Journal of Nursing Education

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Major Articles 

Stress and Perceived Faculty Support Among Foreign-Born Baccalaureate Nursing Students

DeMonica L. Junious, PhD, RN, CNE; Ann Malecha, PhD, RN, CNE; Kathryn Tart, EdD, RN, CNE; Anne Young, EdD, RN

Abstract

Using the triangulation approach at the method level, this study explored and described the essence of stress and perceived faculty support as identified by foreign-born students (N = 10) enrolled in a generic baccalaureate degree nursing program. Philosophical principles outlined by Heidegger served as the core component guiding this study. Quantitative data from a larger study examining nursing students’ stress and perceptions of faculty support served as the supplementary component. Results uncovered an overarching theme of the foreign-born nursing students wanting to be valued and accepted by the nursing faculty, their classmates, and the educational institution leading to patterns of stress, strain, and cultural ignorance. Language issues, stereotyping, discrimination, cultural incompetence, financial issues, and lack of accommodation as an international student were stressors that were not captured by the quantitative measures.

Abstract

Using the triangulation approach at the method level, this study explored and described the essence of stress and perceived faculty support as identified by foreign-born students (N = 10) enrolled in a generic baccalaureate degree nursing program. Philosophical principles outlined by Heidegger served as the core component guiding this study. Quantitative data from a larger study examining nursing students’ stress and perceptions of faculty support served as the supplementary component. Results uncovered an overarching theme of the foreign-born nursing students wanting to be valued and accepted by the nursing faculty, their classmates, and the educational institution leading to patterns of stress, strain, and cultural ignorance. Language issues, stereotyping, discrimination, cultural incompetence, financial issues, and lack of accommodation as an international student were stressors that were not captured by the quantitative measures.

Dr. Junious is Assistant Professor, School of Nursing, University of Houston-Victoria, Cinco Ranch, Katy; Dr. Malecha is Associate Professor and Director of Research, and Dr. Young is Professor, Texas Woman’s University, College of Nursing, Houston; and Dr. Tart is Founding Dean and Professor, University of Houston-Victoria, School of Nursing, Victoria, Texas. At the time this article was written, Dr. Junious was Director of Nursing Programs, Kaplan Higher Education, Texas School of Business Houston North, Houston, Texas.

This study was funded by the John Winston Carter Small Research Grant, Texas Woman’s University, College of Nursing, Houston, Texas.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to DeMonica L. Junious, PhD, RN, CNE, Assistant Professor, School of Nursing, University of Houston-Victoria, Cinco Ranch, 4242 South Mason Road, Katy, TX 77450; e-mail: juniousd@uhv.edu.

Received: March 26, 2009
Accepted: August 10, 2009
Posted Online: May 05, 2010

In 2003, the foreign-born population in the United States totaled 33.5 million, representing 11.7% of the total population (Larsen, 2004). The number of international students enrolled in colleges and universities in the United States increased by 3% to a total of 582,984 in the 2006–2007 academic year (Institute of International Education, 2007). According to the American Association of Colleges of Nursing (2007), nursing students from minority backgrounds represent 26% of students in entry-level baccalaureate programs. Research indicates that minority nursing students are at high risk for failure and attrition (Choi, 2005; Gardner, 2005a; Jeffreys, 2007b).

Research on stress in nursing students indicates these students experience a variety of stressors, such as fear of failure, financial issues, patient care responsibilities, and balancing school work with personal life (Jones & Johnston, 1997, 1999). In addition, the greater the stress experienced, the greater the negative effects it has on student learning and success (Gwele & Uys, 1998; Jones & Johnston, 1997). Studies investigating the effects of stress on nursing students have indicated that perceived faculty support can mediate the effects of the stress experience (Magnussen & Amundson, 2003; Poorman, Webb, & Mastorovich, 2002; Shelton, 2003). Some studies have focused on the stress and stressors of minority or ethnically diverse nursing students, as well as of students for whom English is a second language (Amaro, Abriam-Yago, & Yoder, 2006; Choi, 2005; Gardner, 2005a; Jeffreys, 2007a). However, most of these studies lump together diverse student populations and fail to differentiate between foreign-born and nonforeign-born students. In almost all studies investigating stress in nursing students, foreign-born, immigrant, or international nursing students have been underrepresented.

