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Perceived acculturative stress and sense of coherence in Chinese nursing students in Australia
Nurse Education Today 32 (2012) 345–350
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Nurse Education Today j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / n e d t
Perceived acculturative stress and sense of coherence in Chinese nursing students in Australia Flora X. He a,⁎, Violeta Lopez b, Maria C. Leigh c a b c
School of Health and Psychological Sciences, Australian National University, Australia Research Centre for Nursing and Midwifery Practice, Medical School, Australian National University, Australia School of Nursing (NSW & ACT), Australian Catholic University, Australia
a r t i c l e
i n f o
Article history: Accepted 1 May 2011 Keywords: Acculturation Acculturative stress Chinese nursing students Sense of coherence
s u m m a r y University schools of nursing in Australia are the main providers of nursing education programmes for international students. The large cohort of overseas students requires that universities, as education providers, understand their needs and the problems related to studying and living in Australia. An exploratory descriptive quantitative study was conducted to investigate 119 Chinese international undergraduate nursing students' acculturative stress and sense of coherence at an Australian university in Sydney. Two validated scales were used: Acculturative Stress Scale for International Students (ASSIS) and Sense of Coherence (SOC). Results indicated that overall Chinese nursing students had a moderate level of acculturative stress and sense of coherence. However, there was a significant difference in the level of acculturative stress among three groups of Chinese nursing students enrolled in the Bachelor of Nursing course, and SOC was negatively correlated with the level of acculturative stress. This study extends the knowledge of the experiences of Chinese nursing students studying and living in an English-speaking country. The study also highlights the need for universities to provide relevant support to overseas students to make their study journey smoother and more successful. Crown Copyright © 2011 Published by Elsevier Ltd. All rights reserved.
Introduction The Australian Educational International (AEI)'s data reported that between 2007 and 2008, there were 543,898 enrolments by full-fee paying international students in Australia on a student visa. The enrolments in 2008 exceeded 500,000 for the first time (Australian Education International, AEI, 2008). Although the majority of international students adapt reasonably well to the demands of the host culture and academic institutions, they are likely to experience pressures related to acculturation, racism and decreased access to their usual support system (Sandhu and Asrabadi, 1994; Zhang and Dixon, 2003). University schools of nursing in Australia are the main providers of nursing education programmes for international students. The large cohort of overseas students requires that universities, as education providers, understand their needs and the problems related to studying and living in Australia. Acculturative stress has been identified as a major issue encountered by the international students (Sandhu and Asrabadi, 1994). Acculturative stress refers to stress induced by the adaptation process due to a change of cultural environment. It is the response of individuals to life events, which ⁎ Corresponding author at: Australian Catholic University, 8-10 Berry Street, North Sydney, 2060, Australia. Tel.: + 61 2 9739 2531. E-mail address: fl[email protected] (F.X. He).
originates from intercultural contact, when these events surpass the capacity of individuals to manage (Berry and Ataca, 2000). Sense of Coherence (SOC), on the other hand, is a global measure of coping resources and is an indicator of the availability of, and willingness to use, adaptive coping resources (Antonovsky, 1987). The study aims to obtain information about the characteristics of Chinese international nursing students, to identify their levels of acculturative stress and sense of coherence, and to examine the correlations between acculturative stress and sense of coherence. This study is of significance to the understanding of international nursing students' educational and cultural experiences in an Australian context. The findings of the study will provide information to assist universities to plan students' future education and other support needs. Background Numerous reports have examined the experiences of international or English as a Second Language (ESL) students who are studying in English speaking countries such as the United States, Canada and UK, however, there were not many research papers about Chinese international nursing students studying in Australia. For example, Salamonson et al. (2008) conducted a survey of 273 first year nursing students who were born overseas from a non-English-speaking country, using an English Language Acculturation Scale (ELAS) at
0260-6917/$ – see front matter. Crown Copyright © 2011 Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2011.05.004
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the School of Nursing, University of Western Sydney. It was reported that there was a positive association between the ELAS scores and academic performance in all four subjects of study, namely: behavioural science in nursing, theoretical frameworks in nursing, nursing practice, and bioscience. The students with the lowest ELAS scores obtained the lowest mean subject grades. This study also identified that there was a positive correlation between language acculturation scores, and length of residence in Australia (Salamonson et al., 2008). It was noticed that it would be beneficial for future studies if other students (e.g., the 2nd and 3rd year students) were included for comparative purposes. Thomson et al. (2006) surveyed undergraduate and postgraduate international students from all faculties (n = 979, 64% female, 23% Chinese) about their perceptions of cultural stress and the relationships between cultural stress and social connectedness, mental health, and lifestyle balance in a large Melbourne university in Australia. Findings showed that cultural stress was related to students' cultural background, communication skills, and perceived academic progress. Cultural stress was negatively related to social connectedness (r = −0.39, p b 0.001) and lifestyle balance including both study and social activities (r = − 0.15 and − 0.23 respectively, p b 0.001 for both items) but positively related to depression, anxiety and stress (r = 0.46; r = 0.44; r = 0.44 respectively; p b 0.001 for all correlations) (Thomson et al., 2006, p. 6). Chen et al. (2008) conducted two case studies exploring the adaptation processes of Chinese international students to online learning at one Australian university. The two participants were postgraduate students in the Faculty of Education. Results indicated that the quality of online learning was less satisfactory than face-toface learning experiences. Students did not benefit from the temporal and spatial flexibility online learning provided but needed more teacher control and interpersonal contact. Although the participants of the study were not Chinese nursing students, the findings of the study provided some insightful information about Chinese students' online learning experiences. It was also highlighted that the biggest challenge the participants encountered in their adaptation to online learning stemmed from the perceived absence of the teacher. Cotton (2000) conducted a hermeneutic phenomenological study of overseas nursing students (n = 10) and their educators (n = 10) in an Australian university. Results highlighted that students' concerns were related to not being at home, being an outsider, striving to understand and be understood, seeking and finding help and support, expending current efforts and costs for future gains, and experiencing personal growth and achievement. On the other hand, the educators were concerned about maintaining adequate standards, making appropriate allowance and providing opportunities, giving help and support, needing help and support from the university, educating, and developing educative relationships. The caring student–educator relationship was found to play a major part in relation to shared understanding of educative experiences for students and educators. A study of significance to the topic of interest in this study was conducted by Pan et al. (2007). The study was a cross-cultural comparison of the experiences of Chinese international students in Australia and Hong Kong which investigated acculturative stressors and meaning of life as predictors of negative affect in acculturation. The sample comprised of 627 participants, 400 from six universities in Hong Kong, and 227 from one university in Australia. There was no information about their study majors (e.g., nursing or business), but they were mainly postgraduate students (PhDs and Masters). The study identified that the Australian sample had higher scores in both Acculturative Stressor Scale and Negative Affect Scale, compared to the Hong Kong sample. The univariate F-test showed that the two groups differed significantly in terms of acculturative stressor (F = 18.64, df = 1, p b 0.0001) and negative affect (F = 4.49, df = 1, p = 0.035) (Pan et al., 2007, p. 744). Acculturative stressors had a positive impact on negative affect in both samples, but the impact of
