International student nurses (ISNs) in the UK often experience significant shocks in different settings at different phases during their studies. Cultural shock is often understood as part of the experience of adjusting to an unfamiliar environment (Presbitero, 2016). ISNs may experience these in three key settings: academia, practice placements and their social lives. The authors acknowledge that such shocks happen in distinct phases and recognising them is crucial to providing targeted support. This article will explore these issues, drawing on the authors' professional experience as educators to recommend viable solutions to improve the university experience of ISNs. It will delve into the academic challenges ISNs encounter and the essential support they need to thrive while they are in their UK host institutions.
Culture shocks
Within the academic context, international students encounter several cultural shocks, one of which is the difference in teaching styles. In UK higher education institutions (HEIs), there is a significant emphasis on critical thinking, self-directed learning and interactive participation. This approach to learning stimulates students to engage actively with different literature and resources, challenge established ideas, and expand their perspectives. Shaheen (2016) recognised that international students may face significant difficulties because they have little experience of the critical thinking and reflective practice that they will need in their studies in the challenging educational landscape of the UK. International students may come from cultures where rote learning is deeply embedded, information is commonly presented in a straightforward manner, and traditional didactic pedagogies persist where students heavily memorise and reproduce the same knowledge (Tan, 2011; Loh and Teo, 2017). Thus, transitioning from one context to another presents a change in mindset, practice and learning. The expectation to take charge of their own learning and participate actively in class discussions often requires ISNs to develop new skills and adapt to this new environment.
Transitioning to the UK
To facilitate the initial transition of ISNs, universities must manage academic expectations from the outset. This process can be initiated prior to arrival and complemented during the induction period. The Quality Assurance Agency for Higher Education (QAA) (2023) recommends that all information for international students is provided promptly, comprehensively and transparently. Providing simple yet clear guidelines on academic norms and support services available in the university can help ISNs better prepare for this transition.
Beyond ensuring the timely provision of admissions and arrival processes, ISNs must also receive accessible and accurate information regarding the specific expectations of nursing education in the UK. From the authors' experience, the anxiety ISNs often feel before moving to the UK is largely driven by their ‘fear of the unknown’ – questions about life in the host institution, the structure and requirements of the nursing programme, new pedagogical approaches they will encounter, and expectations for their performance academically and during placements.
The challenge, however, lies in providing accurate and relevant information in an accessible format. One potential intervention to address this could be developing an interactive pre-arrival course specifically designed to help ISNs acclimatise to the academic standards and nursing practices in the UK. Alternatively, a consolidated, user-friendly document could be provided, offering essential information about living, studying and nursing in the UK in a practical, easy-to-navigate format. It is inadvisable to send ISNs lengthy and hard-to-read programme handbooks or multiple emails containing several links to internal and external resources, as this can be confusing and overwhelming. Although ISNs may not fully digest all the information provided, the goal is for them to begin to recognise the fundamental differences in academic and professional expectations and use this understanding to plan and prepare in advance.
Academic writing and assessment
Teaching methodologies in pre-registration nursing education often come with diverse assessment methods (Nursing and Midwifery Council, 2010) with which ISNs may not be accustomed. ISNs may experience shock at such assessments, which leads them to struggle with their course. In the UK, HEI assessments are often essay-centric and reflective, with the aim of evaluating one's ability to bridge the theoretical knowledge-to-practice gap while engaging in critical discussions and personal and professional reflections. These assessment techniques can be unfamiliar and overwhelming for ISNs. The shift from ‘information reproduction’ to ‘knowledge production’ demands that ISNs reshape their approach and accommodate different forms of academic rigour.
Academic English writing and skills are not inherently intuitive to all students, and they often present considerable challenges, particularly to those new to the academic environment. However, ISNs face unique difficulties in this regard. This is primarily due to the explicit and implicit expectations and requirements of western writing conventions and models in HEIs. Such expectations place a significant burden on ISNs, whose cultural and linguistic competencies are often viewed as deficient when compared to western writing traditions and standards of communicative practices (Maringe and Jenkins, 2015). Although international students face strict English language requirements upon enrolment in the programme, academic writing from a British perspective necessitates ISNs to manage the friction between the standards of their host institutions and the communicative practices familiar to them and the discourse approaches deeply rooted in their own cultural contexts (Alegado, 2024).
Universities should consider offering a series of academic English writing and skills workshops, ideally before the start of the nursing programme. This early intervention is crucial as it equips ISNs with the foundational skills to transition into ‘knowledge production’, thereby bridging the gap needed for academic success within a UK HEI framework. However, to ensure sustained progress, these initial workshops should be supplemented with ongoing support sessions, either through personal tutoring or an adjunct English-as-a-Second-Language course throughout the nursing programme. As the level of difficulty increases as they progress in their studies, the expectations for English proficiency, writing standards and critical thinking also increase.
To truly benefit ISNs, these support sessions should not be standalone events but carefully integrated into their academic timetables. Aligning with key assessment dates can create a seamless connection between the support provided and their immediate educational needs. This purposeful alignment will help them view the support as an integral part of their nursing education rather than an optional extra. Such an approach not only improves their writing skills but also fosters greater confidence and academic success as they navigate the complexities of a pre-registration nursing programme.
