CHALLENGES OF INTERNATIONAL NURSING STUDENTS AND PROMOTION OF THEIR
WELLBEING
A guidebook for LAB University of Applied Sciences – International nursing students
.LAB University of Applied Sciences Bachelor of Nursing
Spring 2022 Monica Nkatha Joyce Kiprop
Authors
Nkatha Monica Kiprop Joyce
Publication type Thesis, UAS
Completion year 2022
Number of pages
58
Title of Publication
Challenges of international nursing students and promotion of their wellbeing.
A guidebook for international nursing students Degree and field of study
Bachelor of Nursing Abstract
The focus of this thesis is the challenges of international nursing students and promoting their wellbeing in LAB University of Applied Sciences. The implementation of this thesis was practice-based and the final product was the guidebook for the LAB student services depart- ment. This guidebook aims to bring up some challenges, coping strategies and how LAB University of Applied Sciences can promote the wellbeing of international nursing students.
The guidebook also shows available resources at LAB University of Applied Sciences and self-care tips that helps promote the wellbeing of international nursing students.
The purpose of this thesis is to prevent physiological distress of international nursing stu- dents in LAB and help them successful complete their studies. The guidebook will be availa- ble at LAB University of Applied Sciences department of Student service centre.
The thesis writing process used evidence-based materials which were collected from differ- ent reliable sources and following the LAB thesis guidelines. PDSA model (Plan, Do, Study and Act) was used to conduct this practice-based thesis. A questionnaire was prepared fol- lowing the criteria of a good guidebook. The questionnaire was sent vie email to five interna- tional nursing students.
The feedback collected improved the final copy of the guidebook. The guidebook is easy to read and follow, making it useful to international nursing students. The guidebook can be used for further research about challenges and ways to promote the wellbeing of Interna- tional nursing students in Finland.
The topic of this thesis is found important to international nursing students. Guidebook is useful to international nursing students during their studies and gives tips on how to manage as nurses in Finland following their graduation and as they grow their careers.
This thesis uses the PDSA model to develop the change and improvements that benefits the international nursing students in LAB University of Applied Sciences.
Keywords
Challenges, international students, Well-being
Tiivistelmä
Tekijä(t)
Nkatha Monica Kiprop Joyce
Julkaisun laji
Opinnäytetyö, AMK
Valmistumisaika 2022
Sivumäärä 58
Työn nimi
Kansainvälisten sairaanhoitajaopiskelijoiden haasteet sekä heiden heiden hyvinvoinnin edistäminen
Opas kirja kansainvälisille sairaanhoitajaopiskelijoille
Tutkinto
Sairaanhoitaja (AMK) Tiivistelmä
Tämän opinnäytetyön painopiste ovat kansainvälisten sairaanhoitajaopiskelijoiden haasteet sekä heidän hyvinvoinnin edistäminen LAB-ammattikorkeakoulussa. Opinnäytetyön toteutus oli
käytäntöön perustuvaa ja lopputuotteena syntyi opaskirja LAB:in opiskelijapalveluosastolle.
Oppaan tavoitteena on tuoda esiin haasteita, selviytymisstrategioita ja sitä, miten LAB- ammattikorkeakoulu voi edistää kansainvälisten sairaanhoitajaopiskelijoiden hyvinvointia.
Oppaassa on kuvattu myös LAB-ammattikorkeakoulun käytettävissä olevia resursseja ja itsehoitovinkkejä, jotka auttavat edistämään kansainvälisten sairaanhoitajaopiskelijoiden hyvinvointia.
Opinnäytetyön tarkoituksena on ehkäistä LAB:n kansainvälisten sairaanhoitajaopiskelijoiden fysiologisia vaikeuksia ja auttaa opiskelijoita suorittamaan opinnot onnistuneesti loppuun. Opas on saatavilla LAB Ammattikorkeakoulun opiskelijapalvelukeskuksen osastolta.
Opinnäytetyössä käytettiin näyttöön perustuvaa materiaalia, joka on kerätty eri luotettavista lähteistä LAB:in tutkielmaohjeita noudattaen. Tämän käytäntöpohjaisen opinnäytetyön tekemiseen käytettiin PDSA-mallia (Plan, Do, Study and Act). Kyselylomake laadittiin hyvän oppaan kriteereitä noudattaen. Kyselylomake lähetettiin sähköpostitse viidelle kansainväliselle sairaanhoitajaopiskelijalle.
Kerätty palaute paransi oppaan lopullista versiota. Opas on helppolukuinen, joten se on hyödyllinen kansainvälisille sairaanhoitajaopiskelijoille. Opaskirjaa voidaan käyttää
jatkotutkimuksessa kansainvälisten sairaanhoitajaopiskelijoiden haasteista ja tavoista edistää hyvinvointia heidän Suomessa. Opinnäytetyön aihe koetaan tärkeäksi kansainvälisille
sairaanhoitajaopiskelijoille. Opas on hyödyllinen kansainvälisille sairaanhoitajaopiskelijoille opintojen aikana. Se antaa myös vinkkejä siitä, miten pärjätä sairaanhoitajana Suomessa valmistumisen jälkeen ja myöhemmin urallaan.
Keywords
Haasteet, Kansavälisten opiskelijoita, Hyvinvointi
TABLE OF CONTENTS
1 Introduction ... 1
2 Challenges of international nursing students ... 4
2.1 Nursing studies in Finland ... 4
2.2 International students ... 5
2.3 Challenges of international nursing students... 6
3 Wellbeing of international nursing students in Finland ...12
3.1 Defining well-being ...12
3.2 Wellbeing at LAB ...12
3.3 Promoting wellbeing of international nursing students in LAB ...13
4 Methodology and guidebook developmental process ...18
4.1 Practice Based thesis ...18
4.2 PDSA model ...18
4.3 Development process of the guidebook ...20
5 Discussion ...25
5.1 Ethical aspects and trustworthiness ...25
5.2 Implication for further studies ...25
Appendices
Appendix 1. Co-operation Organisation form Appendix 2. Qualitative Evaluation Questionnaire Appendix 3. Cover letter
Appendix 4. Guidebook
1 Introduction
Studies shows that recently, the number of international students in Finland has increased.
