Table 4 Summary of supportive interventions^a

Institutional level policies and general support

 Hold a pre-admission meeting or interview or request a taped personal statement

 Accept a group of students from the same country as a cohort

 Provide information pre-departure (what to expect, what to bring...) / have a dedicated website

 Initiate mentorship/advisor relationship prior to arrival

 Have a more intensive screening process to identify students who will require additional support / develop and apply strict criteria (language, academic...) for acceptance (especially if support for students with language barriers is limited)

 Have an orientation at the beginning of the program (include social and cultural sensitization, raise their awareness to challenges that they will face, provide information about available resources)/provide ongoing information sessions throughout the program

 Send information letters and/or invite students’ families to orientation to inform them of intensity of the program

 Create a handbook, fact sheet or brochures with information about the program, expectations and practical information

 Provide practical assistance with resettling (administrative and immigration support, finding lodging, healthcare, and transportation etc.) / link students with a host family / provide living accommodations / refer to cultural community supports

 Offer childcare for students with children

 Provide financial assistance or scholarships/ inform and support students’ applications for scholarships and studentships

 Create and encourage work or volunteering opportunities (in a healthcare setting, research) /offer work-study initiatives

 Support applications for a range of different research funding (international funding sources)

 Have a designated liaison person or persons for migrant and international students (a paid position or faculty member with release time)(who speaks the students’ maternal languages)

 Have student advisors who meet regularly one on one with students

 Offer courses and services for language training (prior to beginning the program and ongoing services throughout) / have a dedicated course that is integrated into the program/ create opportunities for practicing inside and outside of the classroom and clinical environment / use other strategies (e.g., intensive language drills, role plays, flash cards with terminology, encourage students to listen to tapes, provide feedback on language pronunciation, spelling of words, encourage students to develop a vocabulary journal, use online resources)/ hire language specialists / monitor language development

 Provide tutoring and academic support services

 Provide workshops / additional courses (e.g., on note taking, to develop technology and computer skills, on test taking, critical thinking, assertiveness and communication, quantitative reasoning, how to participate in study groups, time management, studying, writing and formatting, e.g., APA, publishing, plagiarism)

 Provide writing support (editing/proofreading)

 Pair foreign-born students host country students to practice language / give guidance

 Create and encourage participation in student study groups (with a mix of students)

 Provide a mentorship program with alumni

 Create student / community support groups /buddy program with peers

 Support students to maintain connection with family back home

 Provide counselling/ pastoral services (culturally matched) for discussing problems

 Provide psychological support to promote self-efficacy and empowerment; shift students’ locus of control from external to internal, encourage them to not dwell on small issues and to focus on the positive and successes, and promote students to be active in finding solutions (using resources, seeking support)

 Offer social activities /hold activities that celebrate cultural diversity /have events that include families

 Create associations and organizations on campus for students to get involved in / encourage involvement

 Have student spaces that promote sense of belonging and connection (e.g., student lounge, shared office space) / promote belongingness

 Have a designated prayer time and space in the institution/clinical environment / avoid religious holidays as due dates for assignments and exams

 Implement a strategy and have a mission statement and designated resources that promote inclusion and diversity

 Increase the diversity of the student and faculty body (including clinical instructors), especially as role models

 Use a newsletter and other modes of communication to give visibility on international/migrant students, and as medium for communicating information

 Provide training on racism for students and faculty

 Offer courses / learning for all students on cultural diversity / competency /include international placements for students

 Ensure institutional support is available for educators/offer training to academic and clinical educators to raise awareness on students’ challenges and on how to address needs of students /create structures for clinical sites and academic institutions to work closely together to create inclusive and supportive environments/dedicate funding for the creation of structures and resources

 Foster a team approach between colleagues for supporting students / encourage educators to collaborate with support services

 Offer cross-cultural communication workshops and discussions with educators /encourage educators to visit and get to know different communities

 Create a forum where educators and students can meet and exchange regularly on student issues

 Encourage and support educators to visit the countries of origin of students (to raise awareness of care context, care practices and common illnesses; build research network)

 Invite nurse leaders from abroad to come give lectures/ presentations

 Establish and maintain a network with students post- graduation / use network for developing international placements for local students

 Gather data on diversity indicators (use well defined variables to capture specifics, e.g., international students vs. students with English as an additional language) and outcomes