different domains of acculturative stressors on negative affect varied between the two groups. The authors explained that the cultural distance between Australia and China is greater than that between Hong Kong and China. The findings verified the supposition of the impact of the cultural distance between the host country and the country of origin on acculturative stress. The greater the cultural distance, the more difficulties the students experience in the host society and the greater their stress. The literature review highlighted that there were no published studies which had focused on Chinese overseas students (from mainland China, Hong Kong or Taiwan) who were enrolled in a Bachelor of Nursing (BN) programme in an Australian context. At the time of the review, there were only a few Australian studies that had focused on international nursing students' experiences in educational institutions (e.g., Salamonson et al., 2008; Cotton, 2000). Since there is a paucity of information on the experiences of Chinese nursing students studying in Australia, this study aims to address this knowledge gap. Aim and objectives The aim of this study was to explore the level of acculturative stress of Chinese international students studying and living in Australia. The specific objectives were to: (1) examine whether there were significant differences in the acculturative stress between the three groups (year 1, year 2 and year 3) of Chinese international nursing students, (2) examine the level of sense of coherence of Chinese international nursing students, (3) examine whether there were any significant differences in the sense of coherence between the three groups (year 1, year 2 and year 3) of Chinese international nursing students, and (4) examine whether there were significant correlations between acculturative stress and sense of coherence of Chinese international nursing students. Methods Subjects and setting A convenient sample of 315 Chinese nursing international students at one public university in Sydney, Australia was recruited for participation in the study. Inclusion criteria for selection of the participants were that they were (1) overseas fee paying Chinese students, (2) enrolled in a BN course (3-year programme), and (3) enrolled in 2008 at a Sydney based university campus. The reason for choosing the campus in Sydney to recruit the sample was the large number of international nursing students enrolled in the BN programme at this university. The Chinese was the largest group among all the international students enrolled in 2008 (Australian Catholic University, ACU, 2009). Procedure Following approval by the University Human Research Ethics Committee, the questionnaires and the self-addressed return envelopes were distributed during nursing lectures, tutorials and laboratory sessions with permission of the lecturers-in-charge. The duration of data collection was nine weeks from the 4th week to the 12th week in the second semester, 2008. Students were informed about the nature and purpose of the study. They were also assured of privacy and confidentiality of the information provided and that nonparticipation in the study would not in any way affect their studies. They were asked to complete the questionnaires at their convenience and return these by placing them in one of two sealed boxes provided for collection of questionnaires. The boxes were emptied on a regular basis during the period of data collection. Completion and return of
F.X. He et al. / Nurse Education Today 32 (2012) 345–350
questionnaires were taken to mean that the participant had consented to participate in the study. Measures Demographic data Respondents were asked to provide information about their age, gender, year in the BN programme, employment status, and International English Language Testing System (IELTS) score prior to the university studies. Acculturative Stress Scale for International Students (ASSIS) ASSIS was developed by Sandhu and Asrabadi (1994) to assess the adjustment problems of international students. It is a 36-item scale using a 7-point Likert scale (1 = strongly disagree to 7 = strongly agree). The ASSIS consists of seven subscales: Perceived discrimination, Homesickness, Perceived hate, Fear, Stress due to change, Guilt, and Miscellaneous. The total score for the ASSIS ranges from 36 to 252, with higher scores indicating greater acculturative stress. Sandhu and Asrabadi (1994) encouraged researchers to use the ASSIS total score. They also recommended using subscale scores when researchers are interested in determining the specific sources of acculturative stress. This study, however, intended to examine the level of the acculturative stress of the Chinese international nursing students in general, and the total score was considered as appropriate to use for the study. It was reported that the ASSIS had generated an internal consistency score ranging from 0.87 to 0.95 (Sandhu and Asrabadi, 1998; Sandhu and Asrabadi, 1994). In the present study, the Cronbach's alpha coefficient for the total score was 0.95. Sense of Coherence (SOC) The SOC scale was developed by Antonovsky (1987) to examine the comprehensibility, manageability, and meaningfulness of the participants' lives. The full SOC has 29 items (Antonovsky, 1987). However, the SOC 13-item scale (Antonovsky, 1993) was used in this study because of the length of the questionnaire which has a total of 64 items. The SOC-13 uses a 7-point Likert scale from 1 (very poor) to 7 (very strong). Higher scores indicate greater coherence. Eriksson and Lindström (2005) reported that the Cronbach's alpha in 127 studies using SOC-13 ranged from 0.70 to 0.92. In this study, Cronbach's alpha was 0.75. Data analysis Responses to the questionnaires were entered into an SPSS 17.0 database. Descriptive statistics, such as frequencies, means and standard deviations (SDs) were used for the demographic data and scores for ASSIS and SOC. Relationships between ASSIS and SOC were analysed by linear regression. The total score for the ASSIS and SOC was used to examine the relationship. Analysis of variance (ANOVA) was used for assessing the differences between means of ASSIS among the three groups of nursing students (years 1, 2, and 3), and the differences between means of SOC. The alpha level for significance testing was set at 0.05.
week of the 2nd semester when most of the students' first assessment was due. The sample consisted of 108 females and 11 males nursing students whose ages ranged from 19 to 50. The average age was 25.3 years. The subjects comprised of 42.9% third-year, 25.2% secondyear, and 31.8% first-year students. Of the respondents, the majority (78.2%) had part time jobs and the rest (21.8%) did not work. For the IELTS scores prior to the university study, less than half of the participants (41.2%) scored between 6.0 and 6.5, about one fifth (20.2%) scored less than 5.5, and only 10.9% scored above 7.0. It is interesting to see that 27.7% of the participants did not state their IELTS results (see Table 1). Level of acculturative stress The mean of ASSIS was calculated to indicate the level of acculturative stress. The results showed that Chinese nursing students had a moderately high level of acculturative stress. The total mean of ASSIS was 98.32 (SD 21.86). It is considered as a moderate level of acculturative stress with values ranging from 36 to 252, compared with a study conducted by Constantine et al. (2004) which had a sample of 320 international college students from 33 countries in the United States, with a mean of 81.39 (SD 24.66). Among the three groups, the third year students had the highest ASSIS mean score of 105.16 (SD 22.40), followed by the first year students (Mean 95, SD 18.23), and the lowest scores for the second year students (Mean 90.7, SD 22.31) (see Table 2). Analysis of variance (ANOVA) was performed to address the first objective whether there were any differences in ASSIS between the three groups (year 1, year 2 and year 3) of participants. The result showed that there were significant differences in this regard (p = 0.008) (see Table 3). A further post hoc test using Tukey's HSD was conducted and revealed a significant difference in ASSIS scores between year 2 and year 3 students (p = 0.01). However, there was no significant difference between year 1 and year 2 (p = 0.689) or between year 1 and year 3 (p = 0.074) students' ASSIS scores (see Table 4). Level of sense of coherence To address the second objective, the mean of SOC was computed to indicate the level of SOC of the Chinese international nursing students. The results showed that the mean of SOC was 56.61 (SD 9.74) with values ranging from 13 to 91 (see Table 2). This was indicative of a moderate level of SOC in comparison with several studies. Pallant and Lae (2002) reported a mean of 60.8 (SD 11.7) from an Australian community-based sample (n = 439). Sollerhed et al. (2005) reported a mean SOC of 62.5 (SD 10.5) from a Swedish adolescent sample (n = 285). Grayson (2008) conducted a study with a sample of 1425
Table 1 Demographic data of Chinese international nursing students (n = 119). Variables Gender Age
Results Part-time job
Demographic characteristics IELTS scores
Of the 315 students who received the questionnaires, 119 participants completed and returned the surveys representing a response rate of 37.8%. Firstly, the low response rate could be due to the length of the questionnaire having a total of 64 questions comprising 13 for the SOC, 36 for the ASSIS and 15 for the demographics. Secondly, the survey was conducted from the 4th
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Year of students
Male Female b 24 years 25–29 years 30+ years No Yes b 5.5 6.0–6.5 7.0–8.0 Not stated 1st year 2nd year 3rd year
IELTS = International English Language Testing System.