International students refer to all students whose nationality is other than Finnish and their mother tongue is not Finnish, Swedish or Sami. According to Official Statistics Finland (2021) 1.3 million are students in education leading to a qualification or degree number. The foreign speaking students are 10%. Pupils and students in the comprehensive education are numbered 55,700 and 82,200 in post-comprehensive education leading to a qualifica- tion or degree. According to these statistics every tenth student is a foreign-language speaker. LAB University of Applied Science key facts 2020 states that number of interna- tional degree students are 958 from 84 different nationalities.
Most of the international students are attracted to Finnish health care sector because there are employment opportunities. The quality of education, tuition free, high level of welfare and many programs that are taught in English are other reasons these foreign students have Finland as a destination for their studies. Finland’s higher education agenda is to in- crease the recruitment of international students from outside of the European Union. This has been discussed and passed, students have been recruited to different institutions of higher learning. Finland has aimed at improving the quality and making the education more attractive to the international students. The Finnish authorities have also contemplated on making higher education a way of exporting qualified personnel and a way of generating extra income through charging tuition fees into these programs. Finland is considered to have the best level of education system in the world. (Yuzhuo & Kivisto 2013; Schatz 2015.) Challenges of international nursing students is one of the main reasons why most nursing students of foreign background drop out of the program or take too long to graduate as compared to Finnish students. The challenges these students face varies from low under- standing of the Finnish language, cultural differences, financial and psychological chal- lenges, balancing work and studies and challenges during clinical practices. However, Fin- land has done quite a lot to integrate these students and help them settle well in their pro- gram. For example, teachers have gone an extra mile to have clinical placements arranged for these students. Supervision is well organised and can be done in English if need be.
(Pitkäjärvi et al. 2012.)
Finland maintains good cooperation with international organisations. The cooperation is not based on political ideologies but on governance. This applies to higher education too whereby the Ministry of education has good relationships with other higher education stake- holders within the European Union. (Yuzhuo & Kivisto 2013.)
LAB- University of Applied Sciences are improving the network between international nurs- ing students and Finnish Health sector. These improvements are regards to clinical place- ments which enables the international students to practice the Finnish language and to get knowledge about the Finnish working culture. The wisdom and knowledge gained by the international students during their clinical practices promotes entrepreneurial thoughts and co-operation with other companies. These encourages the international students to remain in Finland and contribute to the Finnish society. (Bottacci 2020.)
Aim and purpose
The aim of this thesis is to provide a guidebook on some challenges of international nursing students and how to promote their wellbeing. The guidebook is also meant to bring up ideas on how LAB- university of applied sciences can support and promote international nursing students to cope during their studies at LAB University of Applied Sciences. The guidebook contains information on how to manage as an international student and links on places to visit during free time. The method used to conduct this thesis was practice based.
The purpose of this thesis is to prevent physiological distress of international nursing stu- dents in LAB and help them successful complete their studies. The guidebook will be avail- able at LAB University of Applied Sciences department of Student service centre.
Commissioning partner
This thesis was conducted in cooperation with LAB University of Applied Sciences under Student’s Services department. LAB University of Applied Sciences whose population is over 8500 students and 857 of these are international students. The institution has more than over 500 staff members and is ranged the 6th largest UAS in Finland. There are about 523 staff members working at the university. LAB University of Applied Sciences has two main campuses, in Lahti and Lappeenranta. They are called LUT universities that is LUT University + LAB University of Applied Sciences = LUT Universities. It also offers education online that is the campus online. The main mission of LUT Universities is WIN-WIN collab- oration in projects and education, while the goal is everyone wins. LAB being part of LUT Universities, it plays a role in corporation groups of independent higher education institution and these Collaborations brings values such as international student recruitment and edu- cation export, novel education paths and impact on industries business. (LAB University of Applies Sciences 2020 a.)
LAB University of Applied Sciences offers different courses such as healthcare and social services, design, business administration, visual communication and visual arts, technol- ogy, tourism and hospitality. Nursing studies is mostly practice oriented which helps stu- dents gain more skills and knowledge. LAB University of Applied Sciences strategy 2030 is to build a better world of work, challenge and to be challenged and to act boldly and fairly.
(LAB University of Applies Sciences 2020 b.)
LAB student service offers different roles to all students. Some of the duties of the student’s service is to provide a friendly and professional services, they serve students at campuses and online as they help students find solutions about study life that is career questions. The promise of student service is to develop their services in cooperation with the students.
Students get support and assistance whenever they ask from the office or by calling. The staff are very friendly and always ready to offer help and guidance regarding school and where to find other services outside the campus. Students are always encouraged to con- tact student service centre to get support. LAB University of Applied Sciences, student ser- vice department has a clear and simple guidance model. The model’s aim is to provide guidance and support in the beginning of the studies, during the studies and at the end of the studies and when graduating. (LAB Student Services, eLAB 2021 a.)
Students’ service ensures that international students get integrated into Finnish system with less distress. They provide support so that students can concentrate on their studies. Stu- dent’s wellbeing is considered important because nursing field is more demanding as it is association with others for it to fully function. (LAB Student Services, eLAB 2021 b.)
2 Challenges of international nursing students
2.1 Nursing studies in Finland
According to Sahlberg (2021) Finland has the best educational system and this explains that teaching is a highly valued profession and teachers take their quality time with the students. Education is researched in Finland and reliable information is availed to the teach- ers both in curriculum and extra-curriculum activities. Ethics or morals of the students are modelled with conviction, Students are the major parties when it comes to education and that is why in Finland their health and wellbeing is a concern of the teaching staff and the society. The study course in Finland goes beyond just learning, it involves putting into prac- tice, reflecting and making changes accordingly.