A review of the literature focusing exclusively on those samples with foreign-born or international nursing students found that the main stressors related to nursing school were language and communication concerns, difficulty adjusting to the host culture and customs, and lack of support from faculty and fellow students (Abu-Saad & Kayser-Jones, 1981; Brown, 2008; Carty et al., 1998; Gardner, 2005b; Kayser-Jones & Abu-Saad, 1982; Pardue & Haas, 2003; Ryan, Markowski, Ura, & Liu-Chiang, 1998; Sanner, Wilson, & Samson, 2002). Overwhelmingly, most of the literature examining minority or ethnically diverse and foreign-born nursing students concludes that the role of the faculty and faculty support can significantly affect students’ success (Amaro et al., 2006; Campbell & Davis, 1996; Gardner, 2005b; Jeffreys, 2007b; Sanner et al., 2002). A paucity of current literature exists examining the experiences of foreign-born nursing students and how these experiences, as well as cultural values or ethnicity, may affect student perceptions of faculty support (Cook, 2005; Shelton, 2003).

The purpose of this phenomenological study was to describe the essence of stress and perceived faculty support as identified by foreign-born students enrolled in a generic baccalaureate degree nursing program. Philosophical principles outlined by Heidegger (1962) were used to guide this study. This exploration of foreign-born student nurse stress and their perceptions of faculty support has the potential to assist educators in identifying and implementing retention interventions better suited for this student population, thereby increasing the overall success of foreign-born nursing students.

Research Questions

The four research questions for this study were:

  • What are foreign-born senior-level nursing students’ perceptions of stress experienced in a generic baccalaureate nursing program?
  • What are foreign-born senior-level nursing students’ perceptions of faculty support while in a generic baccalaureate nursing program?
  • How do foreign-born senior-level nursing students’ perceptions of stress compare with reported scores on the Student Nurse Stress Index (SNSI) (Jones & Johnston, 1999)?
  • How do foreign-born senior-level nursing students’ perceptions of faculty support compare with reported scores on the Perceived Faculty Support Scale (PFS) (Shelton, 2003)?

Method

An interpretive phenomenological design was used to examine stress experiences and perceptions of faculty support among foreign-born generic baccalaureate nursing students. Qualitative data, collected via focus group discussion and follow-up individual interviews, were triangulated with quantitative data at the methods level. Triangulation, often referred to as mixed methods, is defined as the use of more than one theoretical perspective, methodological approach, data source, or investigator in the same study (Polit & Beck, 2008; Speziale & Carpenter, 2007). Morse, Wolfe, and Niehaus (2006) further refined the role of the qualitative theoretical paradigm in a mixed-methods design. The core component of a mixed-methods study is the primary study, whereas the core method is used to examine research questions. The supplementary component is one or more strategies used to obtain additional data to supplement and provide additional description of the phenomenon under study. For this study, the qualitative paradigm remained the worldview and theoretical thrust of the researcher (D.L.J.). The core data collection method was a combination of focus group interviews with follow-up individual interviews. Quantitative data, the supplementary component, were composed of data collected in a larger study that examined nursing student stress and perceived faculty support. Quantitative data were collected using a simultaneous supplementary strategy; that is, both qualitative and quantitative data were collected with the same participants during the same time period.

Setting and Sample

This study was conducted at Texas Women’s University, College of Nursing. Texas Women’s University ranks second in the state and 15th in the nation among universities with the most diverse student populations (US News & World Report, 2009). A purposeful sample of foreign-born baccalaureate senior-level nursing students (n = 10) participated. Participants were recruited from a larger quantitative study examining the stress experiences of nursing students. Inclusion criteria included having been born outside the United States or its territories and having lived in the United States for less than 10 years. Table 1 describes the sample.

