (out of 29) offer degree programmes in nursing in the country. In addition to bilingual education, eight institutions also provide nursing programmes in English. This is a manifestation of the globalisation of the higher education market throughout the world (Speziale and Jacobson, 2005; Bosworth et al., 2006; Statistics Finland, 2006). According to Statistics Finland (2008) the number of international students within higher education has increased from 2% in 1998 to 4% in 2008 of the student population, which reflects the change in population demographics also in broader sense. Nursing education in Finland is a 3.5-year programme, consisting of 210 ECTS credits (European Credit Transfer System). This includes 90 credits of clinical practice meeting the criteria laid down * Corresponding author. Tel.: +358 9 310 81 665; fax: +358 9 310 81 790. E-mail addresses: lea-riitta.mattila@metropolia.fi (L.-R. Mattila), marianne.pitkajarvi@metropolia.fi (M. Pitkäjärvi), elina.eriksson@metropolia.fi (E. Eriksson). 1471-5953/$ - see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.nepr.2009.05.009
in the European Union Council Directives for nursing education and defines the required clinical settings (European Union Council Directive 77/452/EU). The purpose of clinical practice is to provide students with supervised orientation to their future profession in de facto circumstances. The average length of a clinical practice period is 5 weeks (7.5 crore) and it is carried out in clinics belonging to the university – and other teaching hospitals. No theoretical instruction is arranged during this period. Supervision of students’ clinical practice may be carried out in many different manners. It always involves clinical staff and a faculty member, each having differing roles and responsibilities. Most often, students work as pairs with nurses, their clinical instructors, whose role involves supervision of students’ performance. The faculty member’s role may vary, but, it always involves acting as a link between the institution and the clinical practice placement as well as a support person for the clinical instructor and a facilitator of learning for students. Gillespie (2002) has reported of a similar role for the teacher. Meetings involving all three parties are arranged on a regular basis throughout the clinical practice period. The focus of these meetings is on students’ individual objectives. A number of researchers (Löfmark and Wikblad, 2001; Saarikoski, 2002; Andrews et al., 2005) have previously explored the prerequisites of a successful learning experience in the clinical setting. According to their findings, the core elements of positive experiences are related to students’ own motivation to learn, students’ acceptance, positive atmosphere among the caregivers, managers’ supportive attitude as well as distinctive characteristics
154
L.-R. Mattila et al. / Nurse Education in Practice 10 (2010) 153–157
of the interaction between clinical instructors and students. During clinical practice, the most significant factor is the interaction between the clinical instructor and student (Saarikoski, 2002). To explore what is known about international students’ clinical practice experiences, a literature search was carried out by using Ovid-Cinahl and ERIC databases. The period of the search was limited to 2000–2008, and ‘clinical practice’, ‘international student nurse’ and ‘international exchange’ were used as key words. In recent years, a number of studies focusing on international exchange experiences have been published (Walsh and DeJoseph, 2003; Robinson et al., 2006; Bosworth et al., 2006; Koskinen and Tossavainen, 2003) and many of these have involved a clinical element. As stipulated by Rogan et al. (2006), non-native speakers’ experiences of clinical settings involve unique challenges for students, such as wanting to belong but feeling excluded and lack of suitable coping strategies. Besides Koskinen and Tossavainen’s study on British exchange students in Finland, there is a shortage of studies about international students’ experiences of clinical practice in Finland. Despite offering English degree programmes in nursing for over ten years, universities of applied sciences seem not to have provided national or international research about international students’ unique situation during their clinical practice. The multilingual circumstances are evoked because students’ native language, the language of theoretical instruction and the language used by caregivers and patients during clinical practice are all different. Evidence suggests that ethnic students do encounter prejudice, discrimination or racism in their nursing education (Yoder, 1996; Jalili-Grenier and Chase, 1997; Malu and Figlear, 1998; Dickerson et al., 2000; Andrews et al., 2005). Furthermore, previous literature has discussed the difficulties experienced by international students when it comes to active participation whether in class or in clinical practice (Ramsay et al., 1999; Robertson et al., 2000; Grant and McKenna, 2003). The purpose of this qualitative study was to describe international student nurses’ experiences of their clinical practice in the Finnish health care system. The research question was: What kind of experiences do international student nurses describe as positive and negative? The aim was to consolidate body of knowledge necessary to ensure positive experiences in clinical practice in cases when students’ primary language is other than that of patients or clinical instructors.