In Finland, Bachelor of Nursing Education is offered at degree level at the University of Applied Sciences. These universities of applied sciences are included in National and inter- national community of higher education that is tasked with educating specialists for the places of work. Degree programme in Nursing takes 3,5 years with 210 ECTS credits. The programme includes clinical practices, which are done in different workplaces. (LAB 2019.) Nursing studies includes theoretical studies and simulation skill labs, which makes students competent nurses upon graduation. Practical clinicals are 75 ECTS credits which are achieved from different clinical placements that are done during the study period. Clinical placements promote student competence and knowledge on how to handle patients of dif- ferent situations. During practice, nursing students need skills like decision-making and problem-solving, communication and team -working skills, interpersonal skills and interac- tion. (LAB 2019.) During learning in classroom, the students are taught about different parts of nursing that includes procedures, illnesses and conditions and interpersonal skills required to be a qualified nurse. The knowledge gained from theory is practiced in nursing practice environment. (Saifan et al. 2015.)
Valvira is National Supervisory Authority for Welfare and Health department that supervises and guides healthcare professionals and medical facilities both in private and public sector in Finland. Valvira requires that all students graduating to be registered nurses (RN) should apply for a license that will enable them work in Finland. According to Finnish law, licences are granted to 17 different titles on the grounds of application. These professions include psychologist, dentist, physician, pharmacist, dispenser, dietician, nurse, medical laboratory technologist, radiographer, optician, speech therapist and dental. Language is part of re- quirements that health care professionals are evaluated. Every profession should have oral
and written language skills for them to be able to execute their duties sufficiently. Employers have the right to evaluate employee language proficiency. (Valvira 2021.)
The registered nursing education programme is regulated by the law based on European Union directives EU. All countries under the European Union (EU) should follow the direc- tives presented by EU. The directive emphasises on the requirements that a nursing student should accomplish during studies, so that they are professionally competent to handle all kind of patients. (EU directive 2013/55/EU.) According to Henriksen et al. (2019) clinical practice is an essential component of every nursing student. During the clinical practice the students gain knowledge and skill of patients care process.
2.2 International students
International students are people who have moved from their native home countries to Fin- land in search of higher education. Finland attracts a lot of international students including nursing students who come to study and explore the opportunities available. Over 30,000 students move from their home country to Finland because it has a higher hierarchy of education with equality and freedom. Education in Finland is categorized as the best in the world and other countries gets an opportunity to learn from because it has a lot to offer.
International students are encouraged to speak up freely during their studies and everyday life. Education focuses on student-professor relationship. (Stephanie 2019.)
High quality of education is one of the main attractions of international students in Finland.
These students arrive in Finland on temporary student visas and continue holding the same status until when they are eligible for permanent residence permits. Studies have shown that these students choose to leave Finland or stay after graduation. One of the reasons for staying after graduation is opportunities in labour market. Finland has a higher rate of the ageing population and this leads to shortage in skilled labour force. International students are encouraged and supported to start their working life immediately they have the capabil- ities to. There is a huge need for employees in certain fields like social and health depart- ments. (Ministry of the interior Finland 2019.) International students who graduate from Finnish higher education institutions mostly remain in Finland and integrate into the society and boost the labour market. Another reason is family ties established during the study period. The probability of staying after marrying a Finnish spouse is higher and also having children showed a positive pattern in staying. (Mathies & Karhunen 2020.)
2.3 Challenges of international nursing students
International students experience challenges during their studies in Finland. They have dif- ficulty to adapt to new environment and culture, financial constraints, language barriers, clinical practice problem with mentoring nurses, challenges in academic integration among others. These challenges arise in classrooms, clinical practices and even after graduation.
As a result of these challenges students are affected negatively. (Stephanie 2019.)
The proficiency of the host country’s language and cultural adaptations affect international students. It is assumed that the challenges these students face tend to diminish as they continue to stay in a foreign country. This is not the case with most nursing students be- cause of practicalities of their study. Nursing students interact more with the locals as they progress with their studies because they need to work closely with the people. The level of the language nurses require to fulfil their duties is quite high compared to other professions.
These exceptional challenges of international nursing students are in addition to other chal- lenges that are faced by any other international students like financial constraints, housing and food. ln Europe’s statistics which Finland is part of, between the year 2010 and 2011, the foreign-born nurses and physicians accounted for 30% and 40% respectively. Working with culturally diverse health care workers can be so challenging due to different beliefs, customs, opinions and norms. Proper management of these group is key to avoid miscom- munication and even interpersonal conflicts. (Wesołowska et al. 2018.)
Challenges in academic integration
International students’ experiences challenges when integrating into academics in Finland.
The role of the university is to promote and provide a conducive environment for the Finnish and international students to interact freely during their studies. This will encourage inter- cultural skills and expose the students to the new academic system. International teaching includes international curriculum with a perspective from different parts of the world. The orientation process is of great importance to international students. The university infra- structure should support the integration process. Some of the things that enhances integra- tion includes transportation, medical services and taxation. These are the things outside academics, but they are necessary for integration and assist in daily life. (Kauko &
Medvedeva 2016.)
There are differences in teaching methodological between Finnish Universities of Applied Sciences and abroad where international students came from. The teaching methodology in Finland values student being independent and encourages critical thinking while most of
international students are used to focussing on lectures, being forced to memorise study materials that are also used in exams. (Hanwei & Pitkänen 2017.)
Challenges during clinical practice
Clinical practice is defined as an actual space for practicing with real patients where stu- dents practice the skills leant theoretically. The main goal is to have students develop their professional competencies and be ready to become registered nurses when they graduate.
Clinical practice is meant to help students excel in giving safe and patient-centered care while being guided by their mentoring nurses. This excellence is attained when students put their theory work into practice during their clinical practices. (Griffins et al. 2012.)
Clinical practices are considered the most important part of nursing studies curriculum.
Nursing student graduates as a Registered Nurse after attaining 90 credits in clinical prac- tice which includes 15 credits of thesis work. Each credit is equivalent to 27 hours of clinical practice. (LAB 2019.)
