How Learning to be a Nurse in the Clinical Environment Occurs for the International Student

Background: International students comprise some if not the majority of undergraduate nursing cohorts in countries such as Australia, The United States of America and the United Kingdom. As nursing is a socially constructed enterprise students who have not been born into that culture require assistance adjusting to nursing professional expectations, especially during their clinical practicum. Although the literature is replete with analysis of the effects of the clinical environment on learning, and concerns about the quality of learning whilst on placement, what remains to be understood is how students, particularly international students, go about learning to be a nurse as active participants on their own professional journey. Objective: The purpose of this paper is to reveal the complex process undertaken by international students on clinical placement in Sydney, Australia learning to be a registered nurse. Method: A qualitative research design using the method of interpretive description was conducted using a purposive sample of student visa holders enrolled in an undergraduate nursing course in Sydney Australia. Findings: The findings revealed the complexity of the nature of learning that often remains hidden to clinical educators. This paper will highlight the learning journey of international nursing students through actions such as watching and waiting, and seeking and finding which reinforces the applicability and importance of social learning theory in the clinical environment. How Learning to be a Nurse in the Clinical Environment Occurs for the International Student Publication History: Received: November 18, 2015 Accepted: February 11, 2016 Published: February 13, 2016


Introduction
International students enrolling into courses at university and college are not a new phenomenon and currently international student mobility is increasing. According to the Organisation for Economic Co-operation and Development (OECD) more than 4.5 million students are enrolled in courses outside their country of birth [1]. In terms of market share The United States of America (USA) attracts the largest number of students, followed by the United Kingdom (UK) and Australia (AUS) in 4th place. Together these three countries educate 36% of the worlds' international students [1]. Whilst in their host country students make significant contributions to social diversity and culture and to the local the economy. The Australian higher education sector generated $10.8 billion in the 2013-2014 financial year, making education the 4th largest export [2]. What is important for clinical educators to understand about international students and where they come from, is that they travel from countries where English is not the dominant language and the culture not western, posing a unique challenge to nursing educators in host countries.

The International Council of Nurses defines nursing as encompassing [3]:
Autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of the ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles.
Inherent in this definition is that practitioners of nursing worldwide share the same understanding of fundamental key points, such as the meaning and practice of care. However, nursing is a practice based discipline that is governed and structured by national authorities that aim to maintain safe, effective and professional standards of care for the population. These standards reflect the notion of care, the role of the nurse, and the language of nursing as it is constructed in the social culture. Recently, Scott, Matthews and Kirwan argued that some common concepts such as safe, quality and compassionate care are identified in international nursing literature, however practice variations persist [4]. Walton-Roberts presented a comprehensive argument to support the notion that that the work and practice of nursing is considerably different across cultures [5]. What this means for a clinical nurse educator is that the international student's context requires understanding so that appropriate learning support is enacted. Appropriate learning support begins with an understanding and knowledge of how these students learn in the clinical environment.
Undergraduate nursing courses are expected to prepare students to meet the professional and social expectations of a registered nurse, so that they are prepared for graduate practice. These courses rely on the clinical practice learning experience to socialize students into the profession as well as integrate theory with practice. International students who come to study nursing have been found to experience difficulty with learning to nurse in the clinical environment [6][7][8]. Clinical learning experiences for international students have been found to be more difficult and stressful than domestic students. De found that the international students from China, Nepal, India, Iran, Nigeria and Trinidad studying in the United Kingdom, reported more incidents of unfair treatment and felt more racially abused compared to the domestic students who were Welsh Caucasian [9].
A Finnish study found that despite a friendly welcome and orientation to the ward, international students felt ignored, left out and unable to perform higher grade activities resulting in poor self-esteem [10]. In Australia, Shakya & Horsfall [11] found that students relied heavily on their spiritual beliefs and internal strength to maintain motivation to succeed. The issues for international students are clearly identified in the literature and represent the global mobility of students wanting to study nursing.
Concerns within the profession have been raised regarding the quality of learning on clinical placement for some time [12].Issues such as students outnumbering staff, students on evening shifts, and the general 'busyness' of the ward have been noted as impacting on the registered nurses ability to act as learning support [13]. Skill mixes where the divergent needs of new staff, agency staff, and students clashed also impinge on the learning environment [13]. Further, McKenna and Wellard [14] suggest that the culture of nursing itself, where students are seen as a burden, is problematic in meeting the learning needs. Given the nature of nursing and this environment, it is difficult, even for students from the dominant culture to learn effectively.
Students' perceptions of the clinical learning environment have attracted a lot of attention by researchers mainly because of its significant influence on learning to be a nurse. The clinical learning environment has been evaluated across the globe from the students' perspective. A number of these studies have concurred that student's ideal clinical placement expectations were not met by the actual experience [15][16][17][18][19][20]. Findings from these studies reveal that nursing students prefer clinical environments that: recognise their individuality; give some flexibility within the scope of practice, treat them with respect, recognise their knowledge; encourage active participation; clearly explain tasks, and include them as part of the team. In addition, students have been shown to prefer a more personalised approach to their learning needs [18,20,21].
Whilst there is a wealth of literature related to the international student experience generally from the education and psychology professions, there is a paucity of it relative to the discipline of nursing. However, it would appear that interest in international students as a particular cohort has been gaining momentum as the numbers of international students are increasing in the domestic nursing programmes of western countries and as their unique learning needs are explicated.The literature provides insight into the international student experience when learning to nurse in a foreign environment. Salient points derived from analysis of the literature paint a picture of students who have limited ability to communicate in English [22,23] and who are studying in a learning environment that is perceived to be unsupportive [24,22]. This results in feelings of isolation and a need to be valued and accepted [24][25][26].Overall, it is clear that international students want to be valued and respected. What is missing and what is yet to be understood and explicated are the strategies that international students employ to adopt, adapt and become worthy of each jurisdictions embodiment of a registered nurse.

