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INTRODUCTION Australia is becoming an increasingly multicultural nation. It is estimated that the Australian population includes people drawn from more than 200 countries. At the 1996 Census, 3.9 million people were born overseas, forming 23% of Australia’s population. There were 2.6 million people who spoke a language other than English at home (Australian Bureau of Statistics, 1998). As Australia becomes more diverse in cultural and ethnic dimensions, nurses will increasingly work with patients from manifold cultural backgrounds. English as a Second Language (ESL) or bilingual nurses can play a significant role in providing culturally congruent care to clients from diverse ethnic backgrounds. Similarly, it has been claimed that internationalised tertiary education has the potential to improve cross-cultural awareness and benefit both local and overseas students (Cecchin, 1998). However, some commentators consider that the recognition and inclusion of multicultural approaches to nursing education and curricula, as well as the acknowledgement of the importance of cultural phenomena in nursing practice, have yet to be fully realised in the Australian nursing context (Reid, 1994; Cameron-Traub and Stewart, 1996). The opinions of students about nursing curricula and teaching-learning processes do not constitute mainstream nursing knowledge in Australia at present, even though University courses are routinely assessed and academic teaching is often evaluated by students. Consequently, the present authors deemed it important to aim to understand and publish the views and the experiences articulated by a small number of international undergraduate nursing students who participated in recent qualitative research interviews. Nursing and Health Sciences (2000), 2, 163–171 Research Article ESL undergraduate nursing students in Australia: Some experiences Anita Shakya, bn and Jan M. Horsfall, rn, phd Division of Nursing, Faculty of Health, University of Western Sydney, Macarthur, Sydney, New South Wales, Australia Abstract This study explored some experiences of nine English as a second language (ESL)/international nursing students during 1 year of their studies at a large Australian university. From the student narratives, two broad categories emerged to describe the nature of their experiences, namely, challenges and supports. First, the challenges encompassed the themes of: language, which included the technical aspects of language, speaking and listening, and interaction in tutorial group situations; perceptions of ethnocentrism; and lack of orientation. Second, the supports included: University-related support; support from friends and family; and the students’ own personal strengths and strategies. The participants of this study faced various challenges and also struggled to overcome their difficulties through diverse means. Suggestions arising from this research include improving student support systems and increasing awareness of cultural differences among the nursing faculty and registered nurses. Key words Australian nurse education, ESL (English as a second language) nursing students, international nursing students, internationalisation of tertiary education, multiculturalism, university learning support infrastructure. Correspondence address: Jan M. Horsfall, Division of Nursing, Faculty of Health, University of Western Sydney, Macarthur, PO Box 555, Campbelltown, NSW 2560, Australia. Email: [email protected] Received 7 March 2000; revised 29 September 2000; accepted 3 October 2000.

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INTRODUCTION

Australia is becoming an increasingly multiculturalnation. It is estimated that the Australian populationincludes people drawn from more than 200 countries.At the 1996 Census, 3.9 million people were bornoverseas, forming 23% of Australia’s population.There were 2.6 million people who spoke a languageother than English at home (Australian Bureau ofStatistics, 1998).

As Australia becomes more diverse in cultural andethnic dimensions, nurses will increasingly work withpatients from manifold cultural backgrounds. Englishas a Second Language (ESL) or bilingual nurses can play a significant role in providing culturally

congruent care to clients from diverse ethnicbackgrounds. Similarly, it has been claimed thatinternationalised tertiary education has the potentialto improve cross-cultural awareness and benefit bothlocal and overseas students (Cecchin, 1998). However,some commentators consider that the recognition and inclusion of multicultural approaches to nursing education and curricula, as well as theacknowledgement of the importance of culturalphenomena in nursing practice, have yet to be fullyrealised in the Australian nursing context (Reid, 1994;Cameron-Traub and Stewart, 1996).

The opinions of students about nursing curriculaand teaching-learning processes do not constitutemainstream nursing knowledge in Australia atpresent, even though University courses are routinelyassessed and academic teaching is often evaluated bystudents. Consequently, the present authors deemed itimportant to aim to understand and publish the viewsand the experiences articulated by a small number of international undergraduate nursing students whoparticipated in recent qualitative research interviews.