As per EU directives, clinical practice is an important component of every nursing pro- gramme. EU directives brings out the requirements that nursing students have to accom- plish before they become competent nurses. During clinical practices the nursing students are given a chance to work directly with the patients and the multidisciplinary team in provid- ing comprehensive medical nursing care. Nursing competences are practiced during the clinical practice period. Clinical practices empower the nursing students to be qualified and responsible nurses in the health departments and society. (Directives 2013/55/EU of the European Parliament and pf the Council.)
Nursing students are educated to achieve a nursing competence and the competences are evaluated during their clinical practices. The students are given a chance to practice the knowledge, skills and competencies depending on the needs of the society. The role of the clinical practice placements is to provide and ensure that students are given quality support and conducive learning environment. This enables students to put into practice their theo- retical knowledge and develop their competences in the nursing field. This is accomplished with the help of the mentors and nurse educators. (Henriksen et al. 2019.)
The mentoring nurse is responsible for taking the student through the placement. The men- tor nurse gives the guidelines to the student throughout the placement. (Brown et al. 2014, 510 -517.) In Finland, there are no standards for mentoring that are agreed nationally. There are discussions for uniform mentoring and it is still being discussed under EU laws. Men- toring the students by nurses during clinical training is seen as empowering the students
and giving them tools to be professionals when they graduate. It is believed that the stu- dents gain more deeper understanding in giving good quality of health care to patients. The students are introduced and given powers to handle the patients under the watch of a qual- ified nurse. (D’Souza et al. 2015, 833 – 840.) During the mentoring process, the mentee who in this case is the student is empowered to be independent. The mentoring process is meant to have a positive impact to the learner who is the future nurse. (Heeneman & Grave 2017.)
It is important for mentoring nurses to treat students with dignity and respect as a learner nurse. The mentoring nurse is also required to take care of the student under their watch, guide them, show empathy during the period of clinical practice. Mentoring nurses and stu- dents working together creates confidence in students and helps them have mutual trusted communication. Mentoring and acting as role models helps the students to understand their own feelings and emotions when the nursing situations gets difficulty. A student who has good clinical mentoring will be more useful during their working life and give back to the society. (Mikkonen 2017.)
For international nursing students, their situation during clinical training is different. These students’ study in English but are required to fully communicate in Finnish or Swedish. Lack of enough language skills makes international student almost irrelevant as compared to native students. Patients gets uncomfortable being attended to by a student who cannot fully communicate. This stresses out these students who most often feels not competent enough. (Välipakka 2013.)
Language barrier
During the theoretical studies the language of instruction for international nursing students is English. These students are required to have a proof of English language proficiency before being admitted to the nursing program. In addition to the documentation proof, these students are required to sit for an English exam at the beginning of their first semester.
Those who do not pass this exam, take an extra English course to equip themselves well for the nursing program. The English language proficiency is taken seriously to avoid mis- understandings of the content. The seriousness put into this clearly shows how important the nursing course is and that the student is required to understand every detail of the course. (Hadziabdic & Hjelm 2020.)
Studies have shown that Finnish people have a positive attitude towards English language.
The language is well known and spoken by majority of Finnish people. The laws, however, does not accommodate the language as a national language. (Saarinen 2014.) The national languages in Finland are Finnish, Swedish and Sami. However, when these students are
taking their clinical practices, the language of instructions and main language during the entire placement time is Finnish or Swedish. The students often have problems in com- municating or understanding the instructions at their work placements. Having studied in English and being expected to understand and use Finnish is always challenging to these students. International nursing students are judged harshly by their clinical practices super- visors and they are compared to their Finnish colleagues. These leads to stress to the stu- dents and feelings of rejection. (Mikkonen 2017; Ruotsalainen et al. 2020.)
Financial constraints
According to Yuzhuo and Kivistö (2013), majority of Finland’s international students origi- nate from developing countries of Asia and Africa and free education has been a motivating factor to these students. Education was free for all students until 2016. Tuition fees was introduced to international students who comes from outside European Union and the Eu- ropean Economic Area. In 2010 the Finnish government started a five-year trial period to charge school fees, for internationals master's degree programs that are taught in English.
When the trial period ended, the parliament passed the new regulations making it compul- sory for nonEU/EEA to pay tuition fees and this new regulation took effect from Autumn 2017. Finnish higher-education policy about tuition fee was to promote internationalisation and marketisation. The tuition fee system was introduced with an incentive for getting more foreign students to Finland to study degrees at a fast pace. Introduction of the tuition fee limited international students from getting a chance to come to Finland. (Kauko &
Medvedeva 2016; Finnish national agency for education 2017.)
In addition to paying tuition fee, international nursing students have other needs and they need to work to earn money for their upkeep. Considering these students originate from low economies, they require to work longer hours to be able to meet their personal needs.
Therefore, they do not give quality time for their studies. They are already disadvantaged by being charged the tuition fee whereas their colleagues from the EU study tuition free.
(Calikoglu 2018.)
International students should have a plan on how they will finance their studies in Finland.
During study period these students gets an opportunity to work in order to finance their daily needs. International students are required to apply for resident permit that enables them to live in Finland and this is done every year depending on the country they come from. The only thing that is required to obtain a resident permit is supporting documents about financial status. International student should have enough money to support their daily lives in Fin- land. To ease the study process, these students are given an opportunity to apply for grants.
This is possible for students doing undergraduate or master’s degree in English language
and are from outside EU/EEA parts. These grants are given according to achievement in studies and it is applied for. International students need to work hard in their studies to get the grants offered by Finnish higher education institution. (Info Finland 2020.)
Finnish culture and winter darkness (Kaamos)
Finnish culture is based on the Finnish values and customs. These include equality, trust, honesty and nature. Sauna is one of the important part of the Finnish culture. The Finns value this part of sauna as it brings relaxation. Other elements of Finnish culture include food culture which involves meat, fish, potatoes, rice or pasta. The Finns eat fairly common European food. Honesty and punctuality is part of the finnish culture. Time determines a person's personality. (infoFinland 2021.)