Classroom culture
The informal and collaborative nature of classroom interactions in the UK can be another source of cultural shock for ISNs. In many UK institutions, it is common for students to address faculty members by their first names and to engage in open, egalitarian discussions during lectures and seminars. This informal atmosphere can be unsettling for ISNs from cultures where there is a strict hierarchy between students and teachers and where respect is shown through formal address and behaviour.
‘Cultural safety involves actively listening to diverse student voices, addressing systemic barriers that disadvantage them, acknowledging the power imbalances within the education system, and creating learning spaces where they feel recognised and respected’
Addressing these cultural nuances can be complex; however, we can begin to address these subtleties by constructing culturally safe learning spaces for ISNs. The concept of ‘cultural safety’ originated from a nursing education leadership meeting in New Zealand in 1989, and its principles have recently been explored in relation to the UK context (see Lokugamage et al, 2023). At its core, cultural safety involves a process of learning from groups that have historically been marginalised and oppressed. From an education perspective, it focuses on learning from and valuing the experiences of historically marginalised groups. It involves actively listening to diverse student voices, addressing systemic barriers that disadvantage them, acknowledging the power imbalances within the education system, and creating learning spaces where they feel recognised and respected.
However, when implementing cultural safety principles in constructing learning spaces, it is essential to avoid cultural appropriation. Cultural appropriation happens when members of one culture adopt or use elements from another culture in a way that is often perceived as disrespectful or detached from its original cultural significance (Siems, 2019). For example, a ‘cultural competence’ session is added to a nursing module due to the increasing number of ISNs in the nursing programme. Albeit with the intent to acknowledge and celebrate the diversity of the student body, if this session focuses solely on superficial aspects of culture, such as food or clothing, without addressing more profound and critical issues such as systemic racism or power dynamics in healthcare, it can end up being tokenistic. To prevent this, educators must make sure they genuinely understand and apply cultural safety in a manner that respects and honours the cultural integrity and autonomy of their students. This involves engaging with ISNs as active participants in the construction of these culturally safe learning spaces and ensuring that their perspectives and needs are central to the process.
Moreover, there is also an expectation to actively participate and express viewpoints in a collaborative manner, such as in seminars and workshops. This is often another departure from ISNs' previous experiences, requiring them to navigate and adjust to a new academic and social dynamic. The strong hierarchical influence of gender based on culture is particularly discernible and often complicates this already difficult transition. In group discussions, for example, the authors sometimes witness female ISNs' opinions being dismissed by male students from their own cultural background or their views suppressed. This is a manifestation of a patriarchal mindset from some sociocultural contexts, where women still experience overt gender bias in both public and private spaces (Kumari and Siotra, 2023). Some of these issues encompass the intersectionality of gender and power dynamics related to culture, which lecturers and staff must be cognisant of and competent to address appropriately.
Multicultural group work
Student nurses collaborate within multidisciplinary teams in multicultural settings such as the NHS, thus fostering intercultural learning through multicultural group work is essential for their professional development. By engaging in multicultural group work, ISNs are better equipped to understand and navigate the dynamics of gender and cultural diversity, thereby contributing to more inclusive healthcare practices.
However, despite the evidence-based benefits of multicultural group work (see Woods et al, 2011; Stahl and Maznevski, 2021), many students continue to hold negative perceptions and attitudes about working in groups (De Vita, 2002; Reid and Garson, 2017). The authors have observed that UK students and ISNs tend to avoid voluntary socialisation in class and show a strong preference for grouping with peers who share similar backgrounds. Intercultural communication plays a critical role in multicultural group work by facilitating shared understanding and mediating potential conflicts. Therefore, careful consideration must be given when forming student groups, as cultural diversity can have both positive and negative impacts on group dynamics.
Based on experience, randomly grouping students – often by alphabetical order – leads to an uneven distribution of diversity, with some groups consisting entirely of UK students and others exclusively of ISNs from similar cultural backgrounds. Although random assignment may seem fair and convenient, it is akin to a ‘game of roulette’ in assigning students to winning or losing teams (Bacon et al, 2001). To enhance social cohesion and intercultural learning, it is recommended that groups be deliberately mixed prior to first student contact. When thoughtfully designed, multicultural group work can create a more enriching learning environment for all students, not just ISNs.
Challenges
The cultural shock ISNs experience in the academic context poses significant challenges, including teaching pedagogies, the nature of assessments and student expectations in a new learning environment. Targeted support is pivotal to facilitating meaningful integration and transition for ISNs. Ideally, this process should begin pre-arrival, where resources are made available even before ISNs start their course. This must then be supplemented with a bespoke induction upon their arrival, where expectations are outlined and available support is made clear and offered. This process must be maintained throughout their course, specifically addressing new challenges and milestones in their educational journey. Preparing for the success of ISNs entails host universities and educators being aware of these nuanced issues, exploring opportunities for students to engage in their own learning, and creating spaces where they feel safe, heard and valued.