Methods Data collection Because of shortage of studies about international students’ clinical practice experiences in the Finnish health care system, data were collected by semi-structured interviews. In particular, this method enables the interviewee to express sensitive and difficult experiences. The two themes were based on the results of earlier studies (Yoder, 1996; Jalili-Grenier and Chase, 1997; Malu and Figlear, 1998), consisting of descriptions of positive and negative experiences when attending clinical practice. Two students piloted the interview themes. Since the themes appeared relevant and flexible enough to catch the individual experiences, they remained unchanged. These pilot interviews were not, however, included in the data. Three graduating student nurses conducted the interviews. These student nurses were chosen because we assumed international students would share their experiences more openly with peers than with researchers and might reveal feelings and private doubts that contradict student expectations (Rew et al., 1993; Miller and Glassner, 2004). In addition, as fellow students, the interviewers
could identify with the interviews and were able to understand the language in which the experiences were described. Interviewers were from different group than interviewees and they were coached by the authors for interviewing techniques during several meetings. Coaching included themes such as the progress of an interview, the role of the interviewer and the transcription process. Ethical issues relating to conducting interviews were clarified and reflected on. Moreover, interviewers were encouraged to consult the authors in case of possible problems throughout the process. Because of the small amount of potential interviewees, and because we wanted to capture the variation of experiences, the data were collected in two phases. Prior to the interview, those students (n = 17) who had studied a minimum of 2.5 years were inquired about their willingness to participate in the study. The 2.5-year requirement was based on the assumption that by this time students had gained enough experience on clinical practice and various nursing environments. Fourteen international students agreed to be interviewed whilst two potential interviewees refused. All interviewees were of African and Asian origin. Their age varied from 23 to 30 and they had been studying for 2.5–3.5 years. The interviewers and interviewees agreed the time and place of the interviews and to ensure privacy, they were carried out in peaceful surroundings at the institution. The interviews were recorded and their duration varied from 25 to 35 min. The director of the Faculty of Health Care and Social Services gave the permission to conduct the study. The interviewers distributed researchers’ letter to the students. It included an invitation to participate in the study and the information necessary for their consent. The interviewers began the interviews by confirming voluntary participation, confidentiality and anonymity. It was important that the interviewees felt free to speak. The interviewers destroyed the tapes after completion of the transcription process and distributed the transcribed interviews to the authors in sealed envelopes. Data analysis The data were analysed by inductive content analysis based on two themes: positive and negative experiences (Graneheim and Lundman, 2004) which helped the conceptualisation process of students’ descriptions of their experiences. The aim of this was to provide a compact and yet general description of the phenomenon under investigation. The prerequisite of the analysis was an understanding of the interviewees’ social world (Miller and Glassner, 2004). In this study, the social world referred to the clinical practice environment. The interviews were read through several times to gain a comprehensive view of the subject matter. The unit of analysis was a combination of words or a phrase. Students’ descriptions were formed into simplified expressions based on the same terms they had used and they were transformed into plain lists. Those expressions that bore a similar meaning were combined into the same group and were given a name, which indicated their content (subcategory). The subcategories were combined to create categories. The formation of categories was based on students’ expressions and the qualitative content of their meaning. The tentative categories were discussed and revised. Hence, the main categories comprised positive and negative experiences. Results Descriptions of positive experiences Students’ descriptions of positive experiences consisted of diverse staff activities as well as students’ feelings and behaviour.