Most Universities of Applied Sciences in Finland have focused on admitting students of different backgrounds. These increase in number of students has been met with several obstacles both for the host country and the international students themselves. The students have their own cultural beliefs from their native countries which in most cases is different from the Finnish culture. For these students to live and pursue their studies in Finland, they need to adapt to the culture of their host country and this is achieved by the help of their learning institution. (Hsiao-ping Wu et al. 2015.) Transitioning to life abroad can be so hard for students and it is even harder when the culture is very different. The environment is unfamiliar and this can lead to stress and poor wellbeing of the international students. Lack of proper adjustment to the new and challenging environment and culture affects students and their academic success. (Turner 2017.)
Finnish climate is well known because of short summers and long freezing winters. Finn- ish winters is characterised by snow covering all land, hence a beautiful scenery and polar nights (Kaamos) the winter darkness. (StudyLink 2021.) Winters are the longest season with darkness, cold, wet and varying weather. The winter season aligns with some Finnish cultures for example the one that the children can sleep outdoor in the prams. Children sleeping outside in Finland is a normal norm. It is considered to promote health and well- being of the children since they enjoy long naps. (Tourula et al. 2013.) International nurs- ing students originate from different parts of the globe. They have different and diverse culturally experiences that are different from the Finnish ones. It is of great importance if the institution arranges a seminar to discuss about the different cultural elements and cre- ate awareness of the cultural differences. They can organise “International Students Day or week” every semester or occasionally. Having different cultures is richness and it im- proves the wellbeing of the students in a foreign land. The figure 1 below illustrates the
challenges that affects wellbeing of international nursing students at the centre and the ar- rows are pointing to the challenges away from their wellbeing. (Henrikson et al. 2019, Mik- konen 2017, Ruotsalainen et al. 2020.)
Figure 1. Challenges that affect wellbeing of international nursing students
Challenges that affects international
nursing students
Academic intergration
Clinical Practice
Language barrier Financial
Constraints Finnish culture and
Kaamos
3 Wellbeing of international nursing students in Finland
3.1 Defining well-being
Wellbeing can be defined as an individual having social, physical and psychological re- sources in order to meet one’s demands. It is also how one feels about oneself and one’s life. Wellbeing is linked to happiness and satisfaction which helps to improve the overall morale in a human being’s life hence increasing their productivity in what they do on daily basis. It includes aspects such as physical, mental, emotional, social, physiological, spiritual and environmental health. It also emphasises that wellbeing is the state of one’s personal life being satisfactory, desirable and feeling good. (Wilson et al. 2017.)
Wellbeing is being able to overcome life challenges and having a balance, that is being able to juggle between study life, social life and family life. The balance brings positivity, improves the quality of life, gives peace of mind and helps one to have sense of belongings in the society. (Uhlmann et al. 2018.)
3.2 Wellbeing at LAB
Institutions plays an important role in promoting students’ wellbeing. Students get better health and wellbeing through better schools. A comprehensive curriculum should fully sup- port the students and their families. Education and wellbeing are the core factors that need to be considered so that students are healthy and be able to learn. (Pulimeno et al. 2020.) At LAB University of Applied Sciences student’s physical and psychological wellbeing is promoted by the following themes: Well-being from physical activity and the living environ- ment, social inclusion and safety in everyday life, health promotion and smart self- care and Efficient service chains. International students are encouraged to get active in MOVEO- sports and well-being services. MOVEO is a joint sports and wellness service that operates both in Lappeenranta and Lahti. Its main aim is to provide sport facilities, services and ex- periences during studies. Students are encouraged to talk about small and big issue and participate in different kinds of sport activities like gym, going for swimming, taking a walk and guidance about hobbies and priorities. (eLAB 2021.)
LAB University of Applied Sciences have good resources to be utilised by all students.
These resources include gym, group exercise, ball games, break exercise. LAB has also sports and wellness specialist who is available anytime the students need help. (LAB Stu- dent Services, eLAB 2021.)
3.3 Promoting wellbeing of international nursing students in LAB
Wellbeing promotion involves stakeholders like school, entire society, Community and Fam- ily. Wellbeing promotion is an important part of nursing because it is a holistic intervention that improves daily living of a person. Nursing is a demanding career that requires full at- tention by the professionals. Grooming of competent nurses starts from schools and up to their future profession. When the wellbeing of international nursing students is of concern, it reduces the problems and burdens they face during their studies. (Pulimeno et al. 2020.) Promoting wellbeing is done to reduce the pressure that the students go through during their studies. To reduce stigma, stress, improve positive attitude towards seeking help and encourage them to speak out when faced with challenges during studies. Stress manage- ment skills is considered to be very important aspect for nursing students not only during studies but also in working and daily life. When stress is managed the level of production is improved. (Kurki et al. 2021.)
The figure 2 below illustrates the aspects that promotes wellbeing of international nursing students. These aspects include Availability of resources and counselling services, Physical activities, Contact with natural environment and Mentoring. The arrows pointing towards the centre indicates the main factors that promotes the wellbeing.
Figure 2. Aspects that promote well-being of international nursing students (Pulimeno et al.
2020; Pasi et al. 2021.)
Regular Physical activities as a self-care
Physical activities are a psychological factor that aims at promoting well-being of students.
It involves participating regularly to different kinds of exercises during school or during lei- sure time. To participate in physical activities, one needs to be determined and dedicated to the pressure that is involved in the process. Self-determination and attitude are factors that reflect how one is willing to perform according to the set target and plans. These factors can be positive or negative depending on performs. (Pasi et al. 2021.)
Physical activities activate and makes an individual to be active. Motivation is the main factor that enables the young adults participate in physical activities. Young adults are to be motivated to participate in physical activities like gym, sport clubs and taking a walk to the local forest may also improve their wellbeing. (Hilger-Kolb et al. 2019.) Participating in sev- eral physical activities enables one to take care of one's life. Self-care is the capability of
Aspects that promote wellbeing of international
nursing students Availability
of resources
Physical Activities
Mentoring Contact with
Natural
Environment
individuals and the communities around to assist in promoting and maintaining health. It also involves how one is able to cope with disability or illness even when they do not have a health care’s provider support. (World Health Organisation 2020.)
