International Journal of Nursing Studies 74 (2017) 85–94

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International Journal of Nursing Studies

journal homepage: www.elsevier.com/locate/ijns

Factors impacting on psychological wellbeing of international students in MARK

the health professions: A scoping review
⁎
Lisa McKennaa,b, Eddie Robinsonb, Joy Penmanb, Danny Hillsc,
a
Head, School of Nursing and Midwifery, La Trobe University, Bundoora VIC 3086, Australia
b
Nursing and Midwifery, Monash University Clayton, VIC 3800, Australia
c
Nursing and Midwifery, Monash University, Wellington Road, Clayton, VIC 3800, Australia

A R T I C L E I N F O A B S T R A C T

Keywords: Background: There are increasing numbers of international students undertaking health professional courses,
Health profession particularly in Western countries. These courses not only expose students to the usual stresses and strains of
International student academic learning, but also require students to undertake clinical placements and practice-based learning. While
Psychological wellbeing much is known about general issues facing international students, less is known about factors that impact on
Scoping review
those studying in the health professions.
Objectives: To explore what is known about factors that influence the psychological wellbeing of international
students in the health professions.
Design: A scoping review.
Data sources: A range of databases were searched, including CINAHL, Medline, Scopus, Proquest and ERIC, as
well as grey literature, reference lists and Google Scholar.
Review methods: The review included qualitative or quantitative primary peer reviewed research studies that
focused on international undergraduate or postgraduate students in the health professions. The core concept
underpinning the review was psychological issues, with the outcome being psychological and/or social well-
being. Thematic analysis across studies was used to identify key themes emerging.
Results: A total of 13 studies were included in the review, from the disciplines of nursing, medicine and speech-
language pathology. Four key factor groups emerged from the review: negotiating structures and systems,
communication and learning, quality of life and self-care, and facing discrimination and social isolation.
Conclusions: International health professional students face similar issues to other international students. The
nature of their courses, however, also requires negotiating different health care systems, and managing a range
of clinical practice issues including with communication, and isolation and discrimination from clinical staff and
patients. Further research is needed to specifically explore factors impacting on student well-being and how
international students can be appropriately prepared and supported for their encounters.

What is already known about the topic? psychosocial wellbeing of international health profession students,
including to function in unfamiliar health care systems, and com-
• University students are confronted with numerous academic and life municate verbally and non-verbally in culturally appropriate and
challenges but, for international students, the stresses and strains of effective ways.
everyday student life are compounded. • The review consequently highlights the need for research into the
• While there is a body of evidence relating to issues facing the well- most effective interventions to address the key issues and concerns
being of international students, less is known about factors that for these students.
impact on those studying in the health professions.
1. Introduction
What this paper adds
In today’s competitive information-driven global economy, posses-
• This review identifies additional issues impacting on the sing a tertiary qualification is significant. Higher education offers

⁎
Corresponding author.
E-mail addresses: danny.hills@monash.edu, danny.j.hills@gmail.com (D. Hills).