Demographic Data (N = 10)

Table 1: Demographic Data (N = 10)

Instruments

A demographic survey form and semi-structured interview schedule were developed and piloted by the principal investigator (D.L.J.) and used during the focus group and individual interviews as a guide. Quantitative data were collected using the SNSI (Jones & Johnston, 1999) and the PFS (Shelton, 2003). The SNSI is a 22-item scale that measures nursing student stress related to four factors: academic load, clinical concerns, personal problems, and interface worries. The higher the score, the greater the stress. Validity was demonstrated by confirmatory factor analysis, with internal consistency reliability coefficients all exceeding 0.70 (Jones & Johnston, 1999). For this study, reliability coefficients were a total score of 0.92; academic load, 0.86; clinical concerns, 0.91; personal problems, 0.53; and interface worries, 0.86. The PFS is a 24-item scale that measures two types of faculty support, psychological and functional, as perceived by the nursing student. The higher the score, the greater the faculty support as perceived by students. Validity was demonstrated by factor analysis and internal consistency reliability ranged from 0.92 to 0.96 (Shelton, 2003). For this study, reliability coefficients were a PFS total score of 0.96; psychological support, 0.94; and functional support, 0.93.

Data Collection

After receiving approval from the university institutional review board, students who were enrolled in a larger quantitative study examining personal stressors were recruited. The Figure outlines the recruitment and data collection procedures, including the four phases of analysis. All qualitative data were analyzed using the 5-step hermeneutic interpretive analysis process of Crist and Tanner (2003).

Participant Recruitment and Data Collection Procedures (N = 10).Note. SNSI = Student Nurse Stress Index; PFS = Perceived Faculty Support Scale; PI = Principal Investigator.

Figure. Participant Recruitment and Data Collection Procedures (N = 10).Note. SNSI = Student Nurse Stress Index; PFS = Perceived Faculty Support Scale; PI = Principal Investigator.

Results

Qualitative findings of foreign-born baccalaureate senior-level nursing students are summarized with a description of patterns, themes, and subthemes (Table 2). This study uncovered one overarching theme, two patterns that spanned 7 themes, and 25 subthemes. The overarching theme, Desire to be Valued and Accepted, was revealed by participants who experienced a series of interactions with faculty, staff, classmates, and others who made them cling to the hope of being accepted. The two patterns were Stress and Strain, and Cultural Ignorance. Each pattern is described in more detail below.

Overarching Theme, Patterns, Themes, and Subthemes Representative of 10 Foreign-Born Baccalaureate Senior-Level Nursing Students

Table 2: Overarching Theme, Patterns, Themes, and Subthemes Representative of 10 Foreign-Born Baccalaureate Senior-Level Nursing Students

Quantitative Data

Mean scores from the SNSI and PFS are displayed in Table 3, and the instrument items are ranked in order in Tables 4 and 5. For the SNSI subscales, academic load had the highest stress score, closely followed by interface worries. Personal problems had the lowest score. The highest possible score, meaning most stressful, for each item on the SNSI is 5. For this study, only two items had mean scores of 4 or higher: amount of classwork material to be learned and not enough time for my family. Eight items had mean scores of 2.5 or lower. The midpoint range score for academic, interface, and clinical concerns was 21. The mean scores for academic load (22.9) and interface worries (22.5) were slightly higher than the midpoint, whereas the mean score for clinical concerns (18.4) was lower than the midpoint. The mean score reported for personal problems (10.5) was lower than the midpoint range score of 12. Overall, these students did not report high stress scores as measured by the SNSI. Rather, their scores were close to or lower than the midpoint range scores.