Available resources
Availability of resources at the campuses enables the students to be active and it improves their wellbeing. Resources available in the institution include gym, different types of indoor games at the lobby, hangouts and sports areas. Other available resources include MOVEO, KOE and Visit Lakeland. MOVEO is a sport and wellbeing service whose aim is to reduce monotony during long and tiresome lectures. There is availability of instructed breaks workouts which are offered for 10-15. The instructed breaks are found on an app called,
“Break pro”. This app can be installed on phone or computer and it helps take break exer- cises. KOE is a students’ union that supports and advice students about their privileges that will enable them to have a smooth and best time during their studies. Some of the privileges include student discounts from trains and buses, including long distant buses. Visit Lahti Lakeland is a website that is created to help international students discover and explore Lahti. It shows different places that can be visited in Lahti. (eLAB 2021.)
LAB University of Applied Sciences has a counselling department that helps students to cope with challenges they face during studies. The counselling department co-operate with the teacher tutors when supporting the students. (LAB University of Applied Sciences, eLAB 2022.) Academic institutions in Finland have set up centres for counselling to help students wellbeing. However, studies show that there is stigma associated with seeking help and students do not come forward to speak out their problems. The students' knowledge on seeking help when they feel disturbed can be improved by creating awareness of these services and making them as confidential as possible. Providing privacy can encourage students to use the services without feeling stigmatised or embarrassed. (Ahorsu et al.
2021.)
In Finland the responsibility of Finnish Students Health Services – FSHS is to provide stu- dents with health and medical care services, promote student’s health and ability to study and to promote the well-being of the study environment and student community. FSHS provides equal health care support to higher education students who have registered to bachelor and master’s level degree. Exchange students don’t have this privilege. (Finnish Student Heath Service 2021.)
Contact with the surrounding community and natural environment
Community is a setting or place in which people engage in daily activities whereby factors such as environmental, organisational and physical interact to affect health and wellbeing.
(World Health Organisation). Community also implies to a group of people who may not connect but they have or share a common interest, identities and concerns. (World Health Organization 2022.) According to Hilger-Kolb et al. (2019), community refers to geograph- ical and social terms where the residents have common responsibilities and concerns to issues that are of benefit to health promotion and disease prevention.
Studies have shown that being in contact with the natural environment like the parks, for- ests, beaches are linked to good health and wellbeing (White et al. 2019). A walk in the forest for 15 minutes for example decreases salivary cortisol levels which is a stress hor- mone (Song et al. 2016). Closeness to natural environment is so much associated with low stress levels and reduces depression and anxiety (Pearson 2014).
International nursing students can take advantage of nature-based health interventions (NBIs) and at the same time experience Finnish nature. NBIs are activities that are meant to involve people in experiencing nature while improving their health and wellbeing. (Sha- nahan et al. 2019.) LAB University of Applied sciences –Lahti is a modern learning environ- ment that was built and designed on former factory premises It has a mixture of old and new designs that provides a unique and inspiring environment that supports learning and working atmosphere. (LAB 2021.)
Mentoring
Mentorship is considered a very vital psychosocial involvement between nurse teachers, nurse mentors and nurse students during the clinical training. It is a professional relationship between the mentoring nurse and the student. This interconnection is based on mentors providing professional help to students, helping students to apply theoretical knowledge and encouraging the students during their clinical practices. (Tichelaar et al. 2013.)
Mentoring of nurse students during clinical practices requires various competences to make it a success. Good mentorship and relationship between the mentor nurse and students promote wellbeing of student during the clinical trainings. This relationship is based on trust and improves the students’ self-confidence too. Good mentorship of students gives future quality health care nurses. (Tuomikoski et al. 2020.)
Wellbeing of students is positively affected by nurse teachers who play an important role during the clinical placement of students. This cooperation leads to smooth transfer of the- oretical knowledge to practical knowledge. Teachers and nurse mentors work together in making this a success. (Mikkonen et al. 2021.) Mentors are very crucial too in guaranteeing the right skills to the nurse students (Tuomikoski et al. 2020).
There is a possibility of becoming very creative, easy in adjusting to future changes and foreseeing the future, conflict management, good communication skills and a great critical thinker when a mentee becomes self-empowered. There is evidence of togetherness that grows and develops between the student who is the mentee and the mentoring nurse. This closeness enables the mentee to be more creative and even be able to better develop his or her talents. (Grossman 2012.) The mentor is skilled, and the student is less skilled hence the main goal of mentoring is to increase the skills of the students too (Tuomikoski et al.
2020). During mentorship process the student builds networks he or she can turn to for advice and career guidance. These networks are useful to helping the wellbeing of the stu- dent when on clinical practice and when they transition to the working life. (Grossman 2012.) When teachers and the institution is aware of the factors that affect students’ wellbeing, the cases of dropout from the course are minimal. Students’ stress and burnout can be reduced by support from the teachers. (Spilt 2011.)
4 Methodology and guidebook developmental process
4.1 Practice Based thesis
This thesis is implemented as a practice-based thesis. Practice -based thesis is used to produce a guidebook, manual, video, posters or a report. The findings are used to enhance and enlighten the practice. (Linda & Ernest 2018.) Practice-based involves a commission- ing partner, who actively participate in the thesis process through discussion, assessment, evaluation and monitoring the direction of the research by giving feedbacks. This thesis is produced according to the need of the commissioning partner. Commissioning partner plays an important role during the development process of the research. (Salonen 2013, 16 -20.) The objective of this thesis is to produce some information about the challenges of interna- tional nursing students in form of a guidebook. This guidebook aims to promote the well- being of international nursing students and to bring up ideas on how LAB University of Ap- plied Sciences can support and promote international nursing students to cope during their studies.