Nursing and Health Sciences (2000), 2, 163–171

Research Article

ESL undergraduate nursing students in Australia:Some experiences

Anita Shakya, bn and Jan M. Horsfall, rn, phdDivision of Nursing, Faculty of Health, University of Western Sydney, Macarthur, Sydney, New South Wales,Australia

Abstract This study explored some experiences of nine English as a second language (ESL)/internationalnursing students during 1 year of their studies at a large Australian university. From the studentnarratives, two broad categories emerged to describe the nature of their experiences, namely,challenges and supports. First, the challenges encompassed the themes of: language, whichincluded the technical aspects of language, speaking and listening, and interaction in tutorialgroup situations; perceptions of ethnocentrism; and lack of orientation. Second, the supportsincluded: University-related support; support from friends and family; and the students’ ownpersonal strengths and strategies. The participants of this study faced various challenges and alsostruggled to overcome their difficulties through diverse means. Suggestions arising from thisresearch include improving student support systems and increasing awareness of culturaldifferences among the nursing faculty and registered nurses.

Key words Australian nurse education, ESL (English as a second language) nursing students, internationalnursing students, internationalisation of tertiary education, multiculturalism, university learningsupport infrastructure.

Correspondence address: Jan M. Horsfall, Division of Nursing, Facultyof Health, University of Western Sydney, Macarthur, PO Box 555,Campbelltown, NSW 2560, Australia. Email: [email protected] 7 March 2000; revised 29 September 2000; accepted 3 October2000.

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164 A. Shakya and J. M. Horsfall

METHOD

This empirical research was carried out by aninternational nursing honours student who hadcompleted her undergraduate degree at theUniversity at which the research participants werestudying. Ethics approval was granted by theUniversity prior to data collection.

Initially, research information sheets were displayedon student notice boards. In addition, announcementsabout the research were made to students at thebeginning of one 1st, 2nd and 3rd year nursinglecture, and research information sheets weredistributed to the students in these groups. Only fourstudents contacted the researcher to participate inthis study within the first 4 weeks. As the researchtimeframe was limited to one academic year and busyprospective respondents were highly focused on theirwork, a snowballing (or nominated) sampling methodwas then utilised to locate more participants (Crookes& Davies, 1998).

The study drew on Van Manen’s (1990)hermeneutic phenomenological framework as thebasis of research inquiry for guidance in method and data analysis. Semi-structured interviews thatlasted between half and one hour, were audio-tapedand transcribed verbatim. The researcher began eachinterview with a broad open question seeking theparticipant’s view of experiences they had as studentsthat they considered to be important.

The nine ESL/international nursing students whoparticipated in this research came from six differentcountries: three from Vietnam, two from Ethiopia andone each from Iran, Nepal, the Philippines and SouthAfrica. (One of the interviewees came from the samecountry as the primary researcher.) All participantsare women and their age at interview ranged from 23 to 42 years. This is consistent with Wang and Lethbridge’s (1995) comment that internationalnursing students are more likely to be female,mothers, older than other students and have anestablished career. Each participant has been given a pseudonym by which they will be referred tothroughout this paper.

The participants

Jyoti

Jyoti is an international student who had been livingin Australia for 3 and a half years. She had com-pleted a nursing course in Nepal and worked as astaff nurse before coming to Australia. She is in hermid-20s.

Hang

Hang is a Vietnamese student in her early 20s whowas particularly uneasy about participating in theproject. She has been living in Australia for 8 yearswith her family and completed her high schooling inAustralia. She is doing the course part time and isstrongly committed to finishing the program.

Bapindi

Bapindi is an international student in her early 40swho had been living in Australia for 15 months. Sheheld a position of Charge Nurse in South Africabefore coming to Australia. She lives with her 10-year-old son. Her husband and other children haveremained in South Africa.

Mita

Mita is a 29-year-old Ethiopian woman who had beenliving in Australia for 5 years. She works part time ina nursing home as an assistant in nursing. This is her1st year at University.

Bugan

Bugan is an international student in her mid-20s. Shehas been living in Australia for 4 months with herrelatives. She started her nursing training in thePhilippines; and she began her studies in Australiafrom the 3rd year.

Ritu

Ritu, in her mid-20s, is an international student fromEthiopia. She has been living in Australia with herrelatives for 2 and a half years. She originally trainedand worked as a schoolteacher in Ethiopia.