L.-R. Mattila et al. / Nurse Education in Practice 10 (2010) 153–157
This category was called appreciative orientation. From the beginning, students felt that orientation on the ward reflected appreciation towards them. They described how the clinical environment and its facilities, staff members, patients and daily routines were introduced to them. From this introduction, they also understood how they could become involved with the nursing activities. Thus, students knew what was expected of them as student nurses. Students were made feel welcome by supporting them to join the team. Positive attitude towards students manifested itself in allowing them to be included in planning and decision-making of patient care as well as in staff members’ willingness to help and teach. Students did not feel like outsiders and both English and Finnish were used in a flexible manner. Also, dictionaries were employed, whenever appropriate, and written material in English was distributed to students. All students experienced enhancing their possibilities to work independently positive. The name of this category was enhancing independent working. Clinical instructors encouraged critical thinking and reflection on theory before, during and after being exposed to nursing activities. In addition, students appreciated continuous feedback from instructors. In concrete terms, this meant that as the clinical practice progressed, clinical instructors and students reflected on a regular basis. Furthermore, students’ positive experience was reinforced, if clinical instructors shared their good impressions of students with other staff members. Students’ positive experiences and the staff members’ positive attitude towards them were bridged together. This category was called sense of belonging. Students felt they were accepted and welcomed to join the team and work in it as an equal member, holistically caring for their own patients. ‘‘I saw myself as one of them, as one of the working team, because they included me in their planning and decision making . . .” They felt comfortable in the social environment and they felt at ease. These types of experiences allowed students to self-actualise, which further lead to feelings of profound satisfaction. The category named growing towards professionalism included experiences of being empowered and awareness of own potential. Students’ descriptions included feelings of being appreciated, having energy and an increasing amount of motivation as well as feeling of overcoming any difficulties. Students reported to have felt like professionals. Moreover, they felt they were growing up and maturing, which further made them see themselves as members of the larger community. The data included numerous descriptions of happiness, confidence, encouragement and awareness of one’s own abilities. The last category was called working as a member of the team. Students considered this opportunity positive. On one hand, experiences of having worked independently increased their self-confidence, which, in turn, reinforced similar behaviour in future clinical practice placements. ‘‘...when my tutor gave me that chance to just work on my own and consult her once in a while when I needed something, it just made me feel comfortable and accepted. . .” On the other hand, being a team member facilitated displaying initiative and willingness to try hard and to learn more. Descriptions of negative experiences The category named restricted learning included language-related problems, preventing students from meaningful learning, ignoring students and arousing suspicion. Students felt that there were contradictory language expectations. Some students’ poor Finnish was not accepted, nor were they encouraged to use the limited language skills they had. Students also felt their poor Finnish caused anger in some nurses. In these situations, students were asked to use English instead. Some students were not allowed to use English either. In terms of the level of students’ involvement
155
with nursing practice, conflicting demands existed as students were expected to be active, and yet, they did not know how to get involved with nursing activities because of lack of common language. Furthermore, students expressed concern they were prevented from participating in meaningful learning experiences. This took forms of withholding information concerning patients, not being given own patients, and not allowing students to give oral reports. ‘‘I was never given that chance to give a report in Finnish so it affected me in the sense that I never feel so confident. . .” Some students were even forced to wait for foreign patients, whereas some were guided towards task-orientation as opposed to a more holistic caring approach to nursing. Some students had to concentrate on providing basic nursing care instead of administering medications. Some students felt the staff was ignoring them. This manifested itself in leaving students alone and outside the social environment. Nurses were not aware of students’ learning needs, the student – clinical instructor relationship was weak, and the role of the student was unclear. Negative experiences were also related to suspicion against students, which took the form of frequent check-ups with students’ activities, thus, forcing them to learn mainly by observation. Students were not believed to have the required knowledge and skills to participate in nursing. Consequently, patients did not trust students either. The next negative category was named compromised human dignity. Students were called names and remarks were made about their skin colour and ethnic background. Some patients refused to shake hands with some of the students, and some refused to be nursed by them. However, no staff member showed any interest in these experiences, nor tried to support the student. Therefore, the data indicated numerous descriptions of having felt sad, bad, or low, which resulted in unwillingness to begin a new day in the clinical practice placement. These feelings, however, were kept hidden from nurses, patients and teachers. Instead, students tried to act as if everything was fine. Furthermore, students ended up trying to demonstrate their competence and anticipating difficulties. Students described feelings of being intimidated – no matter what good they were trying to do. They felt scared, stupid and humiliated. There were a number of descriptions of feeling unaccepted, being an outsider and not a member of the social environment. This category was named feelings of being an outsider. Students worked and stayed alone, as no one showed positive attention to them. Some students began to think that nursing was a wrong career for them and reported having considered abandoning it and pursuing a career not involving interaction with others. The next category, decreased self-esteem, included students’ descriptions of gradual loss of courage and confidence, and finally, inability to learn. Feelings of inferiority and feeling nothing of oneself were common. ‘‘. . .they oversee you, they don’t always see that you are there. . . and you just feel. . .nothing of yourself”. The data clearly indicated that negative experiences lead to lack of motivation to learn. When experiencing negativity, students either gave up or became more determined to succeed. In the category called giving up, students described withdrawal and distance from the group. Alternatively, they would follow and observe what staff members were doing, as staff did not encourage student participation. Instead, their activities consisted of irrelevant tasks. One of the students called this method ‘‘learning by watching”. Some students stayed in the placement only to earn the credits. Since some patients did not accept care provision from an international student, students learned to approach patients carefully and to interpret their non-verbal cues. This category was called anticipation of difficulties. This manifested itself in avoiding negative responses from patients. In relation to staff, students felt they
156
L.-R. Mattila et al. / Nurse Education in Practice 10 (2010) 153–157
had to prove their competence on continuous basis and with considerable persistence.