Aim
The aim of the qualitative study was to come to an understanding of how international students learn to nurse in the Australian clinical context. The research was guided by the question 'What is the nature of learning to nurse through clinical practice experience for international culturally and linguistically different nursing students in Sydney, Australia?' This paper reports on selected findings related to the participants' actions such as watching and waiting, and seeking and finding that directly relate to Social Learning Theory and further explain the process of learning undertaken by the participants.

Study Design
The study used an interpretive descriptive design [27], and was conducted in a large metropolitan university in the greater western region of Sydney, Australia. The participants were recruited using a purposive sampling technique and were contacted through their student email accounts by an administrative assistant. Inclusion criteria required participants to: hold a current student visa; be enrolled in a Bachelor of Nursing program at the university; have completed, as a minimum, their second or third semester of study; and to have completed at least their first clinical practice experience. In addition, the home country of the participant must have an official language other than English and have a culture not dominated by an Anglo-Celtic influence, thus eliminating the possibility of prior enculturation. After 12 months of recruitment, sixteen participants, two male and 14 female students were recruited from a possible 300 individuals. The participants represented the following world regions: Chinese Asia (n=7), Southern Asia (n=4); Maritime South East Asia (n=2); Middle East (n=1); Eastern Europe (n=1), and Southern East Africa (n=1). Ages ranged from 20-40 years.

Locating the Researcher in the Discipline
To 'do' interpretive description well the researcher needs to make explicit the disciplinary grounding or frame for the research. Firstly and importantly, the researcher needs to assert their position of influence on the work at hand [28,29]. Further, that the position of the researcher to the question and the investigation needs to be clearly articulated as the interpreter of the work.
Nurses define the profession, its philosophies, and the body of knowledge in regard to the culture in which it is practised. Having been born and educated as a nurse in Sydney, Australia the author considers her-self an Australian nurse. In her role as a university lecturer she presents information and stimulates discussion with students about nursing and how it is positioned in Australia both as a caring practice and as a profession. During the study she was also the Deputy Director of Clinical Education, advising clinical educators on the progress of students. In the dual roles of on-campus educator and clinical advisor, the author refers constantly to the frameworks for professional practice set down by the professional bodies in Australia as an explanation or a justification for the many issues that present in the learning of nursing here in Australia.