Lyn

Lyn is in her late 20s and migrated to Australia fromVietnam 7 years ago with her family. She completedher high schooling in Australia and enteredUniversity immediately after gaining her higherschool certificate. She recently completed the finalyear of her nursing studies.

Dinh

Dinh is a Vietnamese woman in her early 40s and has been living in Australia for 10 years. She was a midwife in Vietnam and was especially keen to

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participate in this nursing research. She works parttime with disabled children.

Sara

Sara is a woman in her early 40s who migrated toAustralia from Iran 8 years prior to the interview.She lives alone. She was a qualified nurse in Iran andworked in this capacity for a few years before comingto Australia. To support her studies she works casuallyas an enrolled nurse in a hospital.

RESULTS AND DISCUSSION

The transcripts of the interviews were studiedintensively and the main issues articulated by theparticipants were highlighted, coded and clustered.These issues were then categorised into themes thatmade up two broad categories: (i) challenges and (ii) supports. First, within the category of challengesthere are several topics: language; perception ofethnocentrism; and lack of orientation. Second, theparticipants discussed support from the University,friends and family; and their own personal strengthsand strategies, and these were deemed to constitutethe category of supports.

Challenges

Language

The strongest finding from this study was that most ofthe participants experienced difficulties with variousaspects of language. This may not be surprising ornew but it was the primary concern (and problem)broached by each interviewee. They described thelanguage difficulties in terms that related to technicalaspects of language, speaking and listening, andinteraction in tutorial groups.

Technical aspects of language

The international students who were involved in thisstudy had achieved an IELTS (International EnglishLanguage Testing System) score of at least 6.0. (TheIELTS score ranges from 1 to 9, with some Australianuniversities requiring a score of 6.5.) While their levelof English was adequate for conversation and non-discipline-specific reading, higher levels of proficiencyare required to successfully grapple with verbal andwritten academic demands within the nursing course.All of the participants experienced difficulty in atleast one of the areas of listening, speaking, readingor writing. These findings support those of Wang andLethbridge (1995), who argued that although students

must achieve a certain level of language proficiencybefore entering the University, this does notnecessarily indicate the range of adequate languageskills required to study nursing courses.

Phillips and Hartley (1990) point out that ESLnursing students:

. . . are required to read with speed andcomprehension, speak clearly, write cogent essaysand reports, understand and take notes fromlectures, and employ effective study techniques(p. 29).

Learning a new vocabulary, grammar and academicwriting along with having to explore and understandconcepts from nursing, the bio-sciences and socialsciences is difficult. Such experiences may directlyimpede the academic achievement of students in thissituation (Phillips & Hartley, 1990).

The majority of participants identified problems in expressing themselves in writing. They said thatwritten English grammar was very challenging.Several participants said that their English vocabularylimitations became evident in their studies but werenot so obvious in social conversation. Many studentsfound medical terminology to be difficult tounderstand and master, and dealing with these termsconsumed a lot of time in assignment writing.

Misunderstanding of assignment and examquestions resulted in receiving low marks or failingexams. Several participants said that they wasted a lot of time looking for information that was not rel-evant to the topic of the written assignment. Theyconsidered that this expenditure of non-productivetime became a stressor when assignments in dif-ferent subjects were due for submission one after theother.

Speaking and listening

Effective communication is a significant part ofnursing. Nursing students are expected tocommunicate well with patients, registered nurses andother health personnel. The nursing students whohave difficulties in spoken English face negativereactions during the course of conversation in bothclassroom and clinical situations. These experiencesmay decrease their confidence when speaking.

Some participants were very concerned about theiraccent and speaking style and they were doubtful thatthe listeners would understand them. Menon (1992)indicates that their concerns may be realistic:

Australian nurses rarely listened for longer thanten minutes to someone whose pronunciationwas difficult to understand. They become restless,

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they changed the subject or they interrupted sothat they could speak instead (p. 330).

Although this claim is not representative of theresponses of all Registered Nurses (RNs), it indicatesthat speaking with a discernible accent may createchallenges for both speaker and listener.

Before [verbal] presentation, I prepare myself athome and everything . . . And when I come andgo there and stand up in front of the students, Isay ah, what am I going to say and forget aboutwhat I am talking and I’m just thinking about mylanguage and my accent. And I think the studentsdon’t understand what I am talking ah . . . it’sdifferent when you’re speaking, your accent isdifferent from the students who speak English asfirst language [Ritu].

