Challenges, coping responses and supportive interventions for international and migrant students in academic nursing programs in major host countries: a scoping review with a gender lens

Abstract

Background

International and migrant students face specific challenges which may impact their mental health, well-being and academic outcomes, and these may be gendered experiences. The purpose of this scoping review was to map the literature on the challenges, coping responses and supportive interventions for international and migrant students in academic nursing programs in major host countries, with a gender lens.

Methods

We searched 10 databases to identify literature reporting on the challenges, coping responses and/or supportive interventions for international and migrant nursing students in college or university programs in Canada, the United-States, Australia, New Zealand or a European country. We included peer-reviewed research (any design), discussion papers and literature reviews. English, French and Spanish publications were considered and no time restrictions were applied. Drawing from existing frameworks, we critically assessed each paper and extracted information with a gender lens.

Results

One hundred fourteen publications were included. Overall the literature mostly focused on international students, and among migrants, migration history/status and length of time in country were not considered with regards to challenges, coping or interventions. Females and males, respectively, were included in 69 and 59% of studies with student participants, while those students who identify as other genders/sexual orientations were not named or identified in any of the research. Several papers suggest that foreign-born nursing students face challenges associated with different cultural roles, norms and expectations for men and women. Other challenges included perceived discrimination due to wearing a hijab and being a ‘foreign-born male nurse’, and in general nursing being viewed as a feminine, low-status profession. Only two strategies, accessing support from family and other student mothers, used by women to cope with challenges, were identified. Supportive interventions considering gender were limited; these included matching students with support services' personnel by sex, involving male family members in admission and orientation processes, and using patient simulation as a method to prepare students for care-provision of patients of the opposite-sex.

Conclusion

Future work in nursing higher education, especially regarding supportive interventions, needs to address the intersections of gender, gender identity/sexual orientation and foreign-born status, and also consider the complexity of migrant students’ contexts.

Background

In 2017, there were over 5 million international students worldwide (i.e., individuals pursuing educational activities in a country that is different than their country of residence) and this number is increasing annually [1]. This is largely due to a growing demand from students for higher education (college/vocational and university degrees) and the limited capacity in certain countries to meet this need. International experience is also highly valued by many employers and thus studying abroad makes new graduates more competitive in the workforce [2, 3]. On the pull-side, academic institutions are wanting to draw the most talented candidates and are looking to increase their student enrollment and revenues [2, 3]. Most international students are from Asia, in particular China, India, South Korea and Middle Eastern countries, while top destinations for these students are the US, the UK, France, Australia, Canada and Germany [3]. These same countries are also primary resettlement sites, and have substantial numbers of migrants (e.g., immigrants, refugees), especially from low and middle-income countries, enrolled in their colleges and universities [3,4,5,6,7]. This is driven by migrants who desire, or who are required to supplement their previous education in order to integrate into the local workforce, and by the expectations of many migrants for their children (including the 1.5 generation) to obtain an academic degree. Academic institutions in these major host countries are therefore needing to respond to and serve a more diverse student clientele.

Nursing is one of the many disciplines with an increasing number of foreign-born students. There are several benefits to the globalization of nursing education, including strengthening the healthcare workforce capacity (front-line workers, administrators, policy-makers, academics as well as researchers), increasing the linguistic and cultural diversity of nursing professionals, and the sharing of new ideas across countries toward the improvement of nursing practice [8, 9]. Increasing the level of education among nurses also improves health outcomes, enhances gender equality and contributes to economic growth, especially in low-and-middle-income countries [10, 11]. The course of study and clinical training in academic nursing programs however, are demanding and can affect the well-being of students and result in mental health problems [12,13,14,15,16]. Stress in turn can result in failure or students deciding to withdraw from their studies.

The stresses experienced by foreign-born nursing students are magnified due to factors related to their international/migrant status [17,18,19,20]. Challenges associated with living in a new country, including financial concerns, discrimination (perceived or actual), adapting to a new culture and language, loss of social support and unfamiliarity with the education, health and other systems, may affect education experiences and compound psychological distress. The challenges experienced and impacts may be patterned by gender. Gender is defined as the ‘socially constructed roles, behaviors, activities and attributes that a given society considers appropriate for men, women, boys and girls’ [21]. The migration process itself is influenced by gender as the opportunity and the level of control over the decision to migrate typically differs between men and women. Fear of being persecuted because of one’s ‘gender identity’ (i.e., a person’s individual experience of gender, which may or may not correspond to one’s biological sex) [22], may also be the reason one decides to migrate. Transit and post-migration experiences also diverge along gender lines, for example risks for gender-based violence, perceptions by the receiving-country society and integration outcomes often vary between male and female migrants and also by sexual orientation or gender identity (e.g., if one identifies as lesbian, gay, bisexual, transgender and/or intersex) [23]. Moreover, international female students compared to male students, have reported facing greater expectations to balance home/childcare responsibilities [24, 25], experiencing more value conflicts regarding gender roles [26, 27], and having stronger emotional and physiological reactions to stress [28, 29]. In contrast, male students have expressed feeling stress associated with social status loss and due to traditional expectations to financially provide for the family, and they have been shown to be more likely to process their stress in solitude [30]. Gender norms can also affect both male and female students’ abilities to relate to members of the opposite sex in academic and clinical settings [27, 31]. To effectively support and promote the success of foreign-born nursing students, academic institutions should therefore ensure that approaches and resources not only take into account the foreign-born context, but also consider the gender dynamics that are shaping students’ experiences.