Data collection
Individual, semi-structured interviews were conducted by the authorusing an interview guide. Although a number of questions were asked during the interview, the question related to the data presented in this paper was how do you learn in the clinical environment? The interviews lasted for an average of 56 minutes. The interviews were digitally recorded and transcribed by the researcher to create a text for analysis.

Trustworthiness
Schwandt, Lincoln and Guba [30] recommend the term trustworthiness be utilised in qualitative studies rather than rigour due to the multiple realities, contextual influence on thought and action, and data that is conjointly formed between the participant and the interviewer. The judgement of the trustworthiness of qualitative findings then cannot rely on objectivity and verification. To this end Thorne [29] has nominated a set of four criteria informed by the constructivist tradition that have been accepted as promoting confidence about the researchers understanding of, and the associated actions on, their qualitative data (Table 1).
Epistemological integrity: Throughout this study the alignment of the research with the qualitative tradition and the constructivist paradigm has been explicated. The research question was omnipresent in the analysis and guided the discussion. The questions asked of the data have also been explicated and reflect the underlying constructivist values of interpretive description as designed by Thorne [29]. Therefore, the epistemology, research question; data collection and analysis are congruent with the research tradition and paradigm.
Repesentative credibility: The ability to truly engage with the data and then being able to come to an understanding of meaning can best be achieved through prolonged engagement with the data. Because the author interviewed the participants, checked the meaning and then transcribed the audio, closeness with the data was established that enabled the search for similarities within and across meaning units [30]. The process of inquiry and categorizing then deepened that relationship. The data were collected from a representative sample of the major ethnicities of the student cohort and generated individual meaning units that could be grouped together under common themes for international students learning to nurse in Sydney, Australia.

Analytic logic:
The audit trail of decisions made in relation to the selection of representative data, analysis and formation of themes was a four step process. The findings have also been presented using vignettes from the verbatim transcript to demonstrate grounding in the data.
Interpretive authority: The product of interpretive description is to '…go beyond what an individual might "see" in his or her own situation. ' [31].In this study the author's ability to move beyond was achieved through constant member checking whilst conducting interviews. It was necessary to develop a skilled approach to verifying statements during the interview. This skill enabled the development of understanding through reflecting on the words of the participant. The outcome of that kind of reflection, recorded as field notes, is important as the researcher is a co-constructor of the data. Thorne [29]notes that there are times in the research process that researchers may need to abandon their former selves to be able to interpret participant data with authority. That abandonment was applied when questioning the data during analysis where the focus was on meaning for the participant not for the author as a researcher, lecturer and Deputy Director of Clinical Education. Reducing the distance between researcher and participant is necessary to try to maintain subjectivity where engagement is paramount over detachment [32].
The majority of the participants spoke with heavy accents; therefore, meaning was established concurrently with the data collection. The participants were asked if they would be available for follow-up contact to check their transcripts; all participants were happy with the clarification during the interview and the summary at the end of the interview and did not wish to be sent a transcript.

Analysis
Thematic analysis of the transcripts was informed by the work of Thorne, Reimer-Krikham, and O'Flynn-Magee [31]. The analytic process involved four steps: (1) asking four questions of each whole response from a participant -What is happening here? Why is this here? Why not something else? What does it mean?); (2) deciphering patterns or searching for patterns in the data. This stage is what Thorne [29] called 'from pieces to patterns'; (3) conceptualising subthemes. Subthemes were identified by grouping commonality of meaning; and (4) conceptualising themes. Themes need to reflect the combined collective meaning from all of the subthemes. Deep engagement with the data over an extended period of time resulted in the identification of six themes. This paper will present sub -themes from the major theme Ownership of the Clinical Placement: Crafting Success.

Ethical considerations
The study was approved by the ethics committee in the School of Nursing & Midwifery where the participants were enrolled. Participants gave informed consent, chose pseudonyms for themselves, and were informed that participation was voluntary and that they could withdraw from the study at any time. The author was employed as a lecturer in the courses in which participants were enrolled and to prevent an unequal power relationship, the author agreed to remove herself from assessing the work of any participant.