http://dx.doi.org/10.1016/j.ijnurstu.2017.06.007
Received 5 February 2017; Received in revised form 13 June 2017; Accepted 15 June 2017
0020-7489/ © 2017 Elsevier Ltd. All rights reserved.
L. McKenna et al.
graduates many advantages, such as increase of knowledge and skills,
expansion of social networks, improvement of employment opportu-
nities and earning potential, better quality of life, greater access to
health care and longer life expectancy (Allen, 2007; Strawiński, 2011).
Advantages for the wider community include a more efficient economy
and equitable society (Baum et al., 2013), less dependency on gov-
ernment assistance, and greater community service and leadership
(Allen, 2007).
Participation in higher education is determined by interrelated dy-
namics, including economic, sociocultural, educational, gender and
family (Maani, 2006; Maaz and Watermann, 2007; Andres and
Adamuti-Trache, 2008; Ashby and Schoon, 2010). In addition to de-
mographic profiles and finances, Wilks and Wilson (2012) highlight
geographic location as a determinant in higher education participation.
Students may opt to travel abroad for their higher education, and
concerns such as safety, university rankings, scholarships and finances
are important considerations (Gong and Huybers, 2015).
An individual’s decision to pursue tertiary education in another
country has been a subject of interest for more than a decade, with a
significant rise of international students being observed in developed
countries across the world. In 2012, more than five million students
travelled abroad for education, double the number from 2005 (OECD,
2015). Across the Organisation for Economic Co-operation and Devel-
opment (OECD) countries, 6% of tertiary students in 2014 were inter-
national students (18% or more for Australia, New Zealand and the
United Kingdom), with 53% coming from Asia (OECD, 2016).
University students are confronted with numerous academic and life
challenges. Studies have shown resulting moderate to high levels of
psychological stress and distress in general undergraduate students
(Cooke et al., 2004; Eisenberg et al., 2007; Stallman, 2010). Psycho-
logical stress and distress have also been identified in pre-registration
nursing students (Labrague et al., 2016) and medical students (Iqbal
et al., 2015; Ludwig et al., 2015), who experience the additional
stresses and strains associated with clinical placements, and developing
and utilising critical clinical and clinical reasoning skills.
Being an international student likely compounds the stresses and
strains of everyday student life. More than 25 years ago, in Australia,
Burns (1991) raised the alarm that international students experienced
more stress than their local counterparts. Factors such as language,
culture, social support and financial capacity impact on their academic
performance as well as their health and wellbeing. Sawir et al. (2008)
describe international students as having three types of loneliness −
personal, through lost contact with families; social, through the loss of
networks; and cultural, due to the need to adopt the culture and lan-
guage of the host country. Additional stressors include racism (Iwamoto
and Liu, 2010), discrimination (Jung et al., 2010), expectation gaps
between students and academics (Kingston and Forland, 2008), burnout
(Ishak et al., 2013), clinical placement experiences and expectations
(Alzayyat and Al-Gamal, 2014), and culture or transition shock
(McLachlan and Justice, 2009).
While key mental health and well-being concerns for international
undergraduate students have been identified, factors impacting on the
mental health and well-being of international students enrolled in
health degree courses, such as in nursing, medicine and allied health,
have yet to be fully determined. Consequently, this scoping study was
undertaken to examine the extent and range of evidence-based research
on factors impacting on the psychosocial well-being of international
students enrolled in health degree studies. In mapping and synthesising
the knowledge available, an exploration and preparation for further
research can be facilitated (Peters et al., 2015).
2. Methods
2.1. Aim
This review sought to examine what is known about the
86
International Journal of Nursing Studies 74 (2017) 85–94
psychological well-being of international students enrolled in health
profession courses, in particular, to answer the question: What factors
impacting on psychosocial well-being have been reported in interna-
tional students in the health professions? The purpose of the review was
to identify existing research on the topic, and identify areas of need for
future research aimed at enhancing support for international students.
A scoping review protocol was developed, informed by The Joanna
Briggs Institute, Methodology for JBI Scoping Reviews (Peters et al.,
2015).
2.2. Inclusion criteria
2.2.1. Types of participants
For this review, we included studies that focused on international
undergraduate or postgraduate students in the health professions.
2.2.2. Concept
The core concept underpinning the review was psychological issues,
with the outcome being psychological and/or social wellbeing.
2.2.3. Context