Lack of interaction from the tutorial group duringverbal presentations made Bugan feel that the otherstudents didn’t understand her, but she says:

. . . sometimes the rest of the class go ah . . . as if they didn’t understand me what I am talkingabout so I just felt never mind . . . they don’t ask questions anyway so I pretend that theyunderstand what I am saying.

In this instance the lack of classroom interactionprompts the ESL student to ask herself whether itmeans that others do not understand her use oflanguage.

The participants also expressed difficulty inlistening. Mostly it was because of quickly spokenEnglish along with the use of long, unusual orcomplicated words. Having to ask people to repeattheir words by frequently using apologetic phrasessuch as ‘I beg your pardon’, ‘pardon me’, ‘sorry’ madethem feel embarrassed and frustrated. Some studentsjust pretended that they understood. This is not anunknown response (Dijkhuizen, 1995), however it is astrategy that may not be helpful in study situations.

It is not always possible to have verbal informationrepeated. Lectures can be confusing for ESL studentsbecause new concepts and unfamiliar words areutilised (Phillips & Hartley, 1990).

Interaction in tutorial groups

Sharing ideas with other students in the tutorial classis a part of learning in many contemporary Westernclassrooms. As Cecchin (1998) points out, studentsfrom South-East Asia in particular may be imbuedwith beliefs about the high status of teachers or they

‘may show respect by not speaking until spoken to’.Most of the participants in this study come from aneducational culture where students’ opinions are notsought by the teachers.

Social rules and expectations of ‘obedience andconformity’ (Cecchin, 1998) may prevail in the familyand social milieux with which the research par-ticipants are most familiar. Having come from thiscultural and educational background most of theparticipants felt uncomfortable asking questions ofthe teacher or participating fully with other studentsin classroom situations.

Culture may be defined as ‘. . . transmittedknowledge, values, beliefs and customs in a givensociety’ (Sargent, 1994, p. 76). The absorbed andreproduced ways of interacting, rituals of politenessand the acceptability or not of some forms ofemotional or verbal expression become part of aperson’s ongoing ways of participating in the socialworld. Lyn acknowledges this internalisation and itspotential to inhibit learning in an educational settingimbued with quite different values and expectations.She said:

. . . somehow it has still got something inside likethat culture inside you know. So I think that isone thing that affects my study as well. I don’tblame the culture but it’s already inside me. . . .

In some nursing tutorials students are required towork together and present their information as partof a small group for assessment purposes. Severalparticipants described distressing incidents when they were unable to join a group and were left bythemselves. Dinh and Sara shared similar experiencesabout how hard it was for them to be in a two-to-three person group for verbal presentations. Dinhsaid:

When I got in the class, they already hadgrouping for the presentation. I was out of group.I still try to participate and join the group. Iunderstand my circumstances and situation. Iasked too many of them and I inside myselfwanted to do all by myself but that was a grouppresentation not the individual . . . I asked all ofthem even they neglected me. I still tried. It’sreally really hard for me because they neglectedme but still tried to ask them if I can join theirgroup and work with them. And at the end, theysaid they all full . . .

The nursing education literature reveals thatalthough many academics are aware of the difficulties

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faced by minority students, at times the students areleft with mounting problems that result in anacademic failure, when actions could have been takento prevent or minimise such a crisis (Colling & Liu,1995). Some academics do facilitate discussions aboutforming student study groups or advocate for astudent who is having trouble joining a group.However, the common bureaucratic expectationwithin universities at present is that it is the students’responsibility to negotiate their way into a workinggroup. This is presumably based on the falseassumption that all students have equal skills inmanaging such processes.

These alienating experiences may not be common,but this research reveals that they do occur. Mitasadly described her experience of working solo in alaboratory class. Having to do group work by herselfwas hard—if not impossible—and the outcome wasan academic failure.

If you don’t have a group, you can’t do somequestions, for example, tutorial questions, andsometimes essay or lab report. As for example, alab report, we did an experiment and other groupthey interacted each other and discussed why it iscoming wrong in the solution. They interactedeach other and talked about that and they gotthe solution but I didn’t get some of the answers.I did by myself and I failed. It was the hardestthing for me [Mita becomes tearful].