Mean Scores for the Student Nurse Stress Index and Perceived Faculty Support Scales (N = 10)

Table 3: Mean Scores for the Student Nurse Stress Index and Perceived Faculty Support Scales (N = 10)

Nursing Student Stress Index Items, Rank-Ordered from Highest Stressors to Lowest Stressors (N = 10)

Table 4: Nursing Student Stress Index Items, Rank-Ordered from Highest Stressors to Lowest Stressors (N = 10)

Perceived Faculty Support Items Rank-Ordered from Highest Support to Lowest Support (N = 10)

Table 5: Perceived Faculty Support Items Rank-Ordered from Highest Support to Lowest Support (N = 10)

For the PFS, both subscale findings were above the standard midpoint; meaning these students reported high perceived faculty support. The highest possible score per item is 7 (midpoint = 4), and 23 of the 24 items had mean scores greater than 5. The midpoint range score for sub-scale psychological support is 56 and for functional support is 50, with students reporting mean scores of 73.4 and 60.2, respectively. The highest perceived faculty support item was Encourage students to ask questions (6.2), and the lowest item of perceived faculty support was Provide assistance outside of class (4.7). Overall, faculty support was quantitatively perceived as high.

Qualitative Data Triangulation

Pattern: Stress and Strain. The presence of stress and strain associated with being a foreign-born student enrolled in a baccalaureate nursing program was a reflective pattern verbally communicated among all participants. Qualitative data revealed that students experienced stress and strain in areas of personal relationships, financial issues, feeling as though they have no life, and feeling their institution made no accommodations for them.

Personal Relationships. Participants described demands of the nursing program as extremely time consuming, leaving them with no time for physical contact or communication with family and friends regardless if their loved ones lived in the United States or in their home country. At times their status of living abroad and loss of contact made them feel like outcasts in their families. Ranked as the second highest stressor on the SNSI by this group of participants, Not having enough time for my family (SNSI #22) was noted as a real stressor both qualitatively and quantitatively. Other personal problems (Relationship with partner) (SNSI #12) ranked ninth, whereas Relationship with parents (SNSI #11) ranked thirteenth. One of the female students (all names used are pseudonyms) discussed the effects of nursing school on her relationship with her family:

I always have problems with my mother when she would call and tell me what’s wrong with me. I haven’t called in…2 weeks and honestly…sometimes I just forget that I haven’t spoken to her.

Financial Issues. The SNSI does not address financial stress. Most participants willingly discussed the financial strain placed on their families related to their education. For the most part, students were not granted tuition assistance, nor could they seek employment, due to their status as an international student, yet they desired to work to help defray expenses. Maintaining regular contact (e.g., by telephone calls or travel) with family at home was cost prohibitive. Another female student, addressed the financial issues:

The dollar [at home] is not the same as [it is in] Ameri-ca. You spend a thousand dollars on tuition, we spend two, three times more. Our tuition [per] semester is sometimes a yearly salary for our parents.

Having No Life. All students described being in nursing school as having no life, with multiple school commitments leaving them tired with no time to do anything but study and prepare for the next lecture, examination, and clinical day. Results from the SNSI found that participants reported no time for fun, entertainment, and recreation (SNSI #21) and lack of free time (SNSI #6) ranked equally as the third and fourth highest stressors, respectively, among foreign-born students. According to a 23-year-old female participant, Hanna, there is “no time for anything else. Just come to school, read, and read, and read. Don’t even sleep.”

Lack of Accommodation as an International Student. All participants shared the same viewpoint in that the institution did not accommodate for the needs of foreign-born students. In particular, they disclosed a pressing need to be informed about the process to obtain citizenship, a visa, or a green card; a list of hospital employers that will or will not hire foreign-born individuals with or without these legal documents; how to and whether they should disclose nationality in the interview process; and contact with a campus office or person who can address the needs of international students. Students ranked college’s response to student needs (SNSI #7) as the tenth highest stressor on the SNSI.

In terms of having a supportive or accommodating faculty, it was perceived that not all professors practiced what they taught in the classroom. Students agreed that faculty did recognize them as being foreign born, but no special efforts outside the classroom had been initiated on their behalf. Results of the PFS ranked Provide assistance outside of class (PFS #14) to be the least supportive faculty behavior.

Students were familiar with the meaning of the term retrogression and identified this as a unique stressor. Simply defined, visa retrogression is a delay in obtaining an immigrant visa when there are more people applying for immigrant visas in a given year than the total number of visas available (Hammond Law Firm, 2007). Individuals must then wait until a visa number becomes current before the final adjustment of status to permanent resident can occur. Participants were very vocal about retrogression and believed they would eventually be forced to resign from their jobs and move back to their home country, leaving all of their school efforts in vain, as many of them verbalized the desire to stay and work in the United States.