The context for the review was that of being an international stu-
dent.
2.2.4. Types of sources
The review included qualitative or quantitative primary, peer re-
viewed research studies. Review articles were not included, but re-
ference lists were checked for additional sources.
2.3. Search strategy
A range of databases were searched, including CINAHL, Medline,
Scopus, Proquest and ERIC using the keywords ‘psychological’ or ‘so-
cial’ and ‘wellbeing’ and ‘international’ or ‘overseas’; ‘student’ and
‘health care’. The search was limited to full text papers; published in
English; between the years 2007 and 2016. In addition; grey literature;
reference lists and the search engine Google Scholar were searched for
additional missed papers.
2.4. Selection and extraction
Across the five databases, a total of 455 abstracts were sourced. Two
additional records were identified through the grey literature.
Following removal of duplicates, 450 records remained. Titles were
screened for relevance, leaving 97 for further review. Of these, 27 were
considered directly related to the research question and full texts were
reviewed. A further 14 were removed at this point following application
of inclusion criteria, leaving a total of 13 papers for the final review
(Fig. 1). Data were extracted in order to include important criteria in-
cluding: country of study origin, study design and purpose, sample,
method, main findings and limitations. Inductive thematic analysis,
informed by the work of Braun and Cohen (2012) across studies was
used to identify key themes emerging. This entailed familiarisation with
the findings of each study and generating initial codes. These codes
were then searched for emerging themes which were reviewed and
refined to arrive at the final themes reported in the paper.
3. Results
Across the 13 included studies (Table 1), five were conducted in
Australia, three in the United Kingdom, two in the USA, one in New
Zealand, one in Finland, and one combined across Australia and New
Zealand. The majority of studies (nine) were from nursing, with three
from medicine and one from speech-language pathology. The design
and focus of the studies varied. Seven were qualitative explorations,
three quantitative and three mixed methods designs. Ten studies
L. McKenna et al.
Records idenƟĮed through AddiƟonal records idenƟĮed
database searching through other sources
(n = 455) (n = 2)
Records aŌer duplicates removed
(n = 450)
Records screened Records excluded
(n = 97)
Full-text arƟcles excluded,
Full-text arƟcles assessed following applicaƟon of
for eligibility inclusion/exclusion criteria
(n = 27)
Studies included in review
(n = 13)
referred to Asian students, five to students from the Middle East, three
included African students, three included students from the Americas,
one included students from the United Kingdom, one include European
Union and two did not identify students’ origins. All studies involved
undergraduate students, except Evans (2007) and Evans and Stevenson
(2011) who studied doctoral students, Attrill et al. (2015) and Hillis
et al. (2007) who included undergraduate and graduate entry students,
and Wang et al. (2008) who included both undergraduate and post-
graduate students. Key issues identified are summarised in Table 2.
3.1. Negotiating structures and systems
A key theme arising from the current review is the need for inter-
national students to negotiate a range of systems and structures, both
study-related and personally and how this impacted on their psycho-
logical wellbeing. Adjusting to different academic structures was raised
in a number of contexts as a stressor. Students in seven of the reviewed
studies discussed differences that they had to negotiate, such as the
requirement to be self-directed learners (Evans, 2007; Evans and
Stevenson, 2011; Malau-Aduli, 2011; McDermott-Levy, 2011) and
classroom interaction (Wang et al., 2008).
Students in the health professions not only have to negotiate dif-
ferent academic systems, but also clinical placements in health services
that may be vastly different to those in their home countries. This as-
pect was specifically identified in five studies (Attrill et al., 2015;
Malau-Aduli, 2011; McDermott-Levy, 2011; Siebold et al., 2007; Wang
et al., 2008). A quote presented by Wang et al. (2008), infers that
students may need more introductions to health care systems, and that
learning may be difficult to adapt to their home country on their return.
More broadly, international students may face challenges in main-
taining cultural or religious requirements within the structures of the
new country and this may cause anxiety and stress. In McDermott-
Levy’s (2011) study, students from Oman studying in the United States
needed to adjust to mixed gender situations and find strategies for
maintaining their religious requirements. In the study by Wang et al.
International Journal of Nursing Studies 74 (2017) 85–94
Fig. 1. Identification and Selection of Studies.
(n = 70)
(n = 14)
(2008), students from Taiwan studying in Australia expressed difficul-
ties in adjusting to the culture, leading to a lack of sense of belonging:
Everything is different here, customs, foods, language⋯I don't know
what is the appropriate way to do things…anyway. I don’t feel like I
