In 1981, the World Health Organization adopted a goal of health for all by the year 2000. The concerted efforts of many health disciplines will be necessary to meet this goal. However, an adequate supply of skilled nurse leaders in all countries in the world will be a critical component in its achievement. One way for nursing leaders in the U.S. to help reach this goal is to provide educational opportunities for nurses from other countries.
Over the last decade, the number of foreign students enrolled in health science programs in the U.S., including nursing, has increased over 10% (Zikopoulos, 1990). There is concern, however, that while there has been a steady increase in the number of foreign nurses coming to the U.S. to obtain advanced degrees, they often do not know which nursing programs are best suited to their educational needs or what support services are available to assist them with temporary relocation in the U.S. At the same time, schools of nursing are often unclear about how to ensure a match between the needs and interests of foreign students and the expertise of the faculty. Further, the diversity of state nursing licensure regulations and schools of nursing admission criteria create confusion and can act as barriers to international students' advanced study.
Some schools may also be unaware of the support these students need in the broader educational environment in order to cope. Loneliness and isolation are two particular difficulties that foreign students encounter when they enter the U.S. to study. They are far from cultural peers and family; familiar social customs, food, and transportation; and many aspects of the educational environment are often vastly different from their native country. Interactions are strange and often seem incomprehensible. There is a sense of disorientation, frequently followed by nostalgic idealization of the home country, which only increases the feelings of isolation and loneliness (Kayser-Jones & Abu-Saad, 1982).
Students who undertake study in the U.S. are, on the whole, a physically and psychologically healthy population. However, when studying abroad, students face extraordinary life changes as a result of temporary relocation to a new country. The dimensions of cultural and geographic change added to personal, social, familial, and financial stressors predispose them to a greater likelihood of illness (Sennhauser, 1985).
Few studies have specifically examined the difficulties that foreign nursing students encounter when coming to the U.S. The most recent study, conducted in 1980 among 82 foreign nurse students by Abu-Saad, Kayser-Jones, and Tien (1982) and Abu-Saad and Kayser-Jones (1981) identified language problems as causing the most difficulty for foreign nurses. Understanding and speaking English were more problematic than reading. Similarly, the Commission on Graduates of Foreign Nursing Schools (CGFNS) has reported that only 61% of those taking the CGFNS examination for the first time passed the English portion of the test; worse still, only 33.4% passed the nursing portion (CGFNS, 1986, 1988).
Almost no data have been collected from schools of nursing in regard to the difficulties they encounter in working with foreign nurses or the strategies they use to assist foreign nurses in adjusting to the U.S. culture in order to maximize the value of their educational experiences. The study reported here was designed to fill some of these gaps in our information about the experience of foreign students in U.S. schools of nursing.
The study was designed to gather information on how foreign nurses learn about various schools in the U.S., the type of programs in which they enroll, the barriers they encounter when coming to the U.S. to study, and to identify strategies that schools of nursing are using to manage the educational and cultural challenges posed by international students.
Two survey instruments were developed to gather data. As a basis for developing the questions, nursing faculty and international nursing students were interviewed to identify areas of concern and information that might be useful in helping international students adjust to study in the U.S. Prior to pilot testing the instruments, faculty reviewed them to establish content validity. A small group of international non-nursing students and faculty members then pilot tested both instruments. On the basis of their comments, the instruments were revised, discussed with faculty who were content experts, revised again, and then mailed to all NLN-accredited schools of nursing with both master's and doctoral programs (N =45) and all schools with master's programs only who had enrollments of 100 or more students (N= 39). Each school was asked to complete the School Questionnaire Form and distribute three copies of the form to international students at their school. Questionnaires were accompanied by a cover letter and stamped, self-addressed envelopes; confidentiality and anonymity of participants were assured.
Twenty-seven (60%) of the schools with both doctoral and master's programs completed the survey and 18 (46%) of the schools with master's programs responded for an overall response rate of 53%. Completed school survey forms came from 24 different states across the U.S., as shown in Figure 1. Only eight states that had programs meeting the inclusion criteria were not represented in the returned questionnaires. Eighteen of the 26 responding schools with both master's and doctoral programs were state-supported universities, while eight were private institutions. Of the schools with only master's programs, 10 were statesupported institutions and eight were private colleges or universities (Figure 1)
A total of 239 foreign students, from 49 different countries, were enrolled in the 45 schools in the study. Students from Asia accounted for almost 50% of the total. Although most students were enrolled in either a master's or doctoral program, foreign students in these schools also were enrolled in undergraduate nursing programs, as well as short-term non-degree programs; some were visiting scholars.