Data is collected from reliable database searches like university online library Primo Lut which gives e-books and articles. Sources used include EBSCO, PubMed, Sage Journals online, ProQuest and Directory of Open access journal. Data is also collected from Medical and Nursing Associations websites – World Health Organisations, National Health Service and Google scholar.
4.2 PDSA model
PDSA model is a quality improvement model which is based on scientific method that takes immediate action through studies to implement changes that leads to improvement. This model ensures that all health care workers play a major role in improving quality in the health care setting. The PDSA model has four stages namely: Plan, Do, Study and Act.
Planning stage deals with the changes that needs to be implemented. In planning stage, this thesis is identifying the areas that requires improvement and it will be done in agree- ment with the collaboration partner. Do is concerned with carrying out the test or change, in this thesis the agreed areas of improvement will be tested to see if they can lead to any improvement of the situation of challenges of international nursing students. (Katowa et al.
2020.)
The authors of this thesis choice PDSA model because it is an effective and structured approach that is used for experimental learning and evaluation. The model is considered
appropriate and feasible to guide testing of changes to improve the quality of the final prod- uct. (Katowa et al. 2021.) This model is effective because it enhances changes on a small cycle and allows adjustments based on the data collected. Data and information can be improved and adjusted in every step as needed until the final product is ready. (Connelly 2021.)
Study is the measurable outcomes that is agreed upon before starting. Study also reflects on the impact and what has been learned during that process. (Katowa et al. 2021.) Act is basically planning what next and making changes to the guidebook based on the feedback.
This is a stage that looks into ways of implementing the recommendations in phase one.
(Green, Bonner, Teleni & Bradford 2020.) Creating a good guidebook
Guidebook is one of educational approaches used to present knowledge and information.
The content of the guidebook will be evident-based information presented in a logical, sim- ple and easily understandable format. There are steps to be followed when creating an effective and precise guidebook. The guidebook communicates information in a simple and clear language, it is short and direct to the point and captured all the important points that will benefit the reader. Good layout attracts, makes the guidebook more understandable, appealing and conveys the intended message to the target partner. A good guidebook mo- tivates and encourages the reader to continue reading. It should not be bulky but instate precise. (McCoy 2019.)
According to Centres for disease Control and Prevention centres (2009), a good guidebook follows a clear process when creating. These includes an appealing heading, font size, text appearance and clear content. Sticking to the target audience and choosing the kind of language to be used increases the effectiveness of the guidebook. Text appearance matters in the process. Recommended font size is 12 and 14 points, headings should appear bigger than the main text by 2 points larger and the font style should be clear for easy reading.
When choosing visuals, it is good to use simple and easy to understand images or symbols.
The audiences are attracted by the cover page of the guidebook, it should be attractive and have clear message.
A guidebook to LAB- university of applied sciences, student service department is the final product. The guidebook presents the challenges of international nursing students and pro- motion of their wellbeing for them to cope during their studies. The guidebook is simple, precise and to the point.
4.3 Development process of the guidebook
The creation of the guidebook followed a step- to-step process. The developmental process followed the PDSA (Plan, Do, Study, Act) model. Figure 3 below shows the authors step by step process until the production of the final copy.
Figure 3. Developmental process of the guidebook (Modified from Katowa et al. 2021).
• Commissioning partner was involved.
• Creating of quantitative evaluation questionnaire
• Designing of the guidebook
• Proposed changes were made using peer reviewed data analysis.
• Data analysis and evaluation
• Involving language supervisor.
• Ethical issues considered.
• The aim and the purpose of the guidebook was discussed with the co-operation partner
• Peer reviewed data about the challanges and how to promote international nursing students well-being was searched.
• Improvement goals we set.
• Nesessary changes made to the guidebook based on the feedback.
• Implement the changes to the guidebook
ACT PLAN
STUDY DO
The Plan Stage
The authors of this thesis started a discussion on the topic with the commissioning partner and agreed on the aim, purpose and the final product which is the guidebook. An agreement was signed by the co-operation partner, the agreement is called cooperation agreement as shown in Appendix 1.
The authors searched for information from sources like main University online library LAB Primo Library search engine, Google scholar, CINAHL, PubMed, EBSCO, ProQuest and Sage Journals Online. Data is also collected from online searches like Ministry of interior Finland, World Health Organizations and Centres for disease control and prevention. The keywords used to get reliable information for this thesis include international students, Chal- lenges, nursing students and wellbeing. The targeted articles or information was the peered reviewed ones. The theoretical framework was done based on the collected data.
The main goal of producing a guidebook is to ensure that LAB University of Applied Sci- ences through the student’s service are aware of the challenges of international nursing students and how to promote their well-being. The main idea is to have these students complete their studies smoothly and be competent nurses. The LAB students service is in cooperation with the authors of this thesis. It would not be possible to complete this work without the support of LAB student services. (LAB student services, eLAB 2021.)
The Do Stage (Implementation stage)
The changes proposed in planning stage are implemented. Implementation is not a smooth stage and it may not go as planned because improvement is hard in a situation that has always existed in a certain way. (Crowfoot & Prasad 2017.) The information collected from the different search engines mentioned above guided the creation of the guidebook at this stage. The guidebook was developed according to the criteria of a good guidebook. Rec- ommended font size was 12 and 14 points, headings should appear bigger than the main text by 2 points larger and the font style is clear for easy reading. Good clear visuals are simple and easy to understand, images or symbols are used. The cover page is made at- tractive and uses a clear language. The authors included simple pictures own picture to make the guidebook attractive
The knowledge based and guidebook were emailed to the co-operation partner and the authors received opinions and suggestions about the process. The co-operation partner commented about the changes which needed to be added to the guidebook to meet it’s aim.
Changes were made to the guidebook according to the given comments and emailed back.
The cooperation partner was sanctified about the process and the improvements made to the guidebook to produce the final version which will be beneficial to international nursing students.