belong to here at all. (Wang et al., 2008, p. 144).
3.2. Communication and learning
Across the studies, communication issues raised challenges for stu-
dents. Despite students meeting required English language levels, there
is evidence that students may not have sufficient English competency
for the day-to-day situations they face, including in learning and aca-
demic performance, and lead to additional stress. McDermott-Levy
(2011) reported that there were different levels of English required in
different circumstances, while students may have learnt a different
form of English to what was used in the new country (Wang et al.,
2008). Wang et al. (2008) found students experienced problems with
basic tasks such as making telephone calls and shopping. The use of
slang and accents were reportedly problematic for students studying in
Australia (Malau-Aduli, 2011; Wang et al., 2008) and the United States
(Junious et al., 2010). Studying in English was reported to take addi-
tional time and required additional energy as students needed to work
between two languages for understanding (Evans and Stevenson, 2011;
Junious et al., 2010), increasing the required mental demands.
Non-verbal communication conventions may also be different for
international students and can cause difficulties, particularly in clinical
settings. In some cultures, respect may be shown in different ways and,
in the wrong context, actions may be misconstrued as a lack of respect
(Junious et al., 2010). Attrill et al. (2015) found that in clinical settings,
as a result of language and cultural differences, international speech-
language pathology (SLP) students may be excluded from discussions,
and language had the potential to negatively impact on competence
development and placement experiences. Both Malau-Aduli (2011) and
Wang et al. (2008) highlighted that students need to be educated on
87
 Table 1
Papers exploring international health care students.
Author, year Country Design and purpose
Attrill et al. Australia Qualitative
(2015) To examine perceptions of
international speech-
language pathology (SLP)
students regarding their
clinical placement
experiences, and impact of
these on competency
development, and compare
those to domestic students.
De (2010) United Mixed methods.
Kingdom To explore whether
international students in the
UK faced disadvantages when
caring for patients.
Evans (2007) United Qualitative exploratory.
Kingdom To examine educational
experiences of international
doctoral nursing students and
their supervisors.
Evans and United Qualitative
Stevenson Kingdom To investigate learning
88
(2011) experiences of international
doctoral nursing students
through their PhD journey,
and identify best practice in
supporting effective learning
He et al. (2012) Australia Quantitative
To explore levels of
acculturative stress of
Chinese international
students studying and living
in Australia
Henning et al. New Zealand Quantitative correlational
(2011) study.
To explore the relationship
between motivation and
quality of life for Asian
medical students in New
Zealand.
Hillis et al. Australia and Quantitative
(2010) New Zealand To identify students’ access to
and awareness of support
services, and their views on
teaching of wellbeing .
Sample
19 SLP students, 10 from Singapore, 3
from Malaysia, 2 each from the UK and
Canada, 1 each from Taiwan and
Kuwait.
18 international nursing students from 6
countries (Nepal, China, India, Iran,
Nigeria, Trinidad)
5 international PhD students at one
university. All were senior nurses from
the Middle East or East Asia.
17 doctoral students from 6 UK
universities
Convenience sample of 119
undergraduate international Chinese
nursing students at one public
university in Sydney
97 self-identified Asian medical students
1328 medical students enrolled at five
universities (15% international
students)
Method
Four focus group interviews, two with
domestic students and two with
international students.
Thematic analysis
Survey and semi-structured focus
group interview.
Survey consisting of open-ended
questions.
Content analysis
Semi-structured interviews
Thematic analysis
Survey using Acculturative Stress
Scale for International Students
(ASSIS) and Sense of Coherence (SOC)
Survey using Australian version of the
WHO-BREF questionnaire and
shortened Motivational Strategies for
Learning Questionnaire (MSLQ)
Survey
Findings Limitations
L. McKenna et al.
Shared themes: Small study across two
1. Centrality of the clinical educator universities in Australia.
relationship Students mostly from South
2. Individual nature of placement East Asia.
experience and competency development
International student themes:
1. Influence of my communication skills
2. Adjustment
3. Structure learning environments
Five students identified having been unfairly Small study from one UK
discriminated against by a patient. nursing school.
Four described being racially abused by
patients under their care.
Four had tried to provide care but been
refused by patients.
Three felt nervous around the involved
patients and one reported feeling frightened.
Key issues: Small sample size. Only one
1. Understanding the ‘system’ institution involved.
2. Adjusting to the academic culture
3. Finding a community