N
%
11 108 66 27 26 26 93 24 49 13 33 38 30 51
9.2 90.8 55.4 22.7 21.9 21.8 78.2 20.2 41.2 10.9 27.7 31.9 25.2 42.9
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Table 2 Descriptive statistics for ASSIS and SOC. Variables
N
Mean
SD
SE
95% CI for Mean LCI
UCI
ASSIS Yr1 Yr2 Yr3 Total
36 30 51 117
95.00 90.70 105.16 98.32
18.23 22.31 22.40 21.86
3.004 4.074 3.137 2.021
88.90 82.37 98.86 94.32
101.10 99.03 111.46 102.33
SOC Yr1 Yr2 Yr3 Total
38 27 50 115
56.42 55.74 57.22 56.61
9.89 10.90 9.12 9.74
1.600 4.074 3.137 .908
53.18 51.43 54.63 54.81
59.66 60.05 59.81 58.41
Note: Yr1 = the first year students; Yr2 = the second year students; Yr3 = the third year students. ASSIS = Acculturative Stress Scale for International Students (Sandhu and Asrabadi, 1994). SOC = Sense of Coherence scale (Antonovsky, 1987).
first year students at four Canadian universities study and reported a mean of 56.70 (SD 11.7) which is extremely close to the current study. ANOVA was conducted to address the third objective, however, there were no significant differences between the SOC scores of the three groups of participants (f [2,112] = 0.21 p = 0.81) (see Table 3). Correlations between acculturative stress and sense of coherence For the fourth objective as to whether there are correlations between ASSIS and SOC in Chinese international nursing students, linear regression was conducted using ASSIS as the response variable and SOC as the independent variable. The plot of residuals for normality showed that there was no violation of our assumption that the residuals are normally distributed. The linear regression result revealed that there was a significant negative relationship between ASSIS and SOC. In other words, a person with a high level of acculturative stress would have a low level of sense of coherence and vice versa (see Tables 5 and 6). Discussion The main purpose of the present study was to examine the level of acculturative stress and SOC of Chinese international nursing students and identify the relationships between the acculturative stress and the SOC. We first wanted to investigate the level of acculturative stress of the Chinese international nursing students and expected that a high level of ASSIS would be found. It was anticipated that there would be challenges faced by these students, in terms of adaptation to a foreign land, particularly English language skills, academic performance and social isolation. However, the finding showed that their acculturative stress level was just moderately high.
Table 4 Post hoc analysis of variance by Tukey's HSD test. (The mean difference is significant at the 0.05 level.) Comparison
Yr1 vs. Yr2 Yr1 vs. Yr3 Yr2 vs. Yr3
Mean difference
SE
p-Value
4.300 − 10.157 − 14.457
5.224 4.600 4.862
95% CI for Mean
.689 .074 .010
LCI
UCI
− 8.10 − 21.08 − 26.00
16.70 .77 − 2.91
Note: Yr1 = the first year students; Yr2 = the second year students; Yr3 = the third year students.
The reason for this could be related to some of the barriers previously discussed in the literature for Chinese international students when coping with acculturative stress. For example, when Chinese international students experience acculturative stress, the possibility of losing face and embarrassment may have prevented them from sharing their experiences with others because these experiences may have implied personal failures (Heppner, Witty and Dixon, 2004). When these groups of students in the present study answered the questionnaires, there was a tendency to choose the middle point of the scales or a neutral mark which was not very strong or weak; therefore, this tendency may have resulted in a moderate overall score for the ASSIS. Furthermore, in regard to the first objective in which the differences in the acculturative stress between three groups of Chinese were investigated, a significant difference in ASSIS scores between year 2 and year 3 students was shown. However, there was no significant difference between year 1 and years 2 or 3 students' ASSIS scores. Several reasons for these results are proposed. Firstly, a small sample size (n = 36 for year 1, n = 30 for year 2 and n = 51 for year 3) may have contributed to the results. Secondly, the means of ASSIS of year 1 and year 3 students were higher than year 2 students. This could suggest that the experiences between these two groups of students were different, but the levels of stress were similar. The first year students who come to a foreign country are expected to have a high level of anxiety due to language issues, the adaptation to the new educational system, and the settlement of living including finding an accommodation and a part-time job to support themselves financially. On the other hand, the third year students who could have overcome those issues may possibly face other critical challenges which the first year students consider unnecessary to worry about. For example, the third year students may have issues related to their graduation, the registration with the Nursing and Midwives Board, the competition for getting a place in the new graduate programme, and the decision for their future plans (e.g., migration to Australia). One important fact should be taken into consideration when interpreting this result, i.e. the third year international nursing students in this particular university were facing professional registration problems in 2008. The Nurses and Midwives Board, New South Wales had new policies Table 5 Linear regression.
Table 3 ANOVA for ASSIS and SOC. Source of variation
df
Mean square
F
p-Value
ASSIS Between groups Within groups Total
2 114 116
2261.307 446.518
5.064
.008
SOC Between groups Within groups Total
2 112 114
20.181 96.098
.210
Response variable: ASSIS Independent variable: SOC
.811
Note: ASSIS = Acculturative Stress Scale for International Students (Sandhu and Asrabadi, 1994). SOC = Sense of Coherence scale (Antonovsky, 1987).
Model
df
Mean square
Regression Residual
1 111
9109.341 410.870
Terms
Estimate
SE
Constant SOC
151.318 − .929
11.366 .197
F 22.171
p-Value b .001
t-Tats
p-Value
13.313 − 4.709
b .001 b .001
Note: ASSIS = Acculturative Stress Scale for International Students (Sandhu and Asrabadi, 1994). SOC = Sense of Coherence scale (Antonovsky, 1987).
F.X. He et al. / Nurse Education Today 32 (2012) 345–350 Table 6 Correlation between ASSIS and SOC (significant).
Pearson correlation Sig. (1-tailed) N
ASSIS SOC ASSIS SOC ASSIS SOC
ASSIS
SOC
1.000 − .408
− .408 1.000 b .001
b.001 113 113
113 113
Note: ASSIS = Acculturative Stress Scale for International Students (Sandhu and Asrabadi, 1994). SOC = Sense of Coherence scale (Antonovsky, 1987).