There is an extensive body of literature on foreign-born nursing students [17, 32,33,34], however, we did not identify any review that assessed the literature with a gender lens. Within the nursing education literature, reviews that have examined gender have primarily focused on the experiences of male students in general without any mention of a migrant or international background [35,36,37,38,39]; more recent reviews have considered the experiences of nursing students with diverse sexual and gender identities, although the research in this area remains scarce and also does not refer to foreign-born students [40,41,42]. In parallel, other literature has reviewed or discussed the intersection of gender or gender identity/sexual orientation and international status in relation to students’ experiences and its implications for academic institutions and educators, but none of these address the context of nursing or other healthcare professional education [43,44,45]. We therefore conducted a scoping review to address this gap. The objective of this scoping review was to map the literature on the challenges, coping responses and supportive interventions for international and migrant nursing students in academic institutions in major host countries with a gender lens.

Methods

A scoping review is commonly used to explore and summarize what is known on a particular topic [46]. This methodology was therefore selected since our goal was to describe what is known about gender and foreign-born nursing students’ experiences and supportive interventions across a broad array of existing literature while applying a gender lens. We used the Joanna Briggs Institute (JBI) methodology for scoping reviews to guide our approach [46].

Search strategy

We consulted a university librarian to assist us in selecting the databases and in developing the search strategies. We searched 10 electronic databases including CINAHL, Embase, Cochrane, Medline, Web of Science, the Joanna-Briggs institute EBP database, Psych-Info, Eric, Sociological abstracts and ProQuest. Search terms (subject headings/descriptors, keywords) included those related to international and migrant students and to nursing education; the strategy was adapted for each database and the AND/OR Boolean operators were applied accordingly. Keywords were searched in the titles, abstracts, keywords and subject fields. No language or time restrictions were applied. In order to refine the searches and adjust them for the various platforms, we first conducted test searches in two databases (CINAHL and Medline). An example of one of the search strategies (CINAHL) is presented in Table 1. Additional papers were identified through the examination of the reference lists of literature review papers that met the inclusion criteria.

Table 1 CINAHL search strategy^a

Literature selection

We included peer-reviewed research (qualitative, quantitative or mixed methods), discussion papers and literature reviews. Study protocols, abstracts, books and dissertations/theses were excluded. English, French, and Spanish publications were considered. Literature was included if it discussed or reported on challenges, coping responses and/or supportive interventions for foreign-born students studying in an academic nursing program in Canada, the US, Australia, New Zealand or a European country (i.e., high-income countries according to the Organisation for Economic Co-operation and Development that receive large numbers of migrants and international students and that have similar sociocultural norms and political systems) [47]. Challenges were defined as any difficulties experienced by the students; coping responses referred to any strategies that were used by the students to help overcome, minimize or tolerate challenges; while supportive interventions were policies, programs, or strategies meant to address challenges, enhance coping and improve students’ overall experiences. Challenges, coping and/or interventions could have been examined from the perspective of students and/or educators and administrators or could have just been described and discussed generally. Papers that reported on the evaluation or testing of an intervention were also included.

‘International students’ were defined as individuals with student visas but excluding exchange students and those completing only part of their degree abroad. ‘Migrant students’ were defined as individuals born in another country who moved with the intention of resettling in the new country; this includes immigrants, refugees, and asylum-seekers (i.e., individuals in the process of making a refugee claim) who could have migrated as children or as adults (second generation migrants were excluded). We included literature that focused on ‘English-as a second/additional-language’ (ESL/EAL) students without specifying the countries of origin, since foreign-born students often comprise a significant proportion of ESL/EAL students. Papers that focused on ‘minority’ or non-traditional nursing students were also kept if foreign-born or ESL/EAL students were clearly included and there were results and/or implications specific to this population. Similarly, if a paper included or discussed nursing students generally, it was retained if there were study results and/or implications relevant to foreign-born or ESL/EAL students. Literature that included internationally-trained nurses was considered if the nurses were studying in an academic nursing program; we excluded papers that examined internationally-trained nurses who were completing a transition/integration program.

Lastly, ‘Academic nursing program’ was defined as any program leading to a post-secondary degree including college/vocational, bachelor and graduate degrees in nursing. Papers that studied or discussed students from other healthcare disciplines were only kept if there were results and/or implications that referred to nursing students. Papers could have pertained to students in the context of clinical, theoretical and/or research education and training.

The database searches yielded 8269 records (see Additional file 1 for the search results by database). All citations were downloaded and managed using Endnote. We first removed duplicates and then screened titles to remove citations that clearly did not meet the inclusion/exclusion criteria. We then reviewed abstracts to further eliminate papers that did not meet all of the criteria. For the remaining citations we retrieved and reviewed the full-texts (n = 266) in order to confirm eligibility. The screening and selection process was led by KPV and supported by LM and BV via ongoing discussions to ensure that the criteria were being correctly and consistently applied. Articles at this step were mainly excluded because they did not have results and/or implications specific to foreign-born/ESL/EAL students or to nursing students (i.e., all healthcare professionals were examined and discussed together), or because they were theses/dissertations or descriptions of nursing programs that were intended to be advertisements to recruit new students. When there was uncertainty regarding the eligibility of an article, LM independently reviewed it and a decision on whether to include it was made through joint discussion with the other authors. Twenty-three additional papers were identified by examining the reference lists of included review papers. LM read all of the papers and confirmed the final selection (see Fig. 1 for the PRISMA flow diagram).