4. Dealing with emotional issues
Key categories: Self-selection.
1. A journey of transitions: Adjusting to No member checking
doctoral study in the UK undertaken.
2. A journey of relationships: Finding
support for doctoral study
3. A journey of challenge and a journey of
growth
Chinese nursing students held a moderately Self-report measures.
high level of acculturative stress, with third One cohort of students from
year students being highest. one campus at a single
SOC indicated a moderate level. university.
Correlations between the two tools showed a Tools not validated with
significant negative relationship between international students from
ASSIC and SOC indicating that a person with China or Asia studying in
high acculturative stress would have low Australia.
level sense of coherence and vice versa.
Asian students scored lower in quality of life Self-report measures.
than other New Zealand students, both Appears to have only been
medical and non-medical. conducted in one medical
International Asian medical students were school.
more test anxious than domestic students, but May not represent other
similarly motivated to European medical disciplines.
students.
Only 45% of international students had their Possibility of selection bias.
own GP. Overall response rate was
International male students were found to be 26%.
most likely to perceive stigma associated with
stress and distress.
International students were more likely to
experience discomfort accessing assistance
outside of the university setting.
(continued on next page)
International Journal of Nursing Studies 74 (2017) 85–94
 Table 1 (continued)
Author, year Country Design and purpose
Junious et al. USA Qualitative: interpretive
(2010) phenomenology
To describe the essence of
stress and perceived faculty
support by overseas-born
students in a baccalaureate
program
Malau-Aduli Australia Mixed methods
(2011) To explore experience and
coping strategies of
international medical
students at the School of
Medicine, University of
Tasmania
To examine difficulties and
challenges faced and factors
influencing progression
throughout the course.
Mattila et al. Finland Qualitative
(2010) To explore international
89
nursing students’ experiences
of their clinical practice in
the Finnish health care
system
McDermott-Levy USA Qualitative: phenomenology
(2011) To identify perspectives and
experiences of female Omani
nurses studying the
baccalaureate degree in
nursing in the United States.
Seibold et al. Australia Mixed methods
(2007) To evaluate a program to
support one cohort of
international accelerated
Bachelor of Nursing students.
Sample
10 overseas-born senior level nursing
students
26 third- and fourth-year international
medical students from seven countries
(Malaysia, Singapore, Canada, Hong
Kong, Taiwan, South Korea, Thailand
17 nursing students of African and Asian
origin, with a minimum of 2.5 years of
study
12 practising Omani nurses upgrading
diploma qualifications to Bachelor of
Science in Nursing.
20 commencing students from Asian
countries including Japan, Korea,
Thailand, India, Hong Kong, and
Singapore. All were female and had
between 6 months and 18 years of
nursing experience in their home
country.
Method
Mixed methods: Survey and semi-
structured focus group interviews,
and follow-up individual interview
Mixed methods: Survey, focus group
and individual interview
Semi-structured individual interviews
Semi-structured individual interviews
Thematic analysis informed by
Colaizzi’s existential-
phenomenological method
Survey, and focus group interviews
with 9 participants.
Findings Limitations
Quantitative: Students did not report high Small sample size limits
L. McKenna et al.
stress on survey. generalisability of findings.
Qualitative: Overarching theme: Desire to be
valued and accepted
Themes:
1. Personal relationships
2. Financial issues
3. Having no life
4. Lack of accommodation as an
international student
5. Language issues
6. Stereotyping and discrimination
7. Cultural incompetence
Key themes: Small sample size
1. Cultural adaptation Possible response bias
2. Language issues
3. Academic adjustment
4. Personal and support concerns
Positive experiences: Small sample size drawn
1. Appreciative orientation from a convenience sample.
2. Enhancing independent working
3. Growing towards professionalism
4. Working as a member of the team
Negative experiences:
1. Restricted learning
2. Compromised human dignity
3. Feelings of being an outsider
4. Giving up
5. Anticipation of difficulties
Eleven themes: May not represent the
1. Going alone experiences of other Middle
2. Anti-Muslim Sentiment Eastern students and other
3. Not paying much attention contexts.
4. Having new freedoms
5. Shifting paradigms
6. Maintaining religion
7. Cultural immersion
8. English immersion
9. Making American friends
10. Self-directed learning
11. Growing
Positive aspects reported: Small study conducted at
1. Making friends with other students from one nursing school
different countries and with local
students
2. Learning about one another’s culture and
the Australian way of life
3. Being given timely and appropriate
academic feedback
(continued on next page)
International Journal of Nursing Studies 74 (2017) 85–94
 Table 1 (continued)