Findings
Participants chose to come to Australia to study nursing and, therefore, needed to develop an understanding of the profession and its role in health care provision in the Australian context. The clinical learning experience occurs mainly in the hospital system where students are allocated a clinical facilitator. A clinical facilitator oversees the placement and is responsible for judging students' performances. She/he is a registered nurse usually employed by the university as sessional staff. However, the clinical facilitator is often not the main role model for nursing practice in situ. Registered nurses in the clinical environment are seen as providing role models for clinical practice, not only by students but by the clinical facilitator, and ultimately the university as well. The registered nurse is in this position by default as nursing students are allocated to them for their learning experience. Students entering the clinical environment have expectations about, them-selves, their learning needs and wants, who will help, and how they will achieve success in the clinical environment.

Waiting
Being an international nursing student, with language differences and cultural influences, entering the Australian Health care environment caused the participants to spend time thinking about practice and its importance. Waiting to practice, whether it was caused by events in the clinical learning environment or a strategy by the participant, allowed time situates them-selves in relation to the learning context, and to develop readiness. One of the main purposes of the clinical practice experience is to expose students to health care contexts in which they apply their skills and knowledge of patient care. Waiting and the resultant readiness is shown here in the enthusiasm and excitement verbalised by the participants.
Jin had developed definite ideas about the kind of clinical learning experience that would meet her needs to become a nurse. By identifying her own learning needs, and the kind of supportive clinical experience that will engage her, she understood the ultimate purpose of the clinical learning experience. However, she was kept waiting and her eagerness was evident.
.… because like we are student we want to learn, so that's why we are here. …We want to learn, we want to be a nurse, if you did not let us do anything how can we do a nurse? We need to practice that's why we are here (Jin, p.10).
The act of putting theory into practice was clearly the goal for Mi Mi. She identified that clinical nursing experience was her time to get as much practice exposure as she could, she was patiently waiting to practice as much as she was able.

… all books I have here at uni, this (clinical experience) is my time to gain knowledge over here. It is time to practice based on knowledge…. So I want to practice, practice, practice as much as I can (Mi Mi, p. 8).
Milky had a very insightful understanding of her -self as a learner, what she needed to accomplish during the placement, and the expectations of her performance. She developed this motivational style self -talk while waiting for her clinical to begin.

I really expect myself to learn more in this clinical practicum period because I know what I need to learn, what I need. I know how to learn, so I expect my-self to learn more in this week and … its relative to myself …(Milky, p.10).
The participants clearly articulated the anticipation of beginning clinical placement.Exposure to and actual participation in all aspects of nursing care was something that was longed for as a way of demonstrating what had been learnt and what was possible to learn through doing. Waiting and becoming ready, eager and motivated aided these students in completing their clinical learning goals.

Watching
Responses from the participants about how they thought they learned to nurse in the clinical environment indicated that the overall underlying strategy was to observe. Observance of nursing practice, behaviour and interactions all formed part of the development of confidence for engaging as a nurse.
The ED, I have never been there before it is a new department, as a new learning environment so the previous two days I just observe how they do things and I was planning to do that. I knew for the first two days I would not have clue and [observation] that is my strategy (Milky, p.7).
The pace of a clinical environment and subsequent workload for registered nurses had implications for student learning.
The best thing for me is watching, the most important thing for me because they are very busy. Just watching (Zara, p.4).
Yvonne clearly identified her way of learning in the clinical environment that extended beyond pure observation Um, I observe a lot. Um some things and um, like you might be a teacher or an RN might be doing something and explaining things to me as I observe, but I tend to pick things. I look at body language a lot, that's how I learn (Yvonne, p.6).
Searching for personal success in the clinical environment led the participants to actively develop a learning process. It would appear that a lack of confidence in their own ability led the participants to search for someone to model behaviours upon.

Seeking
Locating the most suitable registered nurse in the clinical environment to answer the student's questions and be a helper in their learning became seek and find mission-a deliberate management strategy. The participants devised small personal tests to ascertain who was the most willing, obliging, and accommodating candidate for a learning helper prior to engagement.