Fig. 1

PRISMA Flow diagram. Moher D, Liberati A, Tetzlaff J, Altman DG, Prisma Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS medicine. 2009 Jul 21;6 (7):e1000097

Data extraction, analysis and synthesis

For all eligible papers, we extracted and stored data in an excel file including: 1) paper characteristics (publication type, year, and language); and 2) study/review/discussion paper information. For the latter this included the paper objective, the location(s) of the study/discussion/review, the foreign-born student population(s) of interest in the paper (international students and/or migrants and their countries/regions of origin and length of time in the country; for migrants we also sought information on immigration status), the educational context, whether or not the perspectives of educators and/or administrators were considered/discussed, and information on challenges, coping responses and supportive interventions. For studies, we also extracted information on the research design and data collection methods, and for reviews, we recorded the type of review conducted, the number and type of sources (e.g., articles, books), and the process used to identify sources.

To address the review objective, we critically assessed each paper and recorded information related to gender. To do this, we drew on existing frameworks used to conduct gender analyses in health research [48, 49] and LM and BV developed key questions to help guide the assessment. These included the following:

• Was sex included or addressed by the authors/researchers?

• Was gender explicitly considered by the authors/researchers through use of a framework or lens?

• Was gender identity/sexual orientation included or addressed by the authors/researchers?

• Was sex and/or gender considered as a variable in analyses?

• Were findings and/or implications reported separately by sex and/or gender?

• Based on the results and/or discussion points of the papers:

  • Did sex or gender (appear to) play a role in the challenges experienced by students? For example, at the intersection of sex and gender such as roles within the family, cultural/religious conventions that dictate how men and women should behave, differential access to resources, and experiences of discrimination.

  • Did coping responses (appear to) differ by sex or gender?

  • Did interventions (appear to) consider gender roles, norms and expectations?

  • Did interventions (appear to) consider diversity in gender identities/sexual orientations?

KPV was responsible for extracting the paper characteristics and information; LM verified all data extraction. The assessment of papers for gender related information was conducted by two research assistants. To ensure consistency in the process, 20 papers were reviewed by both research assistants. LM independently assessed all papers. All information collected was collated and synthesized into summary tables and text.

Results

One hundred and fourteen articles were included in the scoping review. A summary of the literature is reported in Table 2. All of the papers were published in English, 12 were discussion papers, 20 were reviews and 82 were research studies. The publication period spanned 39 years (1981–2019) and just over a quarter of papers (n = 30, 26%) were published within the last 5 years. Two-thirds of the research were qualitative studies.

Table 2 Summary of the literature

Focus of the research, discussion papers and reviews

Twenty-two of the research papers primarily focused on highlighting challenges faced by foreign-born students; nine of these included the perspectives of educators (Table 2). Seventeen research papers aimed to identify or examine coping responses and factors that facilitated success among foreign-born students, while 24 papers generally explored students’ and/or educators’ experiences. Twelve research articles described and reported the findings of evaluations of support programs, courses or other strategies meant to support foreign-born/ESL/EAL students and seven other papers were intervention studies (including qualitative and quantitative), which mostly sought to help students’ overcome learning difficulties due to language barriers.

The discussion papers and reviews had similar foci (Table 2). Three discussion papers provided tips on how educators and institutions can support foreign-born/ESL/EAL students, five discussed challenges, implications and strategies to address these, and four other papers described programs, frameworks or approaches to promote the success of students. Among the 20 review papers, all but three included a mix of qualitative, quantitative and other types of literature and only three specifically named the type of review being conducted. Most (n = 12) aimed to synthesize the literature on foreign-born/ESL/EAL students’ challenges and support strategies for these students, while five were reviews of the literature of foreign-born/ESL/EAL students’ general experiences, and two focused on interventions including mobile applications to support ESL students’ learning, and programs to improve clinical placement outcomes of international students.

Locations, educational contexts and populations

The majority of the research (57%) was conducted in the United States; four studies were conducted in non-English speaking countries (Norway and Finland) (Table 3). All but three of the discussion papers, and one review were also specific to the United States context. Several of the research papers pertained to more than one level of education; overall bachelor or college level studies were included in 90%, and graduate level education in 42%, of studies (Table 3). Four discussion papers were limited to bachelor level, four were focused on graduate level, and four others were relevant to nursing education in general. The literature reviews tended to be non-specific, however one and two papers respectively focused on bachelor and doctorate level education. The clinical learning environment was mentioned in two-thirds of the research papers, although was the primary focus in 18% of the research (Table 3). The clinical context was also the main focus in six of the reviews.

Table 3 Characteristics of the research studies

Across the literature students were described using different terms including ‘foreign-born’, ‘ESL’, ‘EAL’, ‘culturally-and-linguistically diverse (CALD)’, ‘international students’, ‘non-English-speaking background’, ‘immigrants’, and ‘minority or non-traditional students’; in other instances, students were described based on their ethnic background or origin. Length of time in the host country was generally not highlighted; just over a third (34%) of studies with student participants mentioned some information on length of time. International students were the main population of focus in almost half of the studies (Table 3). Similarly, they were also the main focus in seven discussion papers and eight of the literature reviews. Thirteen studies, three discussion papers and one review focused specifically on migrants. The remaining literature examined a mix of international students and migrants or were non-specific in their description of the student population (i.e., described as foreign-born or ESL students).

For migrant students, migration history or status were not reported in the description of the participants in any of the research papers nor were they mentioned or discussed in the review and discussion papers. There were five studies however, that implied based on other sections of the paper that they may have included student participants with a refugee or difficult migration background (i.e., political unrest in their country) [57, 77, 84, 104]. Only one research paper explicitly mentioned students with a refugee background in the introduction and discussion sections [57].