Additionally, many participants said that they didnot feel confident enough to ask questions in theclassroom because of their accent, or perceiveddifficulties in speaking English. However, many ofthem managed to find one or more individualacademics with whom they could comfortably discussspecific topics or resolve difficulties on a one-on-onebasis.

Group discussion, verbal presentations and askingquestions of the teacher in tutorials are theexperiential norm for most Australian high schoolgraduates. However, it is likely that the researchparticipants’ lack of familiarity with the contemporaryWestern classroom expectations may negativelyinfluence their confidence, interpersonal interactionsor academic results.

Perceptions of ethnocentrism

Some nurse educators in multicultural democraticcountries (e.g. the USA and Australia) have beencritical of mainstream nurse education curricula. Attimes the curriculum content and processes do not fit

well with the cultural issues central to studentlearning styles or patients’ health/illness orientations.Among other commentators, Kurz (1993) considersthat a mono-cultural approach to nurse educationultimately impoverishes both students and teachers.

In Australia, Reid (1994) and Omeri (1996), forexample, deem that nursing education continues toreflect the values and health orientations of theAnglo-Celtic mainstream. Furthermore, this is notconfined to education but occurs in the healthservices. Omeri and Nahas (1995 p. 150) state that‘. . . often western cultural values, beliefs and practicesdominate decision making in nursing’ and medicine.

Ethnocentricity involves comparing other cultureswith one’s own and judging the latter to be superiorat least in some important respects (Giddens, 1993).Some research participants noticed what seemed tobe ethnocentric behaviours among some students,lecturers, clinical facilitators or patients.

The verbal and non-verbal behaviour of somenursing students are interpreted negatively by someof the research participants:

Because of my English again I feel isolatedbecause if I say something, they go ahrr . . . whatdid she say? But it is all right because it’s my first time. Sometimes I feel they are annoyed sosometimes I don’t like to communicate withthem [Bugan].

Sara shared a story about classmates refusing tohelp her. She does not name this unhelpfulness orwithholding as ethnocentrism and wonders out loudto the interviewer if this unkindness is related to the age difference between herself and most otherstudents.

Maybe we have some students, they get togethermaybe because they from the beginning togetherand another thing is young people don’t mix withthe old people here . . . and they study togetherand when I ask them a question, they say, ‘wedon’t know, we don’t know’. But at the end, theyget good marks. If they don’t know, how do theyget the top mark? Honestly, I have been a lot oftime I faced it . . . I don’t think anything willchange for them if they explain. Maybe their ageis different.

Some nurse education research in the USA showedthat black students are treated differently by facultymembers and other students, presumably on the basisof racial stereotypes. Rodgers’ (1990) study showed ahigh level of racism, social isolation and alienation

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experienced by minority students on predominantlywhite campuses.

Some of the research participants perceivedethnocentric behaviours from patients and RNs onoccasions during the clinical placement:

I am not sure whether there is a rejection or theydon’t feel very comfortable if you are around. Iremember one day, a certain man [male patient]said to me, ‘why don’t you call somebody tocome and help me’. Then I said, ‘I am here tohelp you. I am not going to call anybody becauseI am allocated to you and I am going to do mywork’. Then I could see that he was not veryhappy because he wanted somebody else. I don’tknow. I don’t know. Whether he wanted him[male nurse] because he was a male or he wantedhim because of colour differences. I don’t know.Then anyway we continued [Bapindi].

Inadequate orientation

The students involved in this study, especially theinternational students, raised issues relating to aninadequate orientation to the faculty of nursing.These students received a brief orientation from theUniversity initially, which was not sufficient toprepare them to start the course and prepare themfor clinical placement.

Some participants started the nursing course in the2nd or 3rd year. They were granted exemptions forsome subjects because of their previous experience innursing. Having to go out on clinical placement withinthe first few weeks of study was hard for thosestudents who were new to this country.

During my first clinical [placement], my problemwas transport. I don’t have a car and I didn’tknow where the station was. Yeah, I know wherethe [train] station is but I didn’t know the routeto go to the hospital. That’s the main problem Iget [Bugan].

At one level the transport problem is compara-tively simple, but newly arrived people do not haveinstant knowledge of the host country’s large city andcomplex transport systems.

Supports

Most interviewees gained pivotal assistance fromlecturers in the Student Services Division (SSD), afacility offering services to specifically support studentlearning and development. Others were able to

receive help from nurse academics, classmates orfamily. Some felt supported by the facilitators onclinical placement.