Assessment and Action
The analysis of PDSA model is assessed at this stage and possible improvements are made to the guidebook. PDSA is a series of cycles process that is repeated until the final product is produced (Crowfoot & Prasad 2017). Feedback collected from 5 international nursing students from LAB University of Applied Sciences helped authors to evaluate if the guide- book meets its aim. Changes were made putting into consideration the received feedback that was given by the respondents. The guidebook was reviewed several times and correc- tions made before the production of the final product which meets its benefits.
The international nursing students specified their level of agreement about the guidebook based on five points that is a scale of 1 – 5. (1) Strongly Disagree, (2) Disagree, (3) Neutral, (4) Agree and (5) Strongly Agree. The questionnaire had seven questions and two open ended questions. The evaluation questionnaire together with the guidebook was send to LAB student service department and 5 international nursing students via email to get feed- back whether the guidebook was beneficial and meets the criteria of a good guidebook.
Ethical issues were considered. The students participated knowingly and voluntarily. The students had a right to choose whether to answer the questionnaire or to leave it unan- swered. The authors motivated the respondents and informed them how the data will be used, that their names will remain confidential. The table 1 below shows the questions asked and assessment of the collected feedback from 5 international nursing students.
Table 1. Summary of the Guidebook Assessment.
The comments that were collected from the questions helped the authors to make changes to the guidebook. The changes were made to the guidebook as follows:
The font sizes were made uniform and same style was used in every page. The words were shortened and made clearer to the point. Some pictures from Canva.com were added to the guidebook to make it more attractive to the reader.
The authors appreciated that the students gave their opinions and suggestions about the guidebook. In summary from the feedback, the aim was achieved because
(1) Strongly Disagree
(2)
Disagree(3)
Neutral(4)
Agree(5)
Strongly AgreeThis guidebook was easy to read 0 1 0 2 2
This guidebook was easy to un- derstand
0
0 1 1 3
This guidebook text was easy to follow
0 1 0 1 3
This guidebook is precise 0 1 0 1 3
This guidebook highlights the main challenges
0 0 0 2 3
This guidebook content suits the purpose
0 0 0 1 4
This guidebook benefits the tar- geted group
1 4
most of the respondents mentioned that the guidebook was beneficial to the tar-
geted group. The co-operation partner was satisfied with the thesis process and the
final product which was the guidebook.
5 Discussion
5.1 Ethical aspects and trustworthiness
Ethics takes into consideration choices and actions. It focuses on decision making about the rights and the wrongs. During the research, all work focused on protecting dignity of individuals and community. The values that a nurse should put into consideration during research includes society, nursing and science. (Georgia & Marianna 2011.)
This thesis process followed the ethical guidelines following the Act on University of Applied sciences (931/2014). The law requires all the students at University of Applied Sciences to adhere to the guidelines. When research deals with human beings, it should be carried out responsibly and in respect of human integrity. The guidelines focused on safeguarding hu- man rights when students are carrying out a thesis process. (Finlex 2020.)
During this thesis process the guidelines, regulations and requirements were followed.
The process involved a commissioning partner who filled the co-operation form and gave a permission for continuity of this thesis. This thesis is not aimed at causing any harm or misconduct but to provide knowledge. The authors of this thesis followed the guidelines and regulations given in Finnish National Board of research integrity (TENK). The re- trieved information was handled responsibly. “Responsible conduct of research and pro- cedures for handling allegations of misconduct in Finland”, as provided by TENK guide- lines of ethical considerations. (Finnish Advisory Board on Research integrity 2012.) Evidence-based referenced were used during the writing process. Reliable databases such as CINAHL, PubMed, EBESCO, Sage Journals was used to collect data. By using Lab primo we were able to access these databases. The information was handled with human dignity and privacy. (Georgia & Mantzorou 2011.) The authors were proactive to avoid pla- giarism and needed to be cautious when handling the collected data. Trustworthiness was considered during the writing process. Information given was reliable and credible and the data provided by LAB-students service were handled with confidentially. Feedback received from the respondents were handled in a trustworthy manner and analysed accordingly.
5.2 Implication for further studies
One of the hardest but necessary choices students make is to apply for studies outside their home country. These students have an unknown desire to explore the world outside of their comfort zone. The curiosity for better life and adventure pushes them harder to go out and
figure out life in a foreign country. In Recent years, this movement of students from one country to another and one continent to another has increased tremendously. However, these students knows at the back of their mind that it will not all be rosy and they prepare for challenges as much as they prepare for excitement but most of the challenges these students meet are totally unanticipated. (Besamusca 2011, 8-9.) These challenges varies depending on destination country of this students. In Finland, many international students fail to complete their studies or take too long to complete due to the challenges that they face. These students get into stressful situations when their goal of completing the course is delayed or never achieved. (Pitkäjärvi et al. 2012.)
The authors worked as a team during the entire process of writing the thesis. The commis- sioning partner was also involved in different stages of writing. The commissioning partner gave advice on what the LAB student services would need. The guidebook will be beneficial to these students because these challenges are common among international nursing stu- dents. The aim of the authors was achieved based on the received feedback from interna- tional nursing students and the co-operation partner. The guidebook which is the final prod- uct contains information on how to manage as an international nursing student in Finland.
It also contains links of places these students can visit for relaxation during their free time.
In consideration of the criteria of a good guidebook, the authors succeeded in creating it. It will be of great help to international nursing students to integrate to the society smoothly and to have a desire of a pleasant life as they serve the society in a foreign land.
During the process of data search, the biggest challenge was finding out the latest compre- hensive and authoritative information about the challenges of international nursing students.
Little research has been carried out. A lot of data indicates the general nursing students but not majorly international nursing students. Despite this challenge, the authors choose the materials carefully and the thesis writing process has been reviewed many times to improve its contents. The authors sourced evident-based materials from European countries and North America. Further research could focus on the long-term solutions for the challenges of international nursing students.f
For further studies this guidebook will be used to do more research about the challenges of international nursing students and solution on how to smoothly integrate into the Finnish system. The guidebook contains self-care tips which can be beneficial to other interested students. The contents are easy to understand and put into practice.
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