In the research studies with student participants (n = 73), students were mainly from East Asia, Sub-Saharan Africa and South East Asia; top source countries in descending order, were China, Vietnam, the Philippines, Korea, India and Taiwan. Asian students (Taiwan = 1, India = 1, China = 1, and one unspecified) were also the population of interest in two discussion papers and two reviews. Instructors/educators were participants in 34% of studies (Table 3) and their perspectives were also explicitly mentioned in two of the literature reviews.

General overview of challenges, coping responses and supportive interventions

Language and communication barriers, including oral and written expression and comprehension, were the challenges highlighted most often in the literature [9, 17,18,19,20, 33, 34, 37, 42, 50,51,52,53, 55, 57,58,59,60,61,62,63,64,65, 67,68,69,70,71,72,73,74,75,76, 78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102,103,104,105,106,107,108,109,110,111,112,113, 115, 117,118,119,120,121,122,123, 125,126,127,128,129,130,131, 133, 134, 136, 139, 141,142,143, 145,146,147,148, 150,151,152,153,154]. Language and communication issues occur in academic and clinical settings as well as in social contexts. Learning nursing and medical terminology and colloquial expressions and adapting to a ‘low context communication’ style, were noted as particularly difficult. At the graduate level, academic writing was the major issue, including demonstrating critical analysis [71, 79, 80, 115, 130, 146, 148].

Cultural barriers were also frequently noted [9, 17,18,19,20, 34, 42, 51,52,53,54,55,56, 59, 63, 64, 67, 68, 71, 73,74,75,76,77, 79, 80, 82,83,84,85,86,87, 89, 96, 97, 100,101,102,103, 105,106,107, 111, 112, 115, 117, 119, 120, 122, 124, 125, 127, 129, 132, 136, 138, 139, 142, 143, 145, 147, 148, 150, 152,153,154]. These included, for example, divergent views regarding the role of nurses in patient care, and different styles of relating socially whether it be with friends or in care-provider-patient interactions. Difficulties with the supervisory-graduate student relationship were identified as well, as international students often expect structured guidance and for supervisors to be readily available to them based on the supervisory styles they have observed in their home countries [56, 80, 146]. The most apparent cultural challenges described were in the classroom milieu; a number of papers reported that foreign-born students struggle with ‘Western’ learning, teaching and evaluation methods (e.g., self-directed and interactive learning, critical analysis and debating). Self-guided learning and conducting independent research were particular concerns for doctoral students [56, 146]. All these issues are due to the fact that many foreign-born students come from cultures where teaching is primarily didactic, rote learning is encouraged and students are expected to be passive and to not question instructors. Educators and clinical preceptors are equally challenged in this dynamic and feel unable to assess whether students have understood content and instructions, especially when language barriers are significant [65, 74, 79, 94, 112, 126, 150]. In the clinical context this also raises concerns about patient safety [50, 74, 99, 112, 150]. Overall, educators/supervisors and preceptors expressed feeling that they have insufficient time and resources to adequately support foreign-born students [65, 74, 79, 94, 112, 126, 150].

In addition to cultural issues, foreign-born students also struggle with the unfamiliarity of the healthcare system and clinical setting [9, 19, 20, 37, 42, 65, 92, 96, 99, 100, 102, 112, 115, 129, 132, 146]. For graduate students, often they are unable to work clinically in the receiving-country and so they grapple in making links between the theory/research and practice. Regardless of the education level, for students who return to their home country post-graduation, the course content and skills learned, and for graduate students, the research conducted, are not always relevant and applicable to their context [53, 54, 75, 84, 85, 129, 148]. Conducting research internationally is also not always feasible due to a lack of funding and/or supervisory support abroad [148].

Other challenges experienced by foreign-born students included loneliness, social exclusion/isolation, discrimination, resettlement issues (e.g., immigration, housing), financial concerns and maintaining a work-life balance [9, 17,18,19,20, 33, 34, 37, 42, 52, 53, 55, 59, 65, 68, 71, 73,74,75, 77, 79, 80, 82,83,84, 87, 89, 91, 93,94,95,96,97, 100, 103, 105,106,107, 109, 111, 113, 115, 120,121,122,123, 127,128,129, 138, 139, 142, 143, 145,146,147,148, 150, 152,153,154]. Access to research funding, limited interaction with student peers and transitioning from a leadership role (held in their home country) to a student position, were challenges specifically noted by international graduate students [79, 80, 148]. Feeling inadequately prepared or overwhelmed and unable to optimize their skills upon return to the home country, were also highlighted as particular issues at the graduate level [56, 75, 79, 148]. Mental health problems, including stress, feeling pressure to succeed, depression, a loss of self-esteem, feelings of guilt (for leaving their families) and anxiety, were commonly reported across the literature irrespective of the level of education [9, 17,18,19,20, 33, 55, 65, 68, 71, 75, 76, 79, 80, 82, 84, 86, 89, 91, 93,94,95, 97, 98, 100, 102, 105, 106, 111, 112, 115, 117, 122, 126,127,128, 130, 134, 138, 139, 142, 143, 145, 146, 148, 152,153,154].