Author, year Country Design and purpose Sample Method Findings Limitations

Negative aspects reported:

L. McKenna et al.

1. Homesickness
2. Difficulties communicating with local
students, academics and in the clinical
setting.
3. Emphasis on doing things ‘the Australian
way’
4. Not having one’s own cultural and
professional background acknowledged.
Wang et al. Australia Qualitative 9 post-registration and 12 postgraduate Semi-structured individual interviews 1. Obstacles to learning within the Small study drawn from a
(2008) To explore the learning Taiwanese nursing students Australian academic environment: convenience sample.
experiences of Taiwanese language barriers, social and cultural
nursing students studying in differences, unfamiliar teaching styles
Australia and strategies, unfamiliar academic
assessment, social isolation, insufficient
clinical experience
2. Learning experience: Differences between
Taiwan and Australia: new perspectives
on learning, more personal approach to
learning, conducive learning environment
3. Coping strategies: Active learning
attitude, extending social circle, seeking
assistance, immersion in English
4. Desired academic assistance: language
and learning skills support, counselling
services and student advisors,

90
accessibility to learning resources,
student organisations.
International Journal of Nursing Studies 74 (2017) 85–94
L. McKenna et al.
Table 2
Key issues emerging.
Key Issues Specific aspects
Negotiating structures/ Adjusting to organisations and
systems different health care delivery
Adjusting to academic culture
Adjusting to mixed gender
situations
Communication and Influence of English language
learning skills on clinical competence/
learning
Different cultural expectations
Participating in group
activities/discussions
Extra time for reading, writing
Use of local slang
Critical and philosophical
thinking
Quality of Life/Self Care Financial issues
Dealing with emotional/health
issues, stigma associated with
stress/distress
Loneliness, isolation,
homesickness
Acculturative stress/anxiety
Potential lower overall quality
of life
Low self-esteem, sense of
belonging
Difficulties maintaining
religious practices
Facing discrimination and Racism and verbal abuse from
social isolation patients
Lack of cultural sensitivity
Public racism and
discrimination
Sources
Attrill et al. (2015); McDermott-Levy (2011);
Siebold et al. (2007); Wang et al. (2008)
McDermott-Levy (2011)
Attrill et al. (2015); Junious et al. (2010); Mattila
et al. (2010); Siebold et al. (2007); Wang et al.
(2008)
Attrill et al. (2015); Junious et al. (2010); Malau-
Aduli (2011)
Attrill et al. (2015); McDermott-Levy (2011);
Wang et al. (2008)
Junious et al. (2010); Malau-Aduli (2011); Wang
et al. (2008)
Evans (2007); Wang et al. (2008)
Evans and Stevenson (2011); Junious et al.
(2010); Malau-Aduli (2011); McDermott-Levy
(2011)
Evans (2007); Hillis et al. (2010)
Evans (2007); Evans and Stevenson (2011);
Junious et al. (2010), McDermott-Levy (2011);
Siebold et al. (2007); Wang et al. (2008)
Evans and Stevenson (2011); He et al. (2012)
Henning et al. (2011); Junious et al. (2010)
Mattila et al. (2010); Wang et al. (2008)
Malau-Aduli (2011); McDermott-Levy (2011)
De (2010); Mattila et al. (2010) Junious et al.
(2010); McDermott-Levy (2011); Siebold et al.
(2007)
Mattila et al. (2010)
McDermott-Levy (2011)
91
International Journal of Nursing Studies 74 (2017) 85–94
Sample quotations
The experience of tutorials is very new to me. I found it is very
hard to follow during tutorial. They speak so fast and they just
jump subjects. I know that I don’t participate enough in tutorials
but I have no idea what is going on. (Wang et al., 2008, p.
143).
Adjusting to a self-inquiry learning style that requires lateral
thinking has been very difficult. (Malau-Aduli, 2011; p.6.)
Australia has a different health care system; it is hard for us to
understand some practical examples. The lectures did not
describe much...We also have different cultures and values,
what we learn here may not be suitable for our own country.
(Wang et al., 2008, p. 144).
As a female, you’re never used to being with males in the same
place, like an elevator. But today I had to stand beside a male on
an elevator. (McDermott-Levy, 2011; p.272)
I had a lot of trouble when I first arrived here. I couldn't even
make a phone call or go to shopping because my English was so
poor. I could read and write all right, but not speaking. (Wang
et al., 2008, p. 143).
I speak fluent English, the only languages problems were various
Australian slang and the Australian accent. (Malau-Aduli,
2011; p.4).
I could speak English all right before I came here. But we usually
learn American English in Taiwan; it is very different from
Australian English. Besides, Australians have a quite different
accent and slang, which makes it harder for us to understand.
(Wang et al., 2008, p. 143).
…the local students don’t understand what we are talking about
especially during presentations and discussion. (Siebold et al.,
2007; p.69)
In my culture, when you talk to someone…that has authority
above you…we try to show respect...I will just look down. I’m
listening, but I don’t have to necessarily look into [his or her]
eyes...I’m so uncomfortable. (Junious, 2010, p. 266).
Students need to be taught about the cultural expectations in