Pattern: Cultural Ignorance. All students experienced some form of cultural ignorance at a point in their nursing education. Experiences included language issues, stereotyping, discrimination, and cultural incompetence by the dominant culture.

Language Issues. The SNSI and the PFS do not address language issues. All students experienced issues with language and communication. Some discussed the need to read and reread assignments to translate and back-translate between two languages. Some expressed limitations placed on themselves due to difficulty expressing oneself because of a heavy accent, as well as having to decipher the marked differences between British English, American English, and modern slang words. A female student brought up problems encountered with the verbiage on examinations:

They use words that are not internationally recognized, words that are just American. I mean, I’m a foreign student. I’m British colonized, and you use words that only somebody…that grew up in America would understand.

A few students mentioned being uncomfortable with using the nonverbal communication technique of looking into another person’s eyes, especially with instructors. A female student shared an experience she had with a faculty member:

In my culture, when you talk to someone…that has authority above you, like an [older adult], we try to show respect.… I will just look down. I’m listening, but I don’t have to necessarily look into [his or her] eyes, but when my teacher does this—literally do this (participant demonstrated how the instructor pulled her chin up)—looks at me and gets so close, I’m so uncomfortable.

Stereotyping and Discrimination. Students felt as though people considered them “dumb” because they had an accent and had difficulty speaking and understanding English. All students were very aware of their accents. They often felt devalued and discriminated against because their culture, accents, or dialogues were difficult for Americans to understand. They felt as if they must act a certain way to “fit in” at the university. One student elaborated on how this made her feel: “You don’t have to accept it or believe it, but act that way.”

Both the SNSI and the PFS address related concerns, such as Relations with other professionals (SNSI #13), Patient or client attitude toward me (SNSI #16), Demonstrate respect for students (PFS #2), and Correct students without belittling them (PFS #8), as well as others. None of these items scored as stressful or as low perceived faculty support for these foreign-born students.

Cultural Incompetence. All students felt as though their fellow American classmates and faculty were incompetent in terms of understanding their foreign values and traditions. These foreign-born students felt they were typically more private in nature, had a desire to be less competitive, and held a much higher level of respect for older adults and authority figures. They ranked Atmosphere created by faculty (SNSI #18) as a low stressor. However, PFS #22, Have a genuine interest in me, is one of the lower-scored perceived faculty support items.

The focus group discussed the issue of being culturally competent versus culturally ignorant. Students verbalized that although cultural competence was addressed in the curriculum, actions of nursing faculty were not sensitive to their cultural needs. One student shared what she felt to be an embarrassing encounter:

We were talking about women seeing their period. I said, “Seeing their period,” because that’s what we say. If you’re on your period, you see it, so the instructor was like, “What?” And she wasn’t joking.

All participants discussed experiencing some form of competition among peers, and for the most part, thought it was a healthy aspect of their program. Competition was consistent with their responses to Competition with peers and classmates (SNSI #4). They verbalized that the peer review grading system used in several classes was biased. They felt it was based solely on whether a student liked or disliked them as a person. Foreign-born participants also agreed that failure for them was not an option. Failure could significantly affect their lives by altering their course load and setting them back in their program for a minimum of 6 months; cause them to return to their home country; cause them to lose face with their families; cause them to lose all money spent on living, studying, and traveling to the United States; and jeopardizing their visa or citizenship status. However, Fear of failing a course (SNSI #8) was not considered a top stressor. One student provided a profound statement of what it means to be a foreign-born student receiving an education in the United States:

People don’t realize that being international is not just having [a] name that [others] can’t pronounce.… It’s a trail of stress.