in regard to the English requirement for the Nursing registration for overseas nursing students. The IELTS score should have an overall band score of 7.0 before the student is eligible to register with the Board. Some of the students were stressed about this requirement because they perceived that such a score was difficult for them to achieve. Therefore, the third year's ASSIS scores were the highest among three groups, followed by the first year's score, and the lowest for the second year students. Not surprisingly, there was a significant difference found in the ASSIS scores between the second and the third year students (see Table 2). Another finding of the present study was that the level of SOC was moderate which reflects the second objective. According to a systematic review conducted by Eriksson and Lindström (2005), they pointed out that Antonovsky never expressed the level of a normal SOC, but recommended the SOC concept to be examined without dividing the sum of the item values into low or high SOC. However, some studies reported divisions into low, moderate, or high SOC. For example, Fok et al. (2005) reported a mean of SOC 51.8 (SD 4.1). It is important to note that the participants in Fok et al.'s study were the 88 patients who were admitted to the ICU for longer than 24 h, and were discharged home. The life experiences of the participants will be very different between the Intensive Care Unit patients and university students. Fok et al.'s mean of SOC (51.8) should be considered low. Several reasons could be considered to explain the SOC findings of the study. The first could be due to the age of this particular group of participants. They ranged from 19 to 50 years old, with an average of 25.3 years. Antonovsky (1979) sought to explain the relationship between life stresses and health by the SOC. He suggested that individuals develop a generalised way of looking at the world as more or less coherent by around age 30. The more one's life experiences are characterised by consistency, participation in shaping outcome, and ability to balance the stimuli that one faces on a day to day basis, the more one is likely to see the world as coherent and predictable. The matured age of the participants in this study may have contributed to a moderate level of SOC. In regard to the third objective, the differences in SOC scores among the three groups (years 1, 2 and 3) of Chinese international nursing students were examined, but no significant differences were found. One possibility could be the participants were from a small homogeneous group (e.g., all Chinese, 90.8% female, nursing students at one university). They were influenced by the same culture, a Chinese culture in this case. One feature of the Chinese culture is their collective orientation. Working as a group and supporting each other are traits of collectivism. If there is stress, Chinese people are likely to share their feelings among themselves and seek family or peer support often. The stressful event could become more manageable. Lastly, as mentioned earlier, there was a tendency that participants chose the middle range scores in answering the ASSIS questionnaire, this similar approach applied to the SOC scale. Most importantly, the results showed that the sense of coherence was negatively correlated with the level of acculturative stress, which was the answer for the fourth objective. This finding is consistent with
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the literature. For example, Eriksson and Lindström (2005) reported that the SOC was negatively correlated with anxiety and depression which are highly correlated with acculturative stress. Elsewhere, acculturative stress was also found to have a strong relationship with psychological distress (Flannery and Flannery, 1990). If the SOC is conceptualised as a coping mechanism characterised by the tendency to see life as predictable and manageable, a person with a strong SOC is less likely to perceive many stressful situations as threatening and anxiety-provoking than one with a weak SOC. The results of the present study indicated that Chinese international nursing students with a higher level of acculturative stress had a lower sense of coherence and vice versa. Implication for nursing Many overseas nursing students travel to Australia every year to further their education, enhance their career opportunities and extend their knowledge so they can contribute to the development of nursing in their home country or their host country. Australian universities are providers of high quality nursing education, a feature which is highly sought after by international nursing students. According to the literature review, the acculturative stress is the most common problem encountered by international students. If the acculturative stress and sense of coherence experienced by international nursing students are better understood by the universities that they enrol in, relevant support is more likely to be provided for them. Their learning journey, therefore, should become smoother, more successful, and less stressful. The international nursing students' well-being will be also enhanced. Furthermore, this study is important in increasing all international students' (not limited to Chinese international nursing students) awareness of how their acculturative stress and sense of coherence are correlated. With this understanding, students could be more alert about what they are experiencing and seek help when needed, therefore minimising their acculturative stress. International students in this university have been advised to seek help from the School International Advisors and Campus Counsellors. Further study is being conducted with Nepalese nursing students as a comparative group to the Chinese students who participated in this study to examine whether there are differences in the level of SOC and ASSIS. Nepalese students were chosen because of their different English language capacity and cultural background. Finally, there is a shortage of nurses in Australia. Nursing has priority for skilled migration; therefore, international nursing students continue to be needed to augment the workforce shortage in the health-care system in Australia. Their success in completing nursing course in universities, has, therefore, become very important and will have strong influence on their future nursing career development and Australian workforce recruitment. The findings of this study should equip the educational providers with sufficient knowledge and understanding of the experiences of overseas nursing students making teaching more effective and providing more appropriate support services to them. Limitations The present findings must be interpreted with caution. First, the study relied on self-report measures and did not include assessments from other sources (e.g., psychologists' interviews or university counsellors' assessment). Second, being a survey-based study, recall was a potential problem. Participants may not have fully understood or may have misinterpreted some questions, thereby misrepresenting their response. Third, the study's findings may be limited as the instruments were used and validated in the United States limiting the conceptual relevance and validity of the instruments for the international students from China or Asia who study in Australia. Fourth, the data were gathered from one cohort of Chinese
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international nursing students in one campus of a university. There could be great homogeneity among the participants; therefore, the sampling limitation may have affected the external validity of the results.
Direction for further research The authors are in the process of extending the study by conducting individual interviews with students who completed the questionnaires in this study, to identify the kinds of stress they have experienced and how they coped with their stress. Furthermore, in order to understand the Chinese international nursing students better, additional validated questionnaires will be used to investigate students' coping strategies, and examine their accessibility to social support networks. In addition, SOC has been reported to have a relatively high negative correlation with anxiety and depression but has a strong positive correlation with optimism and self esteem (Eriksson and Lindström, 2005). Therefore, the presence or severity of depression of this group of students will be further investigated. In addition, a comparable group of Nepalese students will be studied. This is important for the replication of the study with international students from other countries or cultural groups in the future.
Conclusion In summary, this study provides some understanding of the associations between acculturative stress and sense of coherence. It also extends the knowledge of the experiences of Chinese nursing students who study and live in an English speaking country. Those students with high level of acculturative stress were found to have a low level of sense of coherence. The findings highlight the need for universities to provide relevant support to overseas students to make their study journey smoother and more successful. Further research would be beneficial by examining the Chinese nursing students' coping strategies and their accessibility to social support networks in order to gain a deeper level of understanding of this phenomenon.
Acknowledgement We acknowledge the contribution made by all the ACU Chinese nursing students who participated in this study. Our thanks also go to Dr. Yoon (ANU) for his assistance in the statistics report of the study.