Discussion The positive experiences enhanced professional growth, which included sense of awareness of own potential and empowerment. Earlier studies have shown that positive experiences of approval, pleasant atmosphere and support are central to students’ learning (Saarikoski, 2002; Andrews et al., 2005). The students’ negative experiences created feelings of being left out and weakened their self-esteem. According to previous research, ethnic students encounter prejudice, discrimination or racism in their nursing education (Malu and Figlear, 1998; Dickerson et al., 2000; Andrews et al., 2005). As most of the interviewees came from cultures emphasising collectivism as opposed to individuality, they felt disturbed by a taskoriented, non-caring approach to nursing, which seemed to be prominent in some units. Therefore, it seems that staff should use international students’ different ways of interacting with patients and their significant others to a greater degree. The data revealed emotionally sensitive experiences, which the participants had not talked about with their teachers. Based on the transcriptions, some of the interviewees seemed to be in agony whereas some seemed to be relieved when sharing the experiences. Teachers should be aware of the possibility of students’ emotionally sensitive experiences, which they might be reluctant to bring up on their own. The lack of orientation and constant hurry of staff members resulted in students’ feelings of not being welcome to their placement. Instead of focusing on learning, students used their energy in anticipating difficulties and persistently trying to prove their competence. For this reason, it is suggested that more attention should be paid to preparing and supporting the staff to receive an international student. This finding is consistent with previous studies (Gillespie, 2002; Grant and McKenna, 2003). Teachers and clinical instructors should encourage students to reflect on their negative experiences because this might empower them to overcome difficulties. In Finland, the number of international nurses and student nurses is smaller than in many other European countries. Interestingly, Grant and McKenna (2003) have explicated that even if the language of the learning environment was the same as students’ mother tongue, they experienced feelings of fear and frustration as well as difficulties in interaction with the staff. In addition, in terms of students’ skin colour and cultural background, more tolerance and broadmindedness is required in interaction with international students. The nursing staff should take more responsibility for introducing international students to patients. Clinical instructors should pay more attention to the orientation of both students and staff. According to Miles and Huberman (1994), qualitative research has five overlapping issues of reliability and validity: credibility, dependability, confirmability, transferability and utilisation of the results. In this study, credibility means that the students openly expressed their views. The researchers did not carry out the interviews, as suggested by Rew et al. (1993). This was a conscious choice. Since the interviewers and participants were peers, it may be assumed that the participants talked truthfully, which did, in fact, turned out to be evident. The criteria of dependability are met once the credibility of findings has been established. The data collected in 2007 supported the previous data collected in 2004. We discussed the formation of categories several times to improve the validity of the analysis process. Confirmability refers to the freedom of bias in the whole process. Discussion of confirmability must take into account the peer
interviewers and the two researchers who were familiar with the students. The identity of the interviewees was unknown to the authors and it facilitated bracketing. Description of the background information and the steps of the research process allow the reader to follow the progress. Transferability refers to the extent to which findings could be transferred to other subjects and contexts. In this study, fourteen students were interviewed. The sample size was small and selective, but the data were rich and revealed sensitive information. It became apparent that the interviewers were successful in posing questions, probing and encouraging. These findings can be used to prepare nurses to assume the role of the supervisor and to help students to reflect on their experiences during clinical practice. Despite the small sample size, the results can be applied to the development of international students’ clinical practice supervision. Conclusions A successful orientation period had a significant role in facilitating positive experiences for students. Accepting students as team members as well as allowing for independence in patient care and expose to challenges enhanced professional growth, including