Support within the university

The students received assistance from the SSD inareas such as grammar, essay writing, referencing andwritten presentation style. Some participants alsosought help from the counsellors at SSD to discussand resolve personal problems.

All participants were happy that most of thenursing lecturers were willing to further clarifyassessment items and provide direction.

They helped me in every way. If you don’tunderstand the question, they will explain. If youdon’t understand the criteria, what you areexpected to write in that essay or presentation,they will say exactly what they want you to do . . .Yeah they are good . . . If I didn’t understandwhat the criteria really meant, I went to thelecturer. They were very good and helpful . . .[Jyoti].

Hang shared her story about how one of theacademics helped her to gain confidence in the class:

Sometimes but not very often though, I ask thelecturer who that I know is really kind of friendlyto students. For example, now I have ***[lecturer’s name] lecturer right, he is quite goodand he knows that I am a really shy person. Sohe came and asked me if I need anything and heasked me in the class so that I can participate inthe class. So now I am kind of improving myconfidence around the class. But I don’t really goand ask for help much with the lecturer and staffbut my friends yeah.

Bapindi was able to identify a specific difficulty anddiscuss it with a lecturer, which helped her to copewith the situation. She stated:

. . . they are quite helpful, some of them anyway

. . . we discussed my problems. It was not a verybig problem but I felt there was a problem butanyway as I said I was able to cope.

Positive written or verbal feedback from the lecturerswas very encouraging:

. . . he [lecturer] gave me a really good feedbackfor my assignment, which gave me the energy . . .

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He said, ‘you did very well . . .’. I felt good andproved of myself [Dinh].

Clinical experience is an essential part of a nursingprogram. This is the area where the students put theirknowledge and nursing skills into practice. Placementin specialised clinical areas could be particularlychallenging for ESL students because they areexpected to learn and deal with multiple complexclinical problems, often in a highly technologicalenvironment. The research participants neededadequate support from the clinical teachers tofacilitate this multifaceted learning.

The learner–teacher relationship is crucial for manystudents to render clinical experience meaningful andlearning effective. Grigsby and Begel (1995) arguethat it is important for nursing students to feel valuedin the clinical and academic settings and be respectedand cared for in ways that model the provision ofnursing care to patients.

Lucky most of the time I get the good facilitator.It keeps me motivated because of their attitude. . . she explained everything to me. She is alwaysthere for us . . . I feel safe that I have a facilitatorthere to support me and teach me. It’s not themto challenge me or undermine me because I’m astudent. I have to struggle with the patient andRN. Without the support from the facilitator, Iam really really alone and frightened [Dinh].

Peer and family support

The majority of students in this study interacted mostfrequently with people who shared their language orcultural background. Feelings of security and comfortfrom being with people of similar cultural backgroundprovided special support. These relationships oftenhad high interpersonal significance. Lyn and Hangboth said that they felt comfortable working withother ESL students in a group and asked questions ofeach other because they believed that they had thesame learning challenges. Such sharing and mutualsupport helped decrease feelings of isolation andreinforced their sense of personal competence andhope.

Having a nurse in the family was very helpful forLyn. She stated:

. . . when I got a problem, I go home and talk tomy sister and my family. Especially, one of mysisters is a RN. She gave me every example.

Being away from home, missing her family andstudying in Australia was hard for Bapindi at the

beginning. Fortunately, a little later she was able tobring her son to live with her, which made herhappier:

Now I have him [her son] here and we chat, wetalk and we laugh. I think things are better now.

She also said that she received a lot of help fromfriends regarding clinical experience.

Personal strengths and strategies

The participants in this project identified several per-sonal strategies to overcome their various problemsand enhance study effectiveness. Drawing diagrams tohelp understand anatomy was beneficial for Dinh.She also consciously increased eye contact to get theaudience’s attention during verbal presentations toincrease the likelihood of dialogue. Hang stated:

I try to kind of learn to remember my presen-tation so I can have eye contact and gain themark on that. And I try to speak as loud as Icould because the accent I cannot do much aboutit.

Reading more and speaking with others in Englishwere also considered to be useful approaches toenhance learning and language facility. Someparticipants chose to withdraw from one or twosubjects each semester to concentrate their focus on adecreased workload.