References Australian Catholic University (ACU), 2009. Statistical Digest 2009. Australian Catholic University, Strathfeild, NSW http://www.acu.edu.au/staff/organisation/statistics/ statistics_for_acu/statistical_digest_2009/. Accessed, 23/6/2009. Antonovsky, A., 1979. Health, Stress, and Coping. Jossey-Bass, San Francisco. Antonovsky, A., 1987. Unraveling the Mystery of Health. Jossey-Bass, San Francisco. Antonovsky, A., 1993. The structure and properties of the sense of coherence scale. Social Science & Medicine 306 (6), 725–733. Australian Education International (AEI), 2008. International student data. Commonwealth of Australia, Canberra http://aei.dest.gov.au/AEI/MIP/Statistics/StudentEnrolmentAndVisaStatistics. Accessed, 2/08/2008. Berry, J.W., Ataca, B., 2000. Cultural factors. In: Fink, G. (Ed.), Encyclopedia of Stress. Academic Press, San Diego, pp. 604–610. Chen, R., Bennett, S., Maton, K., 2008. The adaptation of Chinese international students to online flexible learning: two case studies. Distance Education 29 (3), 307–323. Constantine, M.G., Okazaki, S., Utsey, S.O., 2004. Self-concealment, social self-efficacy, acculturative stress, and depression in African, Asian, and Latin American international college student. American Journal of Orthopsychaitry 74 (3), 230–241. Cotton, A. H. F., 2000. Nurses studying overseas: a radicalized hermeneutic phenomenological study of overseas nursing students and their educators. Unpublished Ph.D. thesis. University of New South Wales (Australia). Eriksson, M., Lindström, B., 2005. Validity of Antonovsky's sense of coherence scale: a systematic review. Journal of Epidemiol Community Health 59, 460–466. Flannery, R., Flannery, G., 1990. Sense of coherence, life stress and psychological distress: a prospective methodological inquiry. Clinical Psychology 46, 415–421. Fok, S.K., Chair, S.Y., Lopez, V., 2005. Sense of coherence, coping and quality of life following a critical illness. Journal of Advanced Nursing 49 (2), 173–181. Grayson, J.P., 2008. Sense of coherence and academic achievement of domestic and international students: a comparative analysis. High Education 56, 473–492. Heppner, P.P., Witty, T.E., Dixon, W.A., 2004. Problem-solving appraisal and human adjustment: a review of 20 years of research utilizing the Problem Solving Inventory. The Counseling Psychologist 32, 344–428. Pallant, J.F., Lae, L., 2002. Sense of coherence, well-being, coping and personality factors: further evaluation of the sense of coherence scale. Personality and Individual Differences 33, 39–48. Pan, J.-Y., Wong, D.F.K., Joubert, L., Chan, C.L.W., 2007. Acculturative stressor and meaning of life as predictors of negative affect in acculturation: a cross-cultural comparative study between Chinese international students in Australia and Hong Kong. Australian and New Zealand Journal of Psychiatry 41, 740–750. Salamonson, Y., Everett, B., Koch, J., Andrew, S., Davidson, P.M., 2008. English-language acculturation predicts academic performance in nursing students who speak English as a second language. Research in Nursing & Health 31 (1), 86–94. Sandhu, D.S., Asrabadi, B.R., 1994. Development of an Acculturative Stress Scale for International Students: primary findings. Psych Reports 75, 435–448. Sandhu, D.S., Asrabadi, B.R., 1998. An Acculturative Stress Scale for International Students: a practical approach to stress measurement. In: Zalaquett, C.P., Wood, R.J. (Eds.), Evaluating Stress: A Book of Resources, v. 2. The Scarecrow Press, London, pp. 1–33. Sollerhed, A.-C., Ejlertsson, G., Apitzsch, E., 2005. Predictors of strong sense of coherence and positive attitude to physical education in adolescents. Scandinavian Journal of Public Health 33, 334–342. Thomson, G., Rosenthal, D., Russell, J., 2006. Cultural Stress among International Students at an Australian University. www.idp.com/aiec 2006 Accessed, 12/04/ 2009. Zhang, N., Dixon, D.N., 2003. Acculturation and attitudes of Asian international students toward seeking psychological help. Journal of Multicultural Counselling and Development 31, 205–222.
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Nurse Education Today j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / n e d t
Perceived acculturative stress and sense of coherence in Chinese nursing students in Australia Flora X. He a,⁎, Violeta Lopez b, Maria C. Leigh c a b c
School of Health and Psychological Sciences, Australian National University, Australia Research Centre for Nursing and Midwifery Practice, Medical School, Australian National University, Australia School of Nursing (NSW & ACT), Australian Catholic University, Australia
a r t i c l e
i n f o
Article history: Accepted 1 May 2011 Keywords: Acculturation Acculturative stress Chinese nursing students Sense of coherence
s u m m a r y University schools of nursing in Australia are the main providers of nursing education programmes for international students. The large cohort of overseas students requires that universities, as education providers, understand their needs and the problems related to studying and living in Australia. An exploratory descriptive quantitative study was conducted to investigate 119 Chinese international undergraduate nursing students' acculturative stress and sense of coherence at an Australian university in Sydney. Two validated scales were used: Acculturative Stress Scale for International Students (ASSIS) and Sense of Coherence (SOC). Results indicated that overall Chinese nursing students had a moderate level of acculturative stress and sense of coherence. However, there was a significant difference in the level of acculturative stress among three groups of Chinese nursing students enrolled in the Bachelor of Nursing course, and SOC was negatively correlated with the level of acculturative stress. This study extends the knowledge of the experiences of Chinese nursing students studying and living in an English-speaking country. The study also highlights the need for universities to provide relevant support to overseas students to make their study journey smoother and more successful. Crown Copyright © 2011 Published by Elsevier Ltd. All rights reserved.
Introduction The Australian Educational International (AEI)'s data reported that between 2007 and 2008, there were 543,898 enrolments by full-fee paying international students in Australia on a student visa. The enrolments in 2008 exceeded 500,000 for the first time (Australian Education International, AEI, 2008). Although the majority of international students adapt reasonably well to the demands of the host culture and academic institutions, they are likely to experience pressures related to acculturation, racism and decreased access to their usual support system (Sandhu and Asrabadi, 1994; Zhang and Dixon, 2003). University schools of nursing in Australia are the main providers of nursing education programmes for international students. The large cohort of overseas students requires that universities, as education providers, understand their needs and the problems related to studying and living in Australia. Acculturative stress has been identified as a major issue encountered by the international students (Sandhu and Asrabadi, 1994). Acculturative stress refers to stress induced by the adaptation process due to a change of cultural environment. It is the response of individuals to life events, which ⁎ Corresponding author at: Australian Catholic University, 8-10 Berry Street, North Sydney, 2060, Australia. Tel.: + 61 2 9739 2531. E-mail address: fl[email protected] (F.X. He).
originates from intercultural contact, when these events surpass the capacity of individuals to manage (Berry and Ataca, 2000). Sense of Coherence (SOC), on the other hand, is a global measure of coping resources and is an indicator of the availability of, and willingness to use, adaptive coping resources (Antonovsky, 1987). The study aims to obtain information about the characteristics of Chinese international nursing students, to identify their levels of acculturative stress and sense of coherence, and to examine the correlations between acculturative stress and sense of coherence. This study is of significance to the understanding of international nursing students' educational and cultural experiences in an Australian context. The findings of the study will provide information to assist universities to plan students' future education and other support needs. Background Numerous reports have examined the experiences of international or English as a Second Language (ESL) students who are studying in English speaking countries such as the United States, Canada and UK, however, there were not many research papers about Chinese international nursing students studying in Australia. For example, Salamonson et al. (2008) conducted a survey of 273 first year nursing students who were born overseas from a non-English-speaking country, using an English Language Acculturation Scale (ELAS) at
0260-6917/$ – see front matter. Crown Copyright © 2011 Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2011.05.004