Discussion

Study results suggest that although foreign-born nursing students may endure immeasurable amounts of stress, strain, and cultural ignorance, they still hold onto a strong desire to be both valued and accepted. However, this overarching theme and the resulting patterns and subthemes were not captured as well in the quantitative data. Both the SNSI and the PFS failed to uncover the major themes of language issues, stereotyping, discrimination, and cultural incompetence. Although personal relationships and lack of a personal or social life are measured by the SNSI, financial issues and lack of accommodation for international students are not. Both instruments demonstrated high internal consistency for this group of foreign-born nursing students. However, without the qualitative data, it would appear these students reported very low levels of student nurse stress and high levels of perceived faculty support. Triangulating this data revealed incongruent findings, as the focus group and individual interviews found that foreign-born nursing students experience unique stress and strain and perceptions that faculty are not culturally competent.

Consistent with previous studies, issues related to language, heavy accents, and overall communication emerged as significant stressors in the qualitative data of this study (Amaro et al., 2006; Carty et al., 1998; Yoder, 1996). Findings of Sanner et al. (2002) bear many similarities. In their study, eight Nigerian female students spoke of “verbal retreats” (p. 209) as a means to protect themselves when they felt uncomfortable verbally expressing due to their accents and English language skills. These Nigerian students also spoke of social isolation and nonacceptance inside and outside of the classroom. In spite of these feelings, students reported persistence and resolve with no obstacles getting in the way of graduation. More important, not only are findings from the current study similar to research conducted more than 10 years ago, but foreign-born students continue to voice these major concerns.

The findings of this study reflect previous literature indicating that foreign-born nursing students report issues of discrimination, stereotyping, and cultural incompetence or incongruence (Gardner, 2005b; Jeffreys, 2007a). Current study participants extensively described many examples of cultural incompetence displayed by fellow students and nursing faculty. They also reported cultural differences in coping with competitiveness in nursing school, a fast-paced learning environment, and unique financial concerns related to being international students. Many students shared an extremely strong desire for support, understanding, and overall acceptance from nursing school classmates and faculty. Along with wishing for a university advisor dedicated to the foreign-born student population, they also expressed a desire for additional information related to international students at the time of their program orientation. These findings are reflected in recent literature, as well as in literature more than 20 years old (Abu-Saad & Kayser-Jones, 1981; Brown, 2008; Kayser-Jones & Abu-Saad, 1982).

Perceptions of faculty support can be critical to the success of foreign-born nursing students (Abriam-Yago, Yoder, & Kataoka-Yahiro, 1999; Shelton, 2003). Students in this study quantitatively reported high perceptions of faculty support. However, focus group data told a different story of faculty who were culturally incompetent and nonsupportive. In addition, methods of evaluation, such as peer grading, were not fully accepted by these students. Several programs exist that highlight the need to include faculty support as a crucial component to student success (Brown, 2008; Choi, 2005; Yoder, 1996, 2001). Other reports outline various strategies and interventions to enhance retention and success of foreign-born or minority students. Most of these programs incorporate academic and language support components (Brown, 2008; Guhde, 2003; Pardue & Haas, 2003). The Cummins Model provides a framework for nursing faculty to develop educational programs that address the needs of foreign-born students (Abriam-Yago et al., 1999). This model includes 11 teaching strategies, such as preparing learning objectives related to communication, permitting expression of identity and cultural sharing, providing bilingual and bicultural opportunities, modeling the use of texts and resources, and continuous assessment. Some build faculty support into the program in the form of spotlighting cultural awareness (Abriam-Yago et al., 1999; Amaro et al., 2006; Brown, 2008). In fact, several researchers summarized that faculty awareness and support of culture are key to the success of ethnically diverse students (Shelton, 2003; Yoder, 1996, 2001).

Limitations and Recommendations

Findings of this study should be interpreted within the context of the limitations. First, this study demonstrated the value of triangulation in that qualitative and quantitative data revealed incongruent representations of the phenomena. In general, the current nursing student stress research literature is most likely not applicable for the foreign-born student population, as well as other subgroups including older students, students with dependents, male students, and second degree or career students. The instruments in this study demonstrated adequate reliability with the exception of the SNSI Personal Problems sub-scale reliability coefficient (0.53). This could be attributed to the subscale items not capturing the meaning of personal problems for this group of foreign-born students. In summary, neither of the quantitative measures captured the essence of nursing students’ stress and perceived faculty support for this group of students. Further review, development, and refinement of such instruments are needed for future research with growing diversity within the nursing student population. Overall, not only is there a great need for updated research on nursing student stress but also on how faculty can affect stress experiences.