Having a strong spiritual belief was a significantsource of strength for Lyn. She reported:

I got a support from my own belief as well. Ibelieve in God and pray to God.

She felt that her faith in God would give her strengthto overcome her life problems and difficulties.

Although the research participants had languagedifficulties on top of University study, several studentsrevealed a strong determination to successfullycomplete the course. They described several ways ofmotivating themselves to keep on going and beoptimistic. Dinh praised herself for being good inmathematics. She remembers one of the lecturerssaying that ‘we need ESL students’. That made herfeel that she will be able to do something for societyby at least helping the people from her own back-ground when she graduates. Ritu was determined tofinish her course, as she saw good future opportunitiesrelated to gaining a nursing degree in the Englishlanguage and in a country like Australia.

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Many international nursing students gain pride anda sense of achievement from, or despite, theireducational and social struggles (Wang & Lethbridge,1995). Both Dinh and Sara are strongly committed tonursing. Dinh recognises herself as a caring personand said:

. . . I know my characteristic that I love caring forpeople . . .

Similarly, Sara voiced her appreciation of theAustralian health-care system:

I like the way nursing is here. The workplace, Ilove it . . . That’s the best thing I can say.

Some immigrants from non-English-speakingbackgrounds face enormous communication problemsupon arrival in the host country (Cameron-Traub &Stewart, 1995). Although interpreter services havebeen introduced into the health-care system, they areoften insufficient to fulfil the demands and needs ofall clients. Furthermore, Blackford’s (1997) Australianresearch has shown that many nurses do not fully use interpreters for a range of clients. The researchparticipants commonly recognise these patientdifficulties (in part from their own experience) andfelt good about being bilingual. They expressedpositive views about clinical experience when theywere able to explain or translate medical or nursinginformation to patients who didn’t understandEnglish well (cf. Gonda et al. 1995).

Sometimes I find with the patients. You comeacross the patients like they speak different andthey don’t know English and you know and canexplain it and you find it much good and you getfeedback [Sara].

Implications arising from the study

The courage and determination of many ESL nursingstudents and the hard work involved in coming togrips with multiple social, educational and clinicalissues need to be more broadly understood andacknowledged. This study indicates that supportsystems need to be improved to enhance studentclassroom and clinical learning effectiveness. It isimportant for nursing education providers to considersuggestions made by ESL students themselves.

In the USA, Colling and Liu (1995) identified that it is important to provide a good orientationprogram and to have nursing faculty mentors withwhom nursing students can discuss educational and

clinical difficulties. To maximise the learning ofinternational students, they suggested strategies suchas intensive English classes related to generalconversational language as well as the technicalterminology used in nursing, seminars about theculture and customs of the host country, supportgroups and buddy systems, as well as increased facultycultural awareness.

Most of the research participants felt that theyneeded more support from nursing lecturers and theSSD. Although the SSD is a very valuable Universityservice, some students found the traditionalconsultation time to be too short. It is also importantto equip the SSD with a sufficient number ofacademics—which is likely to involve increasedfunding. The students also perceived that continuityof personnel would improve the effectiveness of theSSD educational support.

Proponents of international education claim that it has the ‘potential to foster cross-cultural aware-ness and facilitate teaching innovations that willbenefit both international and Australian students’(Cecchin, 1998). However, for this potential to betruly realised, the tertiary education sector mustprovide and maintain a supportive educationalinfrastructure. This ultimately requires ongoingfinancial support. Education internationalisationcannot earn profit for universities and serendipitouslyimprove intercultural awareness, broaden theknowledge base of academics or teach studentstolerance and mutual respect, without the necessarysupporting structures.

The Australian tertiary education sector must notonly encourage international students, but univer-sities should provide appropriate and sufficientservices to assist them to complete their studies.This research also challenges nursing academics andclinical teachers to view nursing not only from abroad multicultural context, but from multi-ethnicnurse and patient perspectives to create learningenvironments that prepare diverse graduates forincreasingly complex intercultural nursing practice.

ACKNOWLEDGEMENTS

The authors wish to thank the nursing students who participated in this research by devoting theirvaluable time and sharing their experiences.

REFERENCES

Australian Bureau of Statistics. Australia in Profile—aRegional Analysis, 1996 Census of Population andHousing. Canberra: Commonwealth of Australia, 1998.

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