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the School of Nursing, University of Western Sydney. It was reported that there was a positive association between the ELAS scores and academic performance in all four subjects of study, namely: behavioural science in nursing, theoretical frameworks in nursing, nursing practice, and bioscience. The students with the lowest ELAS scores obtained the lowest mean subject grades. This study also identified that there was a positive correlation between language acculturation scores, and length of residence in Australia (Salamonson et al., 2008). It was noticed that it would be beneficial for future studies if other students (e.g., the 2nd and 3rd year students) were included for comparative purposes. Thomson et al. (2006) surveyed undergraduate and postgraduate international students from all faculties (n = 979, 64% female, 23% Chinese) about their perceptions of cultural stress and the relationships between cultural stress and social connectedness, mental health, and lifestyle balance in a large Melbourne university in Australia. Findings showed that cultural stress was related to students' cultural background, communication skills, and perceived academic progress. Cultural stress was negatively related to social connectedness (r = −0.39, p b 0.001) and lifestyle balance including both study and social activities (r = − 0.15 and − 0.23 respectively, p b 0.001 for both items) but positively related to depression, anxiety and stress (r = 0.46; r = 0.44; r = 0.44 respectively; p b 0.001 for all correlations) (Thomson et al., 2006, p. 6). Chen et al. (2008) conducted two case studies exploring the adaptation processes of Chinese international students to online learning at one Australian university. The two participants were postgraduate students in the Faculty of Education. Results indicated that the quality of online learning was less satisfactory than face-toface learning experiences. Students did not benefit from the temporal and spatial flexibility online learning provided but needed more teacher control and interpersonal contact. Although the participants of the study were not Chinese nursing students, the findings of the study provided some insightful information about Chinese students' online learning experiences. It was also highlighted that the biggest challenge the participants encountered in their adaptation to online learning stemmed from the perceived absence of the teacher. Cotton (2000) conducted a hermeneutic phenomenological study of overseas nursing students (n = 10) and their educators (n = 10) in an Australian university. Results highlighted that students' concerns were related to not being at home, being an outsider, striving to understand and be understood, seeking and finding help and support, expending current efforts and costs for future gains, and experiencing personal growth and achievement. On the other hand, the educators were concerned about maintaining adequate standards, making appropriate allowance and providing opportunities, giving help and support, needing help and support from the university, educating, and developing educative relationships. The caring student–educator relationship was found to play a major part in relation to shared understanding of educative experiences for students and educators. A study of significance to the topic of interest in this study was conducted by Pan et al. (2007). The study was a cross-cultural comparison of the experiences of Chinese international students in Australia and Hong Kong which investigated acculturative stressors and meaning of life as predictors of negative affect in acculturation. The sample comprised of 627 participants, 400 from six universities in Hong Kong, and 227 from one university in Australia. There was no information about their study majors (e.g., nursing or business), but they were mainly postgraduate students (PhDs and Masters). The study identified that the Australian sample had higher scores in both Acculturative Stressor Scale and Negative Affect Scale, compared to the Hong Kong sample. The univariate F-test showed that the two groups differed significantly in terms of acculturative stressor (F = 18.64, df = 1, p b 0.0001) and negative affect (F = 4.49, df = 1, p = 0.035) (Pan et al., 2007, p. 744). Acculturative stressors had a positive impact on negative affect in both samples, but the impact of
different domains of acculturative stressors on negative affect varied between the two groups. The authors explained that the cultural distance between Australia and China is greater than that between Hong Kong and China. The findings verified the supposition of the impact of the cultural distance between the host country and the country of origin on acculturative stress. The greater the cultural distance, the more difficulties the students experience in the host society and the greater their stress. The literature review highlighted that there were no published studies which had focused on Chinese overseas students (from mainland China, Hong Kong or Taiwan) who were enrolled in a Bachelor of Nursing (BN) programme in an Australian context. At the time of the review, there were only a few Australian studies that had focused on international nursing students' experiences in educational institutions (e.g., Salamonson et al., 2008; Cotton, 2000). Since there is a paucity of information on the experiences of Chinese nursing students studying in Australia, this study aims to address this knowledge gap. Aim and objectives The aim of this study was to explore the level of acculturative stress of Chinese international students studying and living in Australia. The specific objectives were to: (1) examine whether there were significant differences in the acculturative stress between the three groups (year 1, year 2 and year 3) of Chinese international nursing students, (2) examine the level of sense of coherence of Chinese international nursing students, (3) examine whether there were any significant differences in the sense of coherence between the three groups (year 1, year 2 and year 3) of Chinese international nursing students, and (4) examine whether there were significant correlations between acculturative stress and sense of coherence of Chinese international nursing students. Methods Subjects and setting A convenient sample of 315 Chinese nursing international students at one public university in Sydney, Australia was recruited for participation in the study. Inclusion criteria for selection of the participants were that they were (1) overseas fee paying Chinese students, (2) enrolled in a BN course (3-year programme), and (3) enrolled in 2008 at a Sydney based university campus. The reason for choosing the campus in Sydney to recruit the sample was the large number of international nursing students enrolled in the BN programme at this university. The Chinese was the largest group among all the international students enrolled in 2008 (Australian Catholic University, ACU, 2009). Procedure Following approval by the University Human Research Ethics Committee, the questionnaires and the self-addressed return envelopes were distributed during nursing lectures, tutorials and laboratory sessions with permission of the lecturers-in-charge. The duration of data collection was nine weeks from the 4th week to the 12th week in the second semester, 2008. Students were informed about the nature and purpose of the study. They were also assured of privacy and confidentiality of the information provided and that nonparticipation in the study would not in any way affect their studies. They were asked to complete the questionnaires at their convenience and return these by placing them in one of two sealed boxes provided for collection of questionnaires. The boxes were emptied on a regular basis during the period of data collection. Completion and return of
F.X. He et al. / Nurse Education Today 32 (2012) 345–350
questionnaires were taken to mean that the participant had consented to participate in the study. Measures Demographic data Respondents were asked to provide information about their age, gender, year in the BN programme, employment status, and International English Language Testing System (IELTS) score prior to the university studies. Acculturative Stress Scale for International Students (ASSIS) ASSIS was developed by Sandhu and Asrabadi (1994) to assess the adjustment problems of international students. It is a 36-item scale using a 7-point Likert scale (1 = strongly disagree to 7 = strongly agree). The ASSIS consists of seven subscales: Perceived discrimination, Homesickness, Perceived hate, Fear, Stress due to change, Guilt, and Miscellaneous. The total score for the ASSIS ranges from 36 to 252, with higher scores indicating greater acculturative stress. Sandhu and Asrabadi (1994) encouraged researchers to use the ASSIS total score. They also recommended using subscale scores when researchers are interested in determining the specific sources of acculturative stress. This study, however, intended to examine the level of the acculturative stress of the Chinese international nursing students in general, and the total score was considered as appropriate to use for the study. It was reported that the ASSIS had generated an internal consistency score ranging from 0.87 to 0.95 (Sandhu and Asrabadi, 1998; Sandhu and Asrabadi, 1994). In the present study, the Cronbach's alpha coefficient for the total score was 0.95. Sense of Coherence (SOC) The SOC scale was developed by Antonovsky (1987) to examine the comprehensibility, manageability, and meaningfulness of the participants' lives. The full SOC has 29 items (Antonovsky, 1987). However, the SOC 13-item scale (Antonovsky, 1993) was used in this study because of the length of the questionnaire which has a total of 64 items. The SOC-13 uses a 7-point Likert scale from 1 (very poor) to 7 (very strong). Higher scores indicate greater coherence. Eriksson and Lindström (2005) reported that the Cronbach's alpha in 127 studies using SOC-13 ranged from 0.70 to 0.92. In this study, Cronbach's alpha was 0.75. Data analysis Responses to the questionnaires were entered into an SPSS 17.0 database. Descriptive statistics, such as frequencies, means and standard deviations (SDs) were used for the demographic data and scores for ASSIS and SOC. Relationships between ASSIS and SOC were analysed by linear regression. The total score for the ASSIS and SOC was used to examine the relationship. Analysis of variance (ANOVA) was used for assessing the differences between means of ASSIS among the three groups of nursing students (years 1, 2, and 3), and the differences between means of SOC. The alpha level for significance testing was set at 0.05.