Sometimes I am testing first. So I ask a simple question and if this
person is happy to help me or willing to tell me more I will come to this person more often and ask more questions (Irene, p.8).

… the first time I ask a question they don't answer they say' I am busy' or something. So next time I won't ask (Amy, p.5).
So you have to decide, this can be the test. I can go up to him and ask these questions. The thing is that when I was on wards. I have to check with everyone, the one who finds me more interesting, the one who finds me, more adjusting, what I will say? One who is not having any problem explaining. Not disturbed by my way if interjecting in his work. I go to that person usually. Even if he is not that RN with whom I am working with. (Manoj, p.3).
Testing of clinical learning helpers ranged from the seemingly simple, to a more elaborate and multifaceted criteria. If the criteria were not met the candidate was rejected by the participant as a helper. Once the participant found the appropriate registered nurse, they then became their personal assistant to learning.

Finding
James' confidence was waning until he found nurses form different backgrounds working in the clinical environment.

And then I looked around and saw nurses from other background and I thought if they can do it, I can do it. So I said alright lets'
give it a try and I started copying others, the way they spoke, the way they interacted with the patient s and everything. So that's basically what I did… (James, p.6).
Mi Mi found that a relationship with one role model allowed the student entrée into the clinical team, and the feeling that she and the registered nurse became a team in themselves. their learning goals where they designed characteristics of an ideal role model from whom they could learn to become a registered nurse in Australia. Certain registered nurses were selected then subjected to scrutiny based on the participant's criteria. This covert process remained unknown to the registered nurse who was essentially being interviewed however it was undertaken by most participants. The candidate was given one chance only to prove their worthiness as a role model who had to be willing, helpful, someone who agreed with the participants'personality and learning style, and someone who did not find the student burdensome. These qualities did not differ greatly from the literature available on nursing students opinions of appropriate role models [39,40]. Once this person was located they became the main role model for the student. Edgecombe and Bowden [41] interpreted this as the exploitation of the clinical staffs' goodwill and skill base, where students in their study found it to be a necessary action for learning in the clinical environment. Much of the literature around role modelling discusses its purpose however, how students actually come to choose a role model has not been explicated as clearly as it has been in this study.
The main mode of learning from the clinical practice experience, as presented by the participants in the study, was through observation. Reasons cited by participants for using observational learning were to get some idea of the orientation of the ward, the nurses were too busy, and to learn practice techniques. Individual students from all geographical regions articulated that this was their preferred method of learning to nurse and was deliberate in nature. This way of learning clearly is situated in Bandura's Social Learning Theory [42] where observation of a behavioural demonstration, usually identified as a role model occurs. This observational model has been suggested as most useful for students whose competency or verbal skills are underdeveloped and, as such, has provided the foundation of clinical preceptor development for students with diverse learning needs [43]. Price and Price [44]and Donaldson and Carter [45] conclude that simply shadowing or exposing a student to the practice of a registered nurse is not sufficient for learning as it does not logically follow that learning will necessarily occur. For learning to occur the learner must be actively engaged in the learning process. These findings are indicative of intense engagement for the participants.
According to Bandura [42], virtually all learning results from observing other peoples' behaviour and the consequences of that behaviour. Bandura's Social Learning Theory is particularly relevant to student nurses in the clinical environment for a number of reasons. Firstly, as noted by Roberts [46], the nature of their clinical placements is somewhat nomadic and it is unlikely that students ever return to the same place twice. Secondly, the time spent in the clinical area is often short requiring the students to settle in each time they enter into a new environment. Placements can be as little as one week. White [47]noted that short placements do not allow students to perform anything other than that defined by the role of the observer. However, Bandura [42] argued that observation shortens the acquisition process of a new behaviour because it eliminates the need for trial and error. In particular observation is most appropriate for the clinical environment because mistakes can produce costly or even fatal consequences.
The registered nurse who acts as a role model has long been cited in the literature as the person who could teach nursing students more than any other staff member. As early as 1993, Davies identified that the registered nurse is the primary source of learning from experience [48]. Her position was supported by research conducted by Levett-…if you stick with one nurse and that nurse suits you then you become part of the team or a team yourself, so you know that nurse more than others. So I am always looking for that nurse because she knows me I know her so I know that she will answer me, at least she will try (Mi Mi,p.7).
The seek and find mission to locate the most appropriate candidate for the position of personal learning assistant in the clinical environment was seen by these participants as a worthwhile effort. There was a focused, direct and active process identified that consisted of the formation of a set of criteria specific to the participant, followed by a brief interview and finally a decision to accept or reject the candidate. The engagement of a personal learning assistant guaranteed that participants' questions would be answered and, therefore, their clinical learning goals met.
Learning to be an Australian nurse in the clinical environment was a complex mix of understanding the self in relation to learning needs, wants and expectations, and the ability to procure learning opportunities. There was a clear understanding of the role of the student in learning and the role of others to support that learning. Specific tactics and strategies were designed by the participants and implemented to learn to nurse. The overarching theme of ownership of the clinical placement was reflected in active engagement that was aimed at being a successful learner in the clinical environment through waiting, watching, seeking and finding. The process of analysis undertaken in this research, allowed for the identification of commonalities (within individual, perceptions, beliefs, expectations, culture and language) about learning nursing in the Australian clinical environment to be explicated. Whilst the participants came from different world regions and cultural groups, their responses were remarkably similar, and with further research that is provided in the discussion, a comprehensive understanding of this intricate task is generated.