 Provide (additional) support to help students prepare for licensure exams, career planning or more education / provide support to help students integrate post-graduation

 Offer a ‘reintegration’ seminar to support students to deal with conflicts that they may face when they go back to their home country

 Hold a career day (to promote perseverance in the program and to support career planning)

 Survey students to assess their needs / assess students’ satisfaction with services and resources

Teaching and research training

 Require students to take pre-requisite courses before officially starting the program / have a qualifying session (‘visiting student’ status)/ offer transition courses /provide additional time to complete the program / adapt the program

 Offer a flexible course schedule (evenings)

 Adapt courses so that students can maintain a work-life balance

 Offer smaller classes / adjust supervisor-student ratios for graduate supervision (fewer students per supervisor)

 Speak more slowly when giving lectures, structure the content, avoid abbreviations or explain them, avoid idioms, give handouts, provide information in writing, use audio and visual supports when presenting material, review and repeat key elements with opportunity to ask questions and discuss

 Review course content for cultural biases

 Provide students with real situations taken from nursing practice and use storytelling to provide more context/ provide more instruction on the healthcare system / base assignments on clinical experiences / provide experiential learning activities or community projects/ explain culturally bound concepts

 Use a variety of teaching methods / adapt content to be more culturally relevant (e.g., present examples and assignments relevant to the student’s cultural community or country of origin)

 Engage students to share their (cultural) perspective in discussions / foster exchanges and learning between peers

 Organize course content so that students can adapt to the pace and style over time

 Provide more structured support and foster more self-directed learning over time (e.g., review students’ note taking and give feedback, give them guidance on how to identify important information) / make expectations very explicit

 Encourage students to ask questions / invite students to submit questions by writing

 Use clickers in class (provides opportunity to answer questions anonymously)

 Verify students’ understanding

 Challenge students (ask questions to push their thinking)

 Audio record classes (to practice listening to language and review material that may have been missed during class)

 Use concept maps to develop conceptual and language learning

 Use group work to foster peer learning (mix stronger and weaker students/ mix students with different backgrounds and experiences)

 Use oral presentations to develop language skills (in a supportive environment) /let students with language barriers present after other students so that they have a model to work from/ use the pair share approach (let each student present to another student or in small groups and build up to larger groups over time) /allow additional time for preparation of presentations

 Have writing assignments that require personal reflections and opinions / encourage journal writing (to promote writing and expressing own ideas)

 Provide writing examples for assignments

 Provide frequent and detailed feedback to students

 Provide additional time for test-taking (reduce over time as students become progressively stronger in language) / offer a different environment for test-taking (to reduce anxiety)

 Provide an opportunity to practice test-taking

 Ensure tests are written in clear, grammatically correct English (host-country language) / provide synonyms for terms that may not be easily understood / avoid culturally bound language

 Allow dictionaries or translators during tests / encourage the use of dictionaries when writing assignments

 Consider using different evaluation methods/ adjust tests and assignments and make them more complex over time (once students have developed language skills and have adapted to the pedagogical approach) / have more frequent smaller tests / allow more time to complete assignments/ don’t grade initial work, provide feedback and allow opportunity to revise

 Review tests and assignments with students

 Offer to meet with students one on one/ communicate frequently with students / have regular office hours

 Build self-esteem (give positive feedback, promote leadership, focus on strengths, create positive learning experiences, give feedback constructively and confidentially)

 For graduate students take time to discuss research topics and identify an area of focus/ allow students to choose a research focus that is relevant to their country of origin

 Provide research and learning activities according to the student’s needs (e.g., if they plan to return to their country provide activities relevant to the context in which they will work)

 Offer academic (online) resources that are relevant to their country/language

 Provide opportunities for professional development and academic networking (e.g., conferences, student seminars, research groups, research activities like publishing, committees, joining professional organizations)

 Provide leadership training

Clinical training

 Offer information sessions prior to clinical placements including social and cultural aspects / provide a full day orientation with a clinical preceptor / hold an ‘initiation clinical experience’/ discuss issues that may be culturally different or different than nursing in their country (e.g., roles of nurses)

 Offer a community placement experience as an opportunity to build and practice clinical communication (to build language and culture skills)

 Make the clinical environment welcoming (staff, patients)