week of the 2nd semester when most of the students' first assessment was due. The sample consisted of 108 females and 11 males nursing students whose ages ranged from 19 to 50. The average age was 25.3 years. The subjects comprised of 42.9% third-year, 25.2% secondyear, and 31.8% first-year students. Of the respondents, the majority (78.2%) had part time jobs and the rest (21.8%) did not work. For the IELTS scores prior to the university study, less than half of the participants (41.2%) scored between 6.0 and 6.5, about one fifth (20.2%) scored less than 5.5, and only 10.9% scored above 7.0. It is interesting to see that 27.7% of the participants did not state their IELTS results (see Table 1). Level of acculturative stress The mean of ASSIS was calculated to indicate the level of acculturative stress. The results showed that Chinese nursing students had a moderately high level of acculturative stress. The total mean of ASSIS was 98.32 (SD 21.86). It is considered as a moderate level of acculturative stress with values ranging from 36 to 252, compared with a study conducted by Constantine et al. (2004) which had a sample of 320 international college students from 33 countries in the United States, with a mean of 81.39 (SD 24.66). Among the three groups, the third year students had the highest ASSIS mean score of 105.16 (SD 22.40), followed by the first year students (Mean 95, SD 18.23), and the lowest scores for the second year students (Mean 90.7, SD 22.31) (see Table 2). Analysis of variance (ANOVA) was performed to address the first objective whether there were any differences in ASSIS between the three groups (year 1, year 2 and year 3) of participants. The result showed that there were significant differences in this regard (p = 0.008) (see Table 3). A further post hoc test using Tukey's HSD was conducted and revealed a significant difference in ASSIS scores between year 2 and year 3 students (p = 0.01). However, there was no significant difference between year 1 and year 2 (p = 0.689) or between year 1 and year 3 (p = 0.074) students' ASSIS scores (see Table 4). Level of sense of coherence To address the second objective, the mean of SOC was computed to indicate the level of SOC of the Chinese international nursing students. The results showed that the mean of SOC was 56.61 (SD 9.74) with values ranging from 13 to 91 (see Table 2). This was indicative of a moderate level of SOC in comparison with several studies. Pallant and Lae (2002) reported a mean of 60.8 (SD 11.7) from an Australian community-based sample (n = 439). Sollerhed et al. (2005) reported a mean SOC of 62.5 (SD 10.5) from a Swedish adolescent sample (n = 285). Grayson (2008) conducted a study with a sample of 1425
Table 1 Demographic data of Chinese international nursing students (n = 119). Variables Gender Age
Results Part-time job
Demographic characteristics IELTS scores
Of the 315 students who received the questionnaires, 119 participants completed and returned the surveys representing a response rate of 37.8%. Firstly, the low response rate could be due to the length of the questionnaire having a total of 64 questions comprising 13 for the SOC, 36 for the ASSIS and 15 for the demographics. Secondly, the survey was conducted from the 4th
347
Year of students
Male Female b 24 years 25–29 years 30+ years No Yes b 5.5 6.0–6.5 7.0–8.0 Not stated 1st year 2nd year 3rd year
IELTS = International English Language Testing System.
N
%
11 108 66 27 26 26 93 24 49 13 33 38 30 51
9.2 90.8 55.4 22.7 21.9 21.8 78.2 20.2 41.2 10.9 27.7 31.9 25.2 42.9
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Table 2 Descriptive statistics for ASSIS and SOC. Variables
N
Mean
SD
SE
95% CI for Mean LCI
UCI
ASSIS Yr1 Yr2 Yr3 Total
36 30 51 117
95.00 90.70 105.16 98.32
18.23 22.31 22.40 21.86
3.004 4.074 3.137 2.021
88.90 82.37 98.86 94.32
101.10 99.03 111.46 102.33
SOC Yr1 Yr2 Yr3 Total
38 27 50 115
56.42 55.74 57.22 56.61
9.89 10.90 9.12 9.74
1.600 4.074 3.137 .908
53.18 51.43 54.63 54.81
59.66 60.05 59.81 58.41
Note: Yr1 = the first year students; Yr2 = the second year students; Yr3 = the third year students. ASSIS = Acculturative Stress Scale for International Students (Sandhu and Asrabadi, 1994). SOC = Sense of Coherence scale (Antonovsky, 1987).
first year students at four Canadian universities study and reported a mean of 56.70 (SD 11.7) which is extremely close to the current study. ANOVA was conducted to address the third objective, however, there were no significant differences between the SOC scores of the three groups of participants (f [2,112] = 0.21 p = 0.81) (see Table 3). Correlations between acculturative stress and sense of coherence For the fourth objective as to whether there are correlations between ASSIS and SOC in Chinese international nursing students, linear regression was conducted using ASSIS as the response variable and SOC as the independent variable. The plot of residuals for normality showed that there was no violation of our assumption that the residuals are normally distributed. The linear regression result revealed that there was a significant negative relationship between ASSIS and SOC. In other words, a person with a high level of acculturative stress would have a low level of sense of coherence and vice versa (see Tables 5 and 6). Discussion The main purpose of the present study was to examine the level of acculturative stress and SOC of Chinese international nursing students and identify the relationships between the acculturative stress and the SOC. We first wanted to investigate the level of acculturative stress of the Chinese international nursing students and expected that a high level of ASSIS would be found. It was anticipated that there would be challenges faced by these students, in terms of adaptation to a foreign land, particularly English language skills, academic performance and social isolation. However, the finding showed that their acculturative stress level was just moderately high.
Table 4 Post hoc analysis of variance by Tukey's HSD test. (The mean difference is significant at the 0.05 level.) Comparison
Yr1 vs. Yr2 Yr1 vs. Yr3 Yr2 vs. Yr3
Mean difference
SE
p-Value
4.300 − 10.157 − 14.457
5.224 4.600 4.862
95% CI for Mean
.689 .074 .010
LCI
UCI
− 8.10 − 21.08 − 26.00
16.70 .77 − 2.91
Note: Yr1 = the first year students; Yr2 = the second year students; Yr3 = the third year students.
The reason for this could be related to some of the barriers previously discussed in the literature for Chinese international students when coping with acculturative stress. For example, when Chinese international students experience acculturative stress, the possibility of losing face and embarrassment may have prevented them from sharing their experiences with others because these experiences may have implied personal failures (Heppner, Witty and Dixon, 2004). When these groups of students in the present study answered the questionnaires, there was a tendency to choose the middle point of the scales or a neutral mark which was not very strong or weak; therefore, this tendency may have resulted in a moderate overall score for the ASSIS. Furthermore, in regard to the first objective in which the differences in the acculturative stress between three groups of Chinese were investigated, a significant difference in ASSIS scores between year 2 and year 3 students was shown. However, there was no significant difference between year 1 and years 2 or 3 students' ASSIS scores. Several reasons for these results are proposed. Firstly, a small sample size (n = 36 for year 1, n = 30 for year 2 and n = 51 for year 3) may have contributed to the results. Secondly, the means of ASSIS of year 1 and year 3 students were higher than year 2 students. This could suggest that the experiences between these two groups of students were different, but the levels of stress were similar. The first year students who come to a foreign country are expected to have a high level of anxiety due to language issues, the adaptation to the new educational system, and the settlement of living including finding an accommodation and a part-time job to support themselves financially. On the other hand, the third year students who could have overcome those issues may possibly face other critical challenges which the first year students consider unnecessary to worry about. For example, the third year students may have issues related to their graduation, the registration with the Nursing and Midwives Board, the competition for getting a place in the new graduate programme, and the decision for their future plans (e.g., migration to Australia). One important fact should be taken into consideration when interpreting this result, i.e. the third year international nursing students in this particular university were facing professional registration problems in 2008. The Nurses and Midwives Board, New South Wales had new policies Table 5 Linear regression.
Table 3 ANOVA for ASSIS and SOC. Source of variation
df
Mean square
F
p-Value
ASSIS Between groups Within groups Total
2 114 116
2261.307 446.518
5.064
.008
SOC Between groups Within groups Total
2 112 114
20.181 96.098
.210
Response variable: ASSIS Independent variable: SOC
.811
Note: ASSIS = Acculturative Stress Scale for International Students (Sandhu and Asrabadi, 1994). SOC = Sense of Coherence scale (Antonovsky, 1987).