Discussion
The way that identity as a registered nurse is formed and developed is through the clinical practice experience where students are exposed to the realities of practice. During these multiple experiences students '…. have opportunities to communicate with patients and their families, observe and learn from role models, and practice their skills under supervision' [33]. It is clear from the findings that the participants in this study were in no doubt as to the purpose of the clinical practice experience, their roles as students, and role of the clinical teacher in their learning to be a registered nurse. Active and intentional engagement is a positive attribute, in contrast to the literature that usually focuses on the deficits of international nursing students in the clinical environment.
The clinical role model has the potential to provide learning opportunities for the kind of application analysis and synthesis that gives students an understanding of what nursing is about [34]. It has been noted in the literature that the understanding of the part a role model has in student learning has been misunderstood in the past, with students' learning experiences limited to the performance of delegated tasks in an unsupervised manner [35,36,37]. Participants in this study were actively seeking an appropriate role model who met their own learning needs.
The full learning benefit of the clinical experience lies in the nature of the interaction between student and registered nurse [38]. The participants in this study formulated a strategy that would best suit Jones [33] more than 15 years later. In general terms the quality of the role model was found to be significantly improved if he/she possessed skills in leadership, caring, teaching, and clinical experience [49]. The registered nurse in the clinical environment is seen as central to the socialization process where he/she set standards and acts as gate keeper for professional values and beliefs [45,50,51]. Being a participant in the provision of good nursing practice has been shown to positively benefit student competence and confidence [52,53]. Charters asserts that role modelling is a legitimate way of learning for nursing students because it reconciles the art and science of the profession and, sadly, most nurses devalue its importance [54]. However registered nurses in the clinical environment may be unprepared or unwilling to teach students which could render this type of learning difficult to assess [16,35,55]. Spouse noted that staff may be unaware that students need to be afforded opportunities to work alongside them in order to develop professional skills [36]. Further devolving the importance of the registered nurse from role modelling is the belief by registered nurses themselves that clinical sessional university staff have taken over that responsibility [51].

Conclusion
This research has explicated the strategies that international students undertake to secure themselves a role model who meets their learning needs in their attempt to learn to be an Australian nurse. Whilst the language struggles, the 'fit' with the clinical learning environment and the quality of learning have previously been explored,the findings are unique in relation to the international student as they have not been explicated previously. Throughout the participants responses a sense of ownership of the clinical placement was established despite identification of common issues effecting learning. A variety of means including watching, waiting, seeking and finding, a role model was found who would understand and support their learning. Social Learning Theory was found to be the dominant way of learning for these students, who mainly observed then enacted what they accepted as appropriate nurse behaviours. It is incumbent on all registered nurses in all practice contexts to be mindful of the impact their practice has on students especially those who come to learn to be a nurse from foreign environments.