Foreign Nurse Characteristics
Of 252 international students surveyed, 83 responded, resulting in a 33% response rate for students. There were 76 female and 7 male students among respondents; their average age was 33.4 (range = 22-50, SD = 6.3). Of these students, 40 were married, 40 were single, and 3 gave no response to the question. Half (42) of the students were from Asia, while 18 were from Western Europe, Canada, or Australia, 8 were from the Middle East, 7 from Africa, and 3 from Hispanic countries; 5 gave no information on origin. Respondents said they had been in the U.S. an average of 26.5 months (SD = 30.8 months), although length of stay ranged from 1 to 240 months depending on the type of program in which the students were enrolled, whether a reduced course load was taken, or whether remedial courses were necessary (Table 1).
Sixty-two (77.5%) students had completed their basic nursing education in their home country, while 6 indicated that basic nursing was completed in the U.S., and 3 (3.8%) in a country other than their home country or the U.S. Thirteen students had not yet completed basic nursing requirements. Of the 83 students who responded to the survey, 37 (44.6%) were currently pursuing a masters degree, 28 (33.7%) a doctoral degree, and 13 (15.7%) a bachelor's degree; the remaining 5 (6.0%) were non-degree students.
Students indicated that their decision on where to study was influenced by a variety of sources; 17% said friends had influenced their choice, 13% were influenced by the literature provided by the U.S. schools, 11% by one of thenteachers, and 6% by a visit from a U.S. professor; the remainder reported being influenced by other persons or written materials. Respondents said that it had taken an average of 11.9 months (SD = 20.8) to process their applications for admission to the school of nursing in which they were currently enrolled.
Barriers these nurses encountered after coming to the U.S. to study are shown in Table 2. The greatest difficulties were in English language barriers, financing, getting information about programs of study, and problems in housing. Students obtained several types of visas, although the majority obtained either an Fl student visa or a Jl exchange visa.
Obtaining adequate financing was identified as the greatest barrier to coming to study in the U.S. Table 3 lists the sources of financial support that students used for study in the U.S. Although students had multiple sources of financing, self and family were mentioned most frequently.
Forty of the 45 schools reported that they had an office of international student affairs on campus. However, only 10 actively recruited foreign students into their program. Recruitment methods included professional presentations, advertising, personal contact, and sister school contact.
State licensure was required by 27 (67.5%) of the schools before foreign students could take master's courses. Only 10 (24.4%) schools required state licensure for enrollment in doctoral level courses.
Indeed, almost all schools indicated that foreign nurses needed help with English, their academic program, enculturation, housing, finances, and social activities (Table 2). The strategies used by schools to provide needed assistance are shown in Figure 2. While help in learning English was identified as the area of greatest need, only four schools stated they provided language assistance.
Overall, students and schools identified somewhat different areas as problematic. However, speaking and understanding English was the problem most frequently identified by both students and schools of nursing, as shown in Table 2.
It is notable that the schools in this study reported enrolling students from 49 différent countries. Most nurse educators working with international students are generally aware of the difficulties of foreign students. In this study, there was considerable agreement among school respondents about the areas in which students required most help. It is imperative, however, to recognize the cultural differences between students and to recognize differing professional and personal goals, professional experiences and education, language, and personality characteristics (Gosnell, 1985; Leone, 1982).
Financial Sources for Study in the U.S.
Some students come to the U.S. because they show outstanding academic promise and are under a governmental grant, scholarship, or fellowship program. Most international students' families, however, have contributed a great deal to help them come to the U.S., as was apparent both in this study and in the study by Abu-Saad and Kayser-Jones (1981). Further, U.S. immigration regulations prohibit international students from working off campus without permission, which increases their financial dependence. Thus, away from home, these students are more dependent, both emotionally and financially, on their families than U.S. students. International students are thus under considerable pressure to succeed academically, both to honor their families and to make the investment of their government or employer worth it. Most students also have high expectations for themselves. Academic failure, even in a single course, brings considerable shame, and if a student must return home without completing her or his objectives, the shame is very great. Careful explanations of program requirements and possible extensions before students come to the U.S. may help them plan for such contingencies.
The culture shock experienced by international students can lead to social isolation and, in turn, intense loneliness and depression. Even if new friendships develop, they are frequently not intimate because of language or cultural barriers. Students may withdraw into their studies rather than make an attempt to get out of their isolation. Faculty and students who have contact with international students frequently do not realize that a problem exists until the student becomes ill, fails academically, or encounters some other crisis. Students may be too shy or timid to ask for assistance (Abu-Saad, Kayser-Jones, & Tien, 1982; Bronner, 1982; Kayser-Jones, Abu-Saad, & Akinnaso, 1982; Leone, 1982; Shearar, 1989; Stockert, 1987; Tien, 1982).