The main coping responses used by foreign-born nursing students to overcome challenges, included accessing support (emotional, practical and/or informational) from family and friends, especially student peers with a similar cultural or linguistic background, and staying focused and determined to succeed [18, 20, 34, 52,53,54, 66, 73, 76, 79,80,81,82, 89, 91, 93,94,95,96, 103, 105,106,107, 111, 115, 117, 121,122,123, 127,128,129,130, 141,142,143, 145, 146, 148, 151,152,153,154]. Maintaining their culture and values, but also accepting and being open to differences, were identified as coping mechanisms to deal with cultural barriers, while positive thinking and celebrating successes, were highlighted as ways that students boost their sense of self-worth and reduce stress [20, 34, 56, 64, 71, 73, 79, 80, 85, 89, 91, 93, 96, 107, 123, 127, 145, 152,153,154]. Numerous papers also reported that students use various strategies (e.g., asking for clarifications, using non-verbal communication, doing additional reading), and actively develop their skills, in order to gain confidence and overcome language and academic barriers [18, 20, 61, 71, 73, 75, 76, 80, 82, 84, 88, 90, 92, 93, 98, 99, 101, 103,104,105,106,107, 109, 111, 113, 115, 117, 120, 123, 127,128,129,130, 133, 146, 151,152,153].

There were several interventions that were described or suggested in the literature as being potentially helpful to foreign-born students (reported in Table 4); the vast majority of these were based on anecdotal evidence. At the structural level, it was recommended that institutions be actively committed, in the form of mission statements, action plans and dedicated resources, to cultivating an inclusive and equitable education environment [17, 20, 33, 37, 50, 51, 53, 63, 64, 68, 74, 79, 80, 82, 92, 94,95,96, 103, 106, 108, 110, 112, 113, 115, 117, 119,120,121, 125,126,127, 129, 132, 138, 139, 141, 145,146,147,148,149,150,151,152,153,154]. Equally noted was the importance of promoting diversity and fostering a sense of belonging [17, 37, 108, 127, 145, 146, 148, 151,152,153,154]. It was also recommended that educators and preceptors receive training to ensure that they are aware of the challenges that many foreign-born students encounter and to provide them strategies and tools for teaching a multi-lingual and culturally diverse student population [17, 18, 33, 34, 37, 50, 60, 63,64,65, 68, 71, 73,74,75,76,77,78,79,80,81,82,83,84,85, 87,88,89, 91,92,93,94,95,96, 103, 106,107,108, 111,112,113, 115, 117, 120, 121, 123, 125,126,127,128, 131, 138, 139, 141, 143, 145,146,147, 149,150,151,152,153,154]. It was also suggested that instructors have smaller classes, clinical groups and student-supervisory ratios, and more time allotted to devote to foreign-born students [20, 50, 51, 64, 65, 74, 79, 104, 108, 112, 120, 121, 127, 129, 139, 147, 149,150,151, 153].

Table 4 Summary of supportive interventions^a

According to the literature it may also be beneficial if students have more time to complete their degree, or if the program is adapted to better suit their needs (e.g., an additional session or qualifying year to take pre-requisites, a transition semester with courses modified to allow students to acclimate to their new environment, and/or extra clinical training) [37, 60, 71, 79, 102,103,104, 108, 126, 133, 138, 139, 148, 151, 153]. Screening students at the point of admission may also ensure that those who need supplementary support are identified immediately and referred without delay [34, 37, 73, 74, 79, 92,93,94, 108, 110, 113, 119, 125, 126, 131, 135, 138, 139, 143, 148, 149, 151, 152]. It was also suggested that offering a range of services and resources throughout the academic trajectory could aid students in overcoming a variety of challenges. These included orientation sessions to the institution and clinical settings, workshops to develop writing, critical analysis and test-taking skills, language courses (specific to nursing), writing/editing support (especially at the graduate level), tutoring services, practical assistance including access to financial aid, scholarships and research funding, social activities, peer support initiatives, a mentorship program and counselling/psychological services [9, 17,18,19,20, 33, 34, 37, 50,51,52,53, 55, 60, 61, 63,64,65, 68, 69, 71, 73,74,75,76,77, 79, 80, 82,83,84,85, 87,88,89, 92,93,94,95,96,97,98,99,100,101,102,103,104,105, 107,108,109,110, 113,114,115,116,117,118,119,120,121, 123, 125,126,127,128,129,130,131,132,133, 138, 139, 141,142,143, 145,146,147,148,149,150,151,152,153,154].