 Create a network to support clinical learning

 Provide clinical mentors for students / use role modeling

 Adjust the pace and allot additional time to complete clinical training/ provide additional learning opportunities (e.g., practice clinical skills, give more verbal reports, expose students to situations they may not have experienced in their country) / offer an additional course to support clinical learning/provide more hands-on learning

 Have smaller clinical groups / mix groups to foster peer learning / use a team approach to supervise and provide feedback and learning opportunities / assign the same nurse preceptor so a relationship can build over time / ensure adequate release time for nurses providing clinical instruction or supervision

 Provide more verbal and written feedback on clinical performance / debrief regularly with students

 Before students perform clinical tasks verify their understanding using the teach back method

 Provide structured guidance (e.g., provide written protocols, a standardized form to facilitate documentation, and a list of questions for engaging with patients) / speak slowly and repeat during clinical instruction / review clinical documentation and provide detailed feedback

 Be attentive to situations that make students uncomfortable due to cultural differences and adjust activities to allow students time to adapt (to reduce anxiety) / adjust timing of clinical rotation to allow time to develop communication skills first / offer opportunities to build confidence (e.g., match with patients with same language, allow students to demonstrate skills learned from their country origin)

 Ask students to complete a health education assignment whereby they teach something about their country or culture to the clinical staff (to practice teaching and to share their culture and to promote their contribution) / ask students to draw on cultural experiences to gain insight on patient health problems

 Have more assignments that involve clinical documentation

 For students who cannot do clinical placements provide simulation activities

Teaching, clinical or research

 Be supportive and understanding of students’ situation / be respectful / avoid stereotyping /advocate for students

 Make students feel that they are important/know their names and how to pronounce it, ask students how they are doing, ask them their needs, offer assistance and refer to services, take interest and make them feel valued, relate in personal and informal ways

Other specific interventions identified in the literature

 Linguistic modification (simplification of language to ease reading load and to increase comprehension) of written material [34, 58]

 Course for students to enhance assertiveness, communication and information gathering during clinical interactions and to help students understand and navigate cultural differences [57, 143]

 Support program to help with academic, communication and relational challenges (a series of workshops that include interactive delivery, activities in small groups and the use of video clips, reflective feedback sessions, and open discussions; also includes support for faculty) [59]

 English language program to address communication challenges [61]

 Enhanced language instruction (workshops to promote oral and written comprehension and expression) [62]

 A full semester transition course to develop clinical and communication skills and to adapt to the new clinical context [67]

 PowerPoint learning modules for faculty about barriers experienced by students, strategies to increase cultural competency, strategies to help students overcome language barriers, and strategies to promote academic success [87]

 Intensive individual or group tutoring to practice listening, recording, and transmitting clinical information (to overcome language barriers) [88]

 Clinical coaching / a Clinical Communication Programme (a tool to assist students to understand and apply professional clinical language and jargon common to the clinical environment and to be able to document accurately and to be computer literate) [18, 99]

 Standardized patient simulation to foster a supportive and contextually rich environment for nursing student learning (to practice language, to practice skills, to debrief in a safe space) [101]

 Clinically-speaking workshop (an intensive workshop on clinical communication) Clinically speaking online clinical language resources (a podcast which serves as an audiovisual terminology resource; a vodcast which provides examples of models of nursing interactions in typical clinical scenarios) [20, 109, 116, 119, 120, 149, 150]

 An English for specific purposes (ESP) program to develop English proficiency for academic studies and clinical placements: includes a face-to-face course (writing and proofreading, note-taking, colloquial language, speaking skills, medical terminology, clinical assessments and handovers, intensive language training); support to educators in class and for developing teaching and assessment materials and for giving feedback/support to students; online resources (reading, listening and writing, social/cultural, vocabulary, speaking/pronunciation) [110]

 An intensive, embedded academic support workshop [118]

 A scaffolded small group work intervention to enhance learning for both international and domestic students [124]

 English as an Additional Language support program (mentorship, one on one support, referrals, workshops, and social connection) [132]

 A bridging program for internationally trained nurses to integrate into a fast-tracked bachelor/graduate program (focuses on language development, cultural adaptation, exposure to clinical context/job-shadowing, and theoretical knowledge) [133, 138]

 International partnerships / alliances [64, 138, 139]

 Mobile application for language learning and support (to look up terminology, for communication with instructor during clinical, practice exercises, to listen to podcasts for practicing language, a dictionary, and translation software) [144]