Figure 2. Strategies to assist students identified by schools.
In their book, Uprooting and Health, Zwingmann and Gunn (1983) discuss the inevitable as well as avoidable problems of foreign students. Among those classified as inevitable are language difficulties, separation reactions, climate and dietary difficulties, and age-determined problems. Problems classified as avoidable involve misunderstandings and miscommunication. Thus, to maximize the learning of foreign students, it would be helpful to offer intensive English classes focused on everyday use of English as well as the use of English in nursing, seminars about American culture and social customs, support groups or the buddy system, and to sensitize faculty to the different cultural norms of their foreign students.
There is a particular need to build in a good orientation and to have faculty mentors or counselors who meet regularly with students so that problems do not grow to crisis proportions before coming to the attention of persons who can provide help. Small discussion groups may help with the acculturation process and also serve as peer support groups and as a problem-solving mechanism. Some of these activities can be centralized in an office of international student affairs, and it is laudable that 40 of the schools surveyed have such an office. Other activities may be sponsored by student government on campus or by organizations such as Sigma Thêta Tau.
Glittenberg (1987) notes that schools that accept international students must also accept responsibility for helping process credentials and visas, and for undertaking extra correspondence. In addition, teaching international students often takes more time than teaching American students. Grading systems and fast-paced programs may need adjustment or extension. Schools in this study reported that most international students needed help with their academic program and the help was provided mainly on an individual basis. Perhaps a single admission date for all international students would allow schools to provide intensive group orientation and establish peer support groups to assist the faculty with academic advising and other adjustment situations. This could decrease the need for one-on-one time with busy faculty.
The cultural diversity and professional experiences that foreign students bring to share with U.S. students and faculty can be a valuable resource for both. They enable American students and teachers to learn about and share nursing practices from a more global perspective. This encourages inquiry into current nursing practices while also stimulating students to be creative and adaptive. However, careful pre-admission screening and counseling are critical to prepare foreign nurses for their experiences in the U.S. Schools must also invest in assistance for these students after they arrive to ensure a smooth entry into the school and to help faculty work with these special students.
- Abu-Saad, H., & Kayser-Jones, J. (1981). Foreign nursing students in the USA: Problems in their educational experiences. Journal of Advanced Nursing, 6, 397-403.
- Abu-Saad, H., Kayser-Jones, J., & Tien, J. (1982). Asian nursing students in the United States. Journal of Nursing Education, 21(7), 11-15.
- Bronner, M. (1982). Bridges or barriers to success: The nature of the student experiences in nursing. Journal of Nursing Education, 21(7), 38-41.
- Commission on Graduates of Foreign Nursing Schools. (1986, April). Fact sheet #6. Philadelphia: Author.
- Commission on Graduates of Foreign Nursing Schools. (1988). Statistics from CGFNS annual report. Philadelphia: Author.
- Glittenberg, J. (1987). Responsibilities for international education. Journal of Professional Nursing, 4, 146-149.
- Gosnell, D. (1985). The international implications of nursing education and practice. International Nursing Review, 32(4\ 105-108.
- Kayser-Jones, J, Abu-Saad, H., & Akinnaeo, EN. (1982). Nigeria: The land, its people, and health care. Journal of Nursing Education, 21(7), 32-37.
- Kayser-Jones, J.S., & Abu-Saad, H. (1981). Loneliness: Its relationship to the educational experience in international nursing students in the United States. Western Journal of Nursing Research, 4, 301-315.
- Leone, L.P. (1982). Orienting nurses from other countries to graduate education in the United States. Journal of Nursing Education, 21(7), 45-47.
- Sennhauser, S. (1985). Psychosocial nursing intervention. A vehicle for the prevention of illness among international students. International Nursing Review, 32(6), 176-177.
- Shearer, R. (1989). !baching foreign students. Journal of Nursing Education, 28, 427-428.
- Stockert, N. (1987). Preventive assistance and health care. National Association for Foreign Students 39th Annual Conference, Long Beach, CA, May 26-29.
- Tien, J. (1982). Surviving graduate nursing programs in the United States - A personal account of an Asian-American student. Journal of Nursing Education, 21(7), 42-44.
- Zikopoulos, M. (Ed.). (1990). Part 1: The annual census of foreign students in the United States. In Open doors 1989-1990: Report on International Educational Exchange (pp. 1-4; xi-xii). New York, NY: Institute of International Education.
- Zwingmann, C, & Gunn, A. (1983). Uprooting and health psycho-social problems from abroad. Geneva: World Health Organization.
Foreign Nurse Characteristics
Financial Sources for Study in the U.S.