There were also a number of approaches at the curricular/instructor level that were proposed to help students overcome language and cultural barriers and to facilitate learning whether it be in a classroom, clinical or research supervisory context. For example, using audio-visual material, providing information and expectations in writing, giving frequent and detailed feedback, debriefing one on one with students, speaking more slowly and avoiding colloquial language, verifying understanding, using storytelling, audio-taping lectures, and providing more structured guidance (e.g., writing examples for assignments, standardized forms for clinical documentation) [9, 17, 18, 20, 33, 34, 37, 50,51,52, 60,61,62,63,64,65, 68, 69, 71, 73,74,75,76,77, 79,80,81,82,83,84,85, 87, 88, 90, 92,93,94,95, 98,99,100,101,102,103, 105,106,107,108, 110,111,112, 115, 120, 122,123,124,125,126,127,128,129,130,131, 136,137,138,139,140,141,142,143, 145,146,147,148,149,150,151,152,153,154]. Evaluations, including assignments and tests could also be modified to accommodate students, for example allowing more time to complete an exam or the opportunity to submit an initial draft of an assignment for feedback before submitting the final version that is to be graded [17, 34, 37, 60, 63, 64, 69, 73, 74, 76, 81, 84, 87, 93, 100, 104, 110, 111, 125, 127, 128, 139, 140, 143, 147, 151, 152]. Course content, evaluations, research topics and clinical experiences may also be adapted to make them more culturally relevant, particularly if students plan to return to work in their country of origin following their graduation [17, 34, 37, 60, 64, 65, 68, 71, 77, 87, 92, 93, 95, 111, 125, 127, 128, 131, 136, 139, 141,142,143, 145, 147, 148, 152, 154]. Equally emphasized was the importance to provide content and an opportunity to learn more about the host country’s healthcare system and approach to nursing practice [37, 63, 65, 74, 80, 82, 87, 92, 95, 115, 129, 136, 138, 140, 143, 152]. For doctoral students, offering leadership training and opportunities to network and develop their research identity and skills (e.g., conferences, student seminars, research groups, research activities like publishing, committees, joining professional organizations), were also deemed essential [65, 80, 146, 148, 149]. Lastly, to increase foreign-born students’ confidence and feelings of inclusion, it was recommended that instructors foster peer to peer learning and positive interactions between students, show interest in foreign-born students (know their name, relate to them on a personal and emotional level) and be encouraging and respectful [9, 17, 20, 33, 34, 37, 51,52,53, 55, 65, 69,70,71, 73,74,75, 79,80,81,82,83,84, 87,88,89,90,91, 93,94,95,96,97, 100, 103, 106, 107, 112, 113, 115, 117, 120,121,122,123,124,125, 127, 128, 130,131,132, 136, 138,139,140,141,142,143, 145,146,147,148,149,150,151,152,153,154].

Applying a gender lens

Gender was not explicitly used as a guiding framework or lens, nor was it defined, in any of the studies, literature reviews or discussion papers. Among the research papers that included student participants, 29% did not specify the sex of participants, and although male students were included in 59% of the research (Table 3), overall there were many more female participants compared to male participants across and within studies -over three quarters of the studies with both male and female participants clearly had more females than males. Other gender identities/sexual orientations (e.g., lesbian, gay, non-binary, transgender) were not identified or named in any of the study samples. One study, however, acknowledged that there was a lack of gender diversity among their participants [95].

Of all the studies that included both men and women, only one reported results for the foreign-born students by sex. This study, which examined predictors of success among a cohort of Saudi Arabian students enrolled in an accelerated bachelor program (a collaborative initiative between Saudi Arabia and a US University), showed that the mean graduating grade point average (GPA) varied among female students depending on whether or not they were married or had family present with them in the United States- i.e., single females and women who had no family in the US had lower GPAs compared to their respective counterparts, but these variations were not observed among the male students [66]. One other study and two reviews, which focused on ‘non-traditional students’, also reported results for male nurses, and reported that men tended to feel excluded and delegated to certain roles because of their gender, and felt they were stereotyped as being homosexual [37, 42, 70]. These findings however, did not pertain specifically to foreign-born/ESL/EAL students.

Four quantitative studies included sex as a variable in their analyses with foreign-born students. The study by Carty et al. (2007) showed that overall male students had a higher graduating GPA compared to their female counterparts. A study in Finland with international students found that female students were more likely than male students to perceive cultural diversity in the clinical placement as causing negative consequences, however there were no differences between men and women regarding their perceptions of the impacts of language barriers on their clinical training [109]. Another study, conducted in the US, found sex to not be predictive of attrition among ESL students studying in pre-licensure programs in the state of Texas [72]. Similarly, the fourth study found no association between sex and academic or clinical placement stress among international students studying nursing at the undergraduate level in programs across Australia [100].

With respect to challenges, we identified several papers that reported results and/or that discussed issues related to gender roles and expectations. In one study, conducted more than 30 years ago, a female student participant expressed that it was initially disconcerting, and that it required significant adaptation to come to terms with the idea that women should be assertive and outspoken when interacting with physicians [54]. Similarly, in another study, timidity and not wanting to speak up, was noted to be more challenging for female ESL students compared to male students [84]. In another older study, male students from Saudi Arabia who were studying in the US, found it challenging to have mixed-gender classes, to socialize with female students, to learn about women’s health and to care for female patients in the clinical setting, particularly hygiene and bathing (these same results were also highlighted in a review paper) [17, 64]. Likewise, in another US study (and review), Omani women found it challenging to adapt to openness between sexes, going out alone and independent decision-making [107, 153]. Similar findings were also shown in a study in the UK, where Middle-Eastern women who were completing a doctoral degree, reported finding it difficult to manage everything on their own as they were used to being surrounded by extended family and doing daily activities collectively; consequently these women also reported feeling very lonely [80].

Other difficulties related to gender norms and the mixing of men and women were also reported/discussed, including a hesitation among students to form friendships with the opposite sex because it was deemed inappropriate [81]; male students feeling uncomfortable receiving input or direction from female instructors [84]; female students feeling it is inappropriate to be in ‘intimate’ contact with patients [86]; and women finding it challenging to relate to their native-born female colleagues due to different value systems [97]. The review by Olson (2012) suggested that some female students may not be supported by family during their studies because male family members felt threatened by the possibility that their wives/daughters may earn more income than them [34]. One study also found that female international students more than male students, faced additional challenges professionally post-graduation, irrespective of whether or not they returned to their country of origin, and that these challenges were rooted in the divergent and conflictual cultural norms and expectations of women between the host country and country of origin [84]. Another study supported this notion as it found that international female students from Canada or Europe studying in the US seemed to have less difficulty adjusting to the US compared to other international students due to a greater resemblance in gender norms across the US, Canada and Europe [96].