sense of awareness of own potential and empowerment. These experiences lead to students perceiving themselves as full members of health care providers community as well as of the society as a whole. Students’ poor command of Finnish easily lead to negative experiences. In this case, flexible use of both English and Finnish was found helpful. Putting students into a position where they had no role in patient care resulted in experiences of being left out, wanting to give up or using energy to anticipation of difficulties. Students were not necessarily willing to elucidate the most painful experiences with clinical instructors or teachers. Awareness of students’ tendency to hide these experiences will contribute to developing a more supportive clinical learning environment. References Andrews, G.J., Brodie, D.A., Andrews, J.P., Wong, J., Thomas, B.G., 2005. Place(ment) matters: students’ clinical experiences and their preferences for first employers. International Nursing Review 52, 142–153. Bosworth, T., Haloburdo, E., Hetrick, C., Patchett, K., Thompson, M.A., Welch, M., 2006. International partnerships to promote quality care: faculty groundwork, student projects, and outcomes. The Journal of Continuing Education in Nursing 37 (1), 32–38. Dickerson, S., Neary, M., Hyche-Johnson, M., 2000. Native American graduate nursing students’ learning experiences. Journal of Nursing Scholarship 32 (2), 189–196. Gillespie, M., 2002. Student–teacher connection in clinical nursing education. Journal of Advanced Nursing 37 (6), 566–576. Graneheim, U.H., Lundman, B., 2004. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today 24 (2), 105–112. Grant, E., McKenna, L., 2003. International clinical placements for undergraduate students. Journal of Clinical Nursing 12 (4), 529–535. Jalili-Grenier, F., Chase, M., 1997. Retention of nursing students with English as a second language. Journal of Advanced Nursing 25 (1), 199–203. Koskinen, L., Tossavainen, K., 2003. Relationships with undergraduate nursing exchange students–a tutor perspective. Journal of Advanced Nursing 41 (5), 499–508. Löfmark, A., Wikblad, K., 2001. Facilitating and obstructing factors for development of learning in clinical practice: a student perspective. Journal of Advanced Nursing 34 (1), 43–50. Malu, K., Figlear, M., 1998. Enhancing the language development of immigrant ESL nursing students: a case study with recommendations for actions. Nurse Educator 23 (2), 43–46. Miles, M.B., Huberman, A.M., 1994. Qualitative Data Analysis, second ed. Sage Publications, Thousand Oaks. Miller, J., Glassner, B., 2004. The ‘‘inside” and the ‘‘outside” Finding Realities in Interviews. In: Silverman, D. (Ed.), Qualitative Research. Theory, Method and Practice. Sage Publications, London. pp. 125–139. Ministry of Education, 2001. Ammattikorkeakoulusta terveydenhuoltoon. Koulutuksesta valmistuvien ammatillinen osaaminen, opintojen keskeiset
L.-R. Mattila et al. / Nurse Education in Practice 10 (2010) 153–157 sisälöt ja vähimmäisopintoviikkomäärät. Opetusministeriö 7.9.2001. Helsinki. (English Summary). Ramsay, S., Barker, M., Jones, E., 1999. Academic Adjustment and Learning Processes: a comparison of international and local students in first-year university. Higher Education Research and Development 18 (1), 129–144. Rew, L., Bechtel, D., Sapp, A., 1993. Self-as-instrument in qualitative research. Nursing Research 42 (5), 300–301. Robertson, M., Line, M., Jones, S., Thomas, S., 2000. International students, learning environments and perceptions: a case study using the Delphi technique. Higher Education Research and Development 19 (1), 89–102. Robinson, K., Sportsman, S., Eschiti, V., Bradshaw, P., Bol, T., 2006. Preparing faculty and students for an international nursing education experience. The Journal of Continuing Education in Nursing 37 (1), 21–29. Rogan, F., SanMiguel, C., Brown, D., Kilstoff, K., 2006. ‘‘Find yourself” Perceptions of nursing students from non-English speaking backgrounds of the effect of an
157
intensive language support program on their oral clinical communication skills. Contemporary Nurse 23 (1), 72–86. Saarikoski, M., 2002. Clinical learning environment and supervision. Development and Validation of the CLES Evaluation Scale. Dissertation, Annales Universitatis Turkuensis Medica–Odontologica Ser. D, Tom. 525 (University of Turku, Finland) Speziale, H., Jacobson, L., 2005. Trends in registered nurse education program 1998– 2008. Nursing Education Perspectives 26 (4), 230–235. Statistics Finland, 2008. Statistics Finland. www.tilastokeskus.fi/index_en.html (Site visited December 2, 2008). Walsh, L., DeJoseph, J., 2003. ‘‘I Saw it in a Different Light”: international learning experiences in baccalaureate nursing education. Journal of Nursing Education 42 (6), 266–272. Yoder, M., 1996. Instructional responses to ethnically diverse nursing students. Journal of Nursing Education 35 (7), 315–321.