Second, the unique inclusion criteria limit generaliz-ability of findings to all foreign-born nursing students, as well as minority and ethnically diverse students. Various racial, ethnic, and gender groups were not represented within the sample. It is clear that additional work is needed in this area not only to understand and promote diversity, but also to identify those unmeasured variables identified by study participants.

Third, the research design format may have impacted findings of this study. In phase 1 of this study, participants in the focus group demonstrated an eagerness and willingness to express, share, and exchange experiences. The group setting and dynamics may have provided a supportive foundation that allowed participants to openly display their feelings. For example, the length of the focus group session was extended to 120 minutes simply because everyone had a story that was important to share. However, the structure of the individual follow-up interviews in phases 2 and 3 was such that the time frame was much shorter and the discussion was not as animated. The interviewer did have to increase the use of cues to get at the core of what was being said. The purpose of the follow-up interviews was to validate the focus group findings as well as to uncover additional findings. No new findings were discovered in phases 2 and 3.

Conclusion

Heidegger’s (1962) theoretical framework received validation through an exploration of nursing students’ stress experiences and perceptions of faculty support in foreign-born students enrolled in a U.S. generic baccalaureate nursing program. These students were able to uncover true meanings as they pertained to the individual student, and provide a deeper understanding of their current world far away from home. Although stressors experienced varied from individual to individual, being a foreign-born nursing student in the United States was cumulatively confirmed to be a stressful experience. Students verbalized having to cope with a “trail of stressors” that may follow any foreign-born student enrolled in a baccalaureate nursing program. In summary, they desire acceptance and support from other students, faculty, and the educational institution.

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Demographic Data (N = 10)

Variablen
Gender
  Female9
  Male1
Race/ethnicity (self-identified)
  African/Black7
  Asian3
Country of origin
  Nigeria5
  Cameroon2
  China1
  India1
  Vietnam1
Citizenship status
  No U.S. citizenship3
  Nonresident alien3
  Naturalized citizen2
  I-20 student visa1
  F1 working visa1
Employment status
  Not employed8
  Employed part time2
Relationship status
  Married/committed relationship6
  Not in a relationship4
Dependents
  No children in the home6
  Children in the home4

Overarching Theme, Patterns, Themes, and Subthemes Representative of 10 Foreign-Born Baccalaureate Senior-Level Nursing Students

Overarching ThemePatternThemeSubtheme
Desire to be valued and acceptedStress and strainPersonal relationshipsNo time for family and friends both in the United States and back at home
An outcast in the family
Cannot disappoint family
Financial issuesNot eligible for most scholarships and loans
Want to work but not allowed
Out-of-state tuition fees are costly
High costs of maintaining contact with home (calling cards, travel)
Having no lifeNo time for self
Study all the time
Tired all the time
Lack of accommodation as an international studentVisa and green card issues
Process of becoming a citizen
Want to stay and work in the United States
Would like someone at the university to serve as an advocate
Retrogression issues
Cultural ignoranceLanguage issuesNeed extra time for reading, writing, testing, people talk too fast, translate audiotapes
Use of American words or phrases and slang
Very aware of own accent
Nonverbal communication (eye contact)
Stereotyping and discriminationMust act American to fit in
People think you are dumb because you cannot speak or understand English and have an accent
Cultural incompetenceRespect for authority and elders
Desire more privacy
Noncompetitive
Failure not an option

Mean Scores for the Student Nurse Stress Index and Perceived Faculty Support Scales (N = 10)