Managing family/childcare and household responsibilities while studying, and feeling pressure to ascribe to a ‘traditional’ female role, were described as challenges for women in a number of papers [34, 74, 82, 83, 86, 102, 122, 152, 153]. In one study (but highlighted in four different papers), a woman reported significant stress due to her husband and in-laws who disapproved of her studying and who felt that she was a ‘bad wife and mother’ for pursuing her studies [34, 82, 83, 153]. Feeling guilty about leaving children behind also appeared to be a concern particularly affecting women [89, 128]. In contrast, a male student, in the study by Gardner (2005), reported feeling immense pressure to succeed, because he was recognized as a leader in his community in his home country and he felt he needed to return with a nursing degree so that he could help his community [83].

Perceived discrimination was noted in four papers; in one (a research study), an instructor participant reported that a student had shared with her that a patient had said that he did not like the student because the student was ‘a man and foreign’ [74]. In another study, women reported discrimination due to wearing a hijab and being Arab [115]. This latter issue was further highlighted in two review papers [145, 153].

Nursing being perceived as a feminine profession and low status employment was also highlighted as an issue. In one study, a male student participant shared that he felt that his father had concerns about him pursuing nursing as a profession because of his gender [76]. In another study, women from non-English speaking background cultures reported not being supported by their family to pursue their studies in nursing as the profession was deemed to be the type of work that is only done by “loose women or prostitutes” [86].

We did not identify many results or discussion points related to gender and coping. One recent US study, suggests that female students who were mothers found mutual understanding and support from other female students who also had children [76]. Extended family support also seems to be source of help for female students who are trying to balance studying with home/family obligations [34]; in one study a student sent her child to India to be cared for while she completed her studies; providing a better life for her daughter was also a motivating factor that kept her going [83]. Family back home, calling male family members, was also identified as a source of support for the Omani nursing students in the US who were not used to being alone and who found making decisions on their own, challenging [107]. Although not a coping mechanism per se, a number of papers also mentioned that female international students had increased confidence over time and enjoyed the new independence that they had gained while living and studying in the host country [75, 80, 101, 115, 128, 153].

A handful of papers made reference to gender in relation to supportive interventions. One study described a female educator calling on a male colleague to intervene with a male international student on a sensitive topic in order to make the student more comfortable since he was from a cultural background where women usually do not have authoritative roles [84]. Sending letters or involving family members in the orientation was recommended in one study and two reviews, as an approach to enhance family support and understanding for female students who face challenges balancing their studies with family and household responsibilities [34, 83, 152]. Similarly, including fathers and husbands in the admission process was a strategy described in the paper by Robinson et al. (2006) to ensure support for Indian women who wished to pursue their studies in an American university [138]. In the same paper, female applicants were interviewed by women during the recruitment process, and gender dynamics (in reference to male dominance) was considered when pairing female students with community supports once arrived in the US [138]. Matching advisors and international students by sex was also discussed in the paper by Thompson (2012) as an approach to promote comfort for students who are not used to receiving advice from or confiding in someone of the opposite sex [141]. In the study by King et al. (2017), a standardized simulation patient was used as a method to give EAL students an opportunity to get used to providing care to patients of the opposite sex [101]. And avoiding gender bias when presenting exemplars, was given as teaching tip when teaching international students, in the paper by Henderson (2016), [136].

Lastly, gender identity/sexual orientation was not considered or highlighted in any of the results or discussions related to challenges, coping responses or interventions across the literature. The review by Greene et al. (2012) which outlines strategies for promoting the success of international students, however, recommended that students be exposed to and learn how to care for patients with different backgrounds, including different sexual orientations, although no details were provided on how this should be done [33]. The review by Koch et al. (2015) also reported on the clinical placement experiences of lesbian, gay, bisexual, transgender and queer/questioning (LGBTQ) nursing students, but this was for nursing students in general and not specific to foreign-born/ESL/EAL students [42]. The review highlighted that overall there is very little known about the experiences of LGBTQ nursing students.

Discussion

Overall, the literature mostly reflects women’s experiences, there was less focus on men, and students who identify as other genders/sexual orientations were not visible in the research and discussions. Our review shows that international and migrant nursing students face a number of challenges associated with different cultural roles, norms and expectations for men and women; other challenges included perceived discrimination, and in general nursing being viewed as a feminine, low-status profession. We only identified a couple of strategies, accessing support from family and other student mothers, used specifically by female students to cope with some of the challenges associated with gender roles and norms, and we found nothing regarding men’s coping responses. Supportive interventions that considered gender were limited; these included matching students with support persons and advisors by sex, involving male family members in admission and orientation processes, and using patient simulation as a method to prepare students for care-provision of patients of the opposite-sex. Taken together, the results reveal that sex, gender and gender identity/sexual orientation have been under examined and discussed in the literature on international and migrant nursing students in academic institutions in major host countries.