Model
df
Mean square
Regression Residual
1 111
9109.341 410.870
Terms
Estimate
SE
Constant SOC
151.318 − .929
11.366 .197
F 22.171
p-Value b .001
t-Tats
p-Value
13.313 − 4.709
b .001 b .001
Note: ASSIS = Acculturative Stress Scale for International Students (Sandhu and Asrabadi, 1994). SOC = Sense of Coherence scale (Antonovsky, 1987).
F.X. He et al. / Nurse Education Today 32 (2012) 345–350 Table 6 Correlation between ASSIS and SOC (significant).
Pearson correlation Sig. (1-tailed) N
ASSIS SOC ASSIS SOC ASSIS SOC
ASSIS
SOC
1.000 − .408
− .408 1.000 b .001
b.001 113 113
113 113
Note: ASSIS = Acculturative Stress Scale for International Students (Sandhu and Asrabadi, 1994). SOC = Sense of Coherence scale (Antonovsky, 1987).
in regard to the English requirement for the Nursing registration for overseas nursing students. The IELTS score should have an overall band score of 7.0 before the student is eligible to register with the Board. Some of the students were stressed about this requirement because they perceived that such a score was difficult for them to achieve. Therefore, the third year's ASSIS scores were the highest among three groups, followed by the first year's score, and the lowest for the second year students. Not surprisingly, there was a significant difference found in the ASSIS scores between the second and the third year students (see Table 2). Another finding of the present study was that the level of SOC was moderate which reflects the second objective. According to a systematic review conducted by Eriksson and Lindström (2005), they pointed out that Antonovsky never expressed the level of a normal SOC, but recommended the SOC concept to be examined without dividing the sum of the item values into low or high SOC. However, some studies reported divisions into low, moderate, or high SOC. For example, Fok et al. (2005) reported a mean of SOC 51.8 (SD 4.1). It is important to note that the participants in Fok et al.'s study were the 88 patients who were admitted to the ICU for longer than 24 h, and were discharged home. The life experiences of the participants will be very different between the Intensive Care Unit patients and university students. Fok et al.'s mean of SOC (51.8) should be considered low. Several reasons could be considered to explain the SOC findings of the study. The first could be due to the age of this particular group of participants. They ranged from 19 to 50 years old, with an average of 25.3 years. Antonovsky (1979) sought to explain the relationship between life stresses and health by the SOC. He suggested that individuals develop a generalised way of looking at the world as more or less coherent by around age 30. The more one's life experiences are characterised by consistency, participation in shaping outcome, and ability to balance the stimuli that one faces on a day to day basis, the more one is likely to see the world as coherent and predictable. The matured age of the participants in this study may have contributed to a moderate level of SOC. In regard to the third objective, the differences in SOC scores among the three groups (years 1, 2 and 3) of Chinese international nursing students were examined, but no significant differences were found. One possibility could be the participants were from a small homogeneous group (e.g., all Chinese, 90.8% female, nursing students at one university). They were influenced by the same culture, a Chinese culture in this case. One feature of the Chinese culture is their collective orientation. Working as a group and supporting each other are traits of collectivism. If there is stress, Chinese people are likely to share their feelings among themselves and seek family or peer support often. The stressful event could become more manageable. Lastly, as mentioned earlier, there was a tendency that participants chose the middle range scores in answering the ASSIS questionnaire, this similar approach applied to the SOC scale. Most importantly, the results showed that the sense of coherence was negatively correlated with the level of acculturative stress, which was the answer for the fourth objective. This finding is consistent with
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the literature. For example, Eriksson and Lindström (2005) reported that the SOC was negatively correlated with anxiety and depression which are highly correlated with acculturative stress. Elsewhere, acculturative stress was also found to have a strong relationship with psychological distress (Flannery and Flannery, 1990). If the SOC is conceptualised as a coping mechanism characterised by the tendency to see life as predictable and manageable, a person with a strong SOC is less likely to perceive many stressful situations as threatening and anxiety-provoking than one with a weak SOC. The results of the present study indicated that Chinese international nursing students with a higher level of acculturative stress had a lower sense of coherence and vice versa. Implication for nursing Many overseas nursing students travel to Australia every year to further their education, enhance their career opportunities and extend their knowledge so they can contribute to the development of nursing in their home country or their host country. Australian universities are providers of high quality nursing education, a feature which is highly sought after by international nursing students. According to the literature review, the acculturative stress is the most common problem encountered by international students. If the acculturative stress and sense of coherence experienced by international nursing students are better understood by the universities that they enrol in, relevant support is more likely to be provided for them. Their learning journey, therefore, should become smoother, more successful, and less stressful. The international nursing students' well-being will be also enhanced. Furthermore, this study is important in increasing all international students' (not limited to Chinese international nursing students) awareness of how their acculturative stress and sense of coherence are correlated. With this understanding, students could be more alert about what they are experiencing and seek help when needed, therefore minimising their acculturative stress. International students in this university have been advised to seek help from the School International Advisors and Campus Counsellors. Further study is being conducted with Nepalese nursing students as a comparative group to the Chinese students who participated in this study to examine whether there are differences in the level of SOC and ASSIS. Nepalese students were chosen because of their different English language capacity and cultural background. Finally, there is a shortage of nurses in Australia. Nursing has priority for skilled migration; therefore, international nursing students continue to be needed to augment the workforce shortage in the health-care system in Australia. Their success in completing nursing course in universities, has, therefore, become very important and will have strong influence on their future nursing career development and Australian workforce recruitment. The findings of this study should equip the educational providers with sufficient knowledge and understanding of the experiences of overseas nursing students making teaching more effective and providing more appropriate support services to them. Limitations The present findings must be interpreted with caution. First, the study relied on self-report measures and did not include assessments from other sources (e.g., psychologists' interviews or university counsellors' assessment). Second, being a survey-based study, recall was a potential problem. Participants may not have fully understood or may have misinterpreted some questions, thereby misrepresenting their response. Third, the study's findings may be limited as the instruments were used and validated in the United States limiting the conceptual relevance and validity of the instruments for the international students from China or Asia who study in Australia. Fourth, the data were gathered from one cohort of Chinese
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international nursing students in one campus of a university. There could be great homogeneity among the participants; therefore, the sampling limitation may have affected the external validity of the results.
Direction for further research The authors are in the process of extending the study by conducting individual interviews with students who completed the questionnaires in this study, to identify the kinds of stress they have experienced and how they coped with their stress. Furthermore, in order to understand the Chinese international nursing students better, additional validated questionnaires will be used to investigate students' coping strategies, and examine their accessibility to social support networks. In addition, SOC has been reported to have a relatively high negative correlation with anxiety and depression but has a strong positive correlation with optimism and self esteem (Eriksson and Lindström, 2005). Therefore, the presence or severity of depression of this group of students will be further investigated. In addition, a comparable group of Nepalese students will be studied. This is important for the replication of the study with international students from other countries or cultural groups in the future.
Conclusion In summary, this study provides some understanding of the associations between acculturative stress and sense of coherence. It also extends the knowledge of the experiences of Chinese nursing students who study and live in an English speaking country. Those students with high level of acculturative stress were found to have a low level of sense of coherence. The findings highlight the need for universities to provide relevant support to overseas students to make their study journey smoother and more successful. Further research would be beneficial by examining the Chinese nursing students' coping strategies and their accessibility to social support networks in order to gain a deeper level of understanding of this phenomenon.
Acknowledgement We acknowledge the contribution made by all the ACU Chinese nursing students who participated in this study. Our thanks also go to Dr. Yoon (ANU) for his assistance in the statistics report of the study.
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