Instrument SubscaleMean (SD)
Student Nurse Stress Index
  Academic load22.9 (6.5)
  Interface worries22.5 (6.2)
  Clinical concerns18.4 (8.1)
  Personal problems10.5 (3.8)
  Total score65.4 (17.6)
Perceived Faculty Support Scale
  Psychological support73.4 (9.2)
  Functional support60.2 (9.9)
  Total score133.6 (18.2)

Nursing Student Stress Index Items, Rank-Ordered from Highest Stressors to Lowest Stressors (N = 10)

Item No.Item DescriptionMean (SD)
1Amount of classwork material to be learned4.1 (0.737)
22Not enough time for my family4.0 (1.33)
21No time for fun, entertainment, recreation3.9 (1.10)
6Lack of free time3.9 (1.10)
3Examinations or grades3.8 (0.918)
2Difficulty of classwork material to be learned3.5 (0.849)
14Too much responsibility as a student nurse3.4 (1.34)
5Attitudes and expectations of other professionals toward nursing3.3 (1.49)
20Unsure what is expected of me3.1 (1.44)
10Health problems of family member(s)3.1 (1.37)
12Other personal problems (relationship with partner)2.8 (1.54)
7College’s response to student needs2.7 (0.948)
8Fear of failing a course2.6 (1.71)
19Relations with staff in the clinical area (nurses, physicians)2.6 (1.42)
13Relations with other professionals (faculty, nurses, physicians)2.5 (1.64)
11Relationship with parents2.5 (1.71)
18Atmosphere created by instructors and faculty2.4 (1.42)
4Competition with peers and classmates2.4 (1.34)
17Patient or client attitudes toward my profession2.3 (1.49)
15Lack of timely feedback about performance2.3 (1.05)
9Actual personal health problems2.1 (1.28)
16Patient or client attitudes toward me2.1 (1.19)

Perceived Faculty Support Items Rank-Ordered from Highest Support to Lowest Support (N = 10)

Item No.Most Faculty Members…Mean (SD)
13Encourage students to ask questions.6.2 (0.92)
2Demonstrate respect for students.5.9 (0.875)
11Give helpful feedback on student assignments.5.9 (0.737)
4Acknowledge when students have done well.5.8 (0.918)
23Provide study guides and written materials.5.8 (1.13)
24Demonstrate confidence in students.5.8 (0.788)
5Are helpful in new situations without taking over.5.7 (1.05)
6Stress important concepts.5.7 (1.25)
12Are open to different points of view.5.7 (0.823)
18Are good role models for students.5.7 (1.25)
3Set challenging but attainable goals for students.5.6 (0.966)
7Are approachable.5.6 (1.07)
8Correct students without belittling them.5.6 (0.966)
9Listen to students.5.6 (0.966)
10Can be trusted.5.6 (0.699)
15Vary teaching methods to meet student needs.5.5 (1.17)
20Present information clearly.5.5 (1.17)
19Are realistic in expectations.5.4 (1.07)
21Clarify information that is not understood.5.4 (1.17)
22Have a genuine interest in students.5.3 (1.33)
16Make expectations clear.5.3 (1.25)
17Are patient with students.5.2 (0.421)
1Know if students understand what is being taught.5.1 (1.19)
14Provide assistance outside of class.4.7 (1.34)
Authors

Dr. Junious is Assistant Professor, School of Nursing, University of Houston-Victoria, Cinco Ranch, Katy; Dr. Malecha is Associate Professor and Director of Research, and Dr. Young is Professor, Texas Woman’s University, College of Nursing, Houston; and Dr. Tart is Founding Dean and Professor, University of Houston-Victoria, School of Nursing, Victoria, Texas. At the time this article was written, Dr. Junious was Director of Nursing Programs, Kaplan Higher Education, Texas School of Business Houston North, Houston, Texas.

This study was funded by the John Winston Carter Small Research Grant, Texas Woman’s University, College of Nursing, Houston, Texas.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to DeMonica L. Junious, PhD, RN, CNE, Assistant Professor, School of Nursing, University of Houston-Victoria, Cinco Ranch, 4242 South Mason Road, Katy, TX 77450; e-mail: juniousd@uhv.edu

10.3928/01484834-20100217-02

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