Equity, diversity and inclusion (EDI) are fundamental to the nursing profession and its practice as nurses interface with individuals, families and communities in very intimate ways (physically, psychologically, socially and spiritually/existentially) and during the most vulnerable moments of life, which are greatly influenced by one’s social group memberships/identities such as gender, culture, religion, ethnicity and sexuality. Therefore in order to promote the health and well-being for all, nurses must be prepared to respond to the needs of diverse populations and to provide care that is safe and that addresses inequities. It also requires a workforce that reflects the population demographics. Despite there being a movement towards inclusivity, the profession, however, remains predominantly Caucasian (in high-income countries) and heteronormative, especially at the leadership levels, and gender and gender identity/sexual orientation discrimination are still prevalent [39, 155,156,157,158]. Rectifying this problem begins with nursing education programs that are inclusive, fair, and that celebrate diversity within the curriculum, and among the student, faculty and administrative bodies. EDI are currently top priority for many academic institutions in major migrant/international student receiving-countries [159,160,161]. Many have developed strategic plans and have a mandate to implement strategies to reduce discrimination and bias and create more respectful learning environments where the presence and expression of differences are valued and supported and everyone feels they belong and can thrive. Gender issues in higher education and the need for gender-sensitive interventions at the structural and curricular levels in order to attract and retain students, have been identified in both the nursing and international education literature, respectively [25, 30, 31, 36, 162,163,164]; more recently, there has also been greater attention given to gender identity/sexual orientation [40, 41, 43, 45, 165]. To further develop EDI best practices, and to advance the profession and practice, future research and discussion papers in nursing higher education must also address the intersections of gender, gender identity/sexual orientation and foreign-born status.

The review also highlights that a variety of terms have been used in the literature to describe foreign-born students, and that although migrant students have been included to some extent, the role of migration history/status and length of time in country have not been considered, making it difficult to tease out information about groups in more vulnerable contexts. More recently-arrived migrants are more likely compared to more established migrants to experience cultural barriers, be unfamiliar with a host country’s systems and have difficulty accessing services. Many refugees and asylum-seekers have experienced trauma and difficult migration trajectories that can exacerbate mental health issues and further complicate adjustment to a new academic environment [166,167,168]. Refugees and asylum-seekers are also more likely compared to other migrants and international students to have experienced disruptions in their education and to face language barriers and social-economic disadvantages during resettlement [166,167,168]. They are also more likely to experience family separation and may feel greater pressure to succeed especially if family members in the home country are financially dependent on them. Asylum-seekers also are commonly excluded from social programs and have the added strain of not knowing what their future holds. Therefore to have a more nuanced understanding of foreign-born nursing students’ challenges and coping responses, and to better identify supportive interventions, future work should take into account not only gender and gender identity/sexual orientation, but also the migration context (status and length of time), which should be clearly defined [41, 169,170,171,172].

The results of the review show that generally there is an abundance written on supportive interventions for foreign-born nursing students in academic institutions, however it remains mostly descriptive and anecdotal. The results raise a number of questions regarding the specifics on how institutions and educators can best be supportive. For example, language and communication remain significant issues yet it is unclear what level of language ability should be required upon admission- high level requirements restrict access while a low level requirement puts undue stress on students, particularly since nursing requires knowledge of specific terminology. Likewise, to what extent should educators adapt teaching approaches and evaluations to facilitate adjustment to the new academic milieu and how can educators effectively provide emotional support whilst maintaining their professional stance? Furthermore, what should the role of institutions be in ensuring that foreign-born students are adequately prepared for work post-graduation, whether they stay in the host country or decide to return to their country of origin, especially when increasingly these institutions are integrating notions of EDI in their mandates? For example, should institutions provide additional support to prepare foreign-born students for the licensure exam in the host country? Alternatively, should institutions provide training within the program that is relevant to international students’ country of origin context and/or provide re-entry programs prior to students’ return home? It would be timely to also study and debate these broader questions related to supportive interventions.

Limitations and strengths

We purposely chose to not use ‘gender’, ‘gender identity’ or related terms in our search strategy so that our search would be broad, however, this exclusion may have contributed to missing some literature. We did not include grey literature, which may explain the lack of language diversity (French and Spanish publications), and consequently the small number of papers on students’ experiences in non-English speaking host countries. Due to the scoping nature of the review we did not closely analyze or report on the evidence related to the identified challenges, coping responses and supportive interventions (e.g., prevalence of challenges, evaluations of interventions). We also did not report on the overall benefits or positive experiences of foreign-born nursing students, which would have been informative. Nevertheless, the review was very thorough and provides a comprehensive overview with a gender lens, of the challenges, coping strategies and supportive interventions that have been studied and discussed over a 39 year period. The results also highlight gaps in the literature, especially with regards to gender.

Future research

Future research on challenges, coping responses and supportive interventions for international and migrant students in academic nursing programs in major host countries, should include sex and gender-based analyses; an intersectionality-based approach, including gender, gender identity/sexual orientation, migration/international status and context, as well as other identity markers (e.g., race, religion) is warranted. Additional reviews on existing gender and gender-identity/sexual orientation sensitive interventions in nursing/healthcare education in general, and for foreign-born students across a variety of disciplines, would also be informative. Overall, more studies that test and evaluate supportive interventions for international and migrant nursing students, at both the structural and curricular levels are needed; a systematic review would be useful as well to provide a better evidence base for academic institutions to draw from. Since most of the literature to date has focused on the US context, and much more has been written on undergraduate students, more research in non-English speaking countries, and with graduate students, especially at the doctoral level, would also be worthwhile.

Conclusion

The literature on the challenges, coping responses and supportive interventions for international and migrant students in academic nursing programs in major host countries, has significant gaps with regards to how it addresses the contributions and consequences of sex, gender and gender identity/sexual orientation related experiences. To draw and retain a diversity of candidates to the nursing profession, and to create more inclusive and equitable learning environments, future work, especially with respect to supportive interventions, needs to address the intersections of gender, gender identity/sexual orientation and foreign-born status, and also consider the complexity of migrant students’ contexts.