relation to communication skills. (Malau-Aduli, 2011; p.6).
I had some struggle to find house and at the same time I need to
attend classes. (Malau-Aduli, 2011; p.4).
The dollar [at home] is not the same as [it is in] America. You
spend a thousand dollars on tuition, we spend two, three times
more. Our tuition [per] semester is sometimes a yearly salary for
our parents. (Junious et al., 2010; p.265)
No time for anything else. Just come to school, read, and read,
and read. Don't even sleep. (Junious et al., 2010; p.265)
People don't realise that being international is not just having
[a] name that [others] can’t pronounce...It’s a trail of stress.
(Junious et al., 2010; p.267)
Back home, my father takes care of things for me. Here, I have
to pay the bills….I have to become strong. Because coming here
it is so challenging. Going alone. At home someone is with me.
(McDermott-Levy, 2011; p.270)
…they oversee you, they don't always see that you are there…
and you just feel…nothing of yourself. (Mattila et al., 2010;
p.155)
My friend she was wearing abayah [a robe-like garment worn
over clothing] and I was wearing a hijab, jeans and a sweater
without an abayah, and a woman came up to us and said,
“These Muslims, I want to kill these Muslims.”⋯Then we were
really frightened. (McDermott-Levy, 2011; p.271)
I don't like group work. You feel that the Australian students
never want to be in the same group with overseas students. I end
up with other overseas students all the time. I do not mind to
work with other overseas students, but I feel that I am
discriminated [against]. (Wang et al., 2008, p. 145).
Making friends with local Australians was not an easy task as
either they already had their own click of friends…or they
simply were not interested in making Asian friends as they seem
to think we had a very poor command of the English language.
(continued on next page)
L. McKenna et al.
Table 2 (continued)
Key Issues Specific aspects Sources
Lack of interaction with local Evans (2007); Malau-Aduli (2011); McDermott-
students Levy (2011); Wang et al. (2008)
cultural expectations surrounding, and better supported in improving
communication to enhance learning and academic outcomes.
3.3. Quality of life/self-care
Quality of life and self-care for international students can directly
impact on their psychological well-being. Students across studies re-
ported experiencing financial issues (Junious et al., 2010; Malau-Aduli,
2011; McDermott-Levy, 2011), feeling lonely, isolated and homesick
(Evans, 2007; Evans and Stevenson, 2011; McDermott-Levy, 2011;
Siebold et al., 2007; Wang et al., 2008). Junious et al. (2010) high-
lighted that international students paid more for their tuition and were
likely to lose financially on exchange rates. Furthermore, pressure can
be compounded by family expectations to succeed (Malau-Aduli, 2011).
They may spend so much time studying that they have little time for
anything else, even sleep (Junious et al., 2010).
Students can experience acculturative stress and anxiety from a
range of sources, such as in response to family expectations (Evans and
Stevenson, 2011; He et al., 2012; Malau-Aduli, 2011). Henning et al.
(2011), in their study comparing quality of life for international Asian
and local students in New Zealand, found that the international stu-
dents had lower quality of life, were less satisfied with their personal
relationships and had higher test anxiety. Despite these issues, Hillis
et al. (2010) found that international medical students were less likely
than local students to have their own general practitioner, and seek
support outside of the university.
3.4. Facing discrimination and social isolation
Discrimination and isolation for international health professional
students was another theme identified in the reviewed studies. This
reportedly occurred in public settings, as well as classroom and clinical
practice contexts and contributed to additional stress and anxiety for
students. Students in the Australian study by Wang et al. (2008) re-
ported being forced to do group work with other international students,
as local students did not want to work with them. This led to feeling
discriminated against.
A number of studies discussed frustration by international students
at not being able to make friends with local students (Evans, 2007;
Malau-Aduli, 2011; McDermott-Levy, 2011; Siebold et al., 2007; Wang
et al., 2008). Malau-Aduli (2011) described segregation between local
and international students. Students in this study perceived that local
students already had their own developed social groups and had no
interest in making Asian friends, while students in the study by Junious
et al. (2010) felt they were considered to be “dumb” due to their English
communication.
One study described the aspect of public discrimination.
McDermott-Levy (2011) found that Omani nursing students reported
incidents of non-verbal and verbal racial abuse while off campus. Of
particular concern, discrimination in clinical settings was also reported.
Students in De’s (2010) study in the UK reported receiving verbal, racial
abuse from patients and patients refusing to be cared for by them.
Mattila et al. (2010) reported that students in their Finnish study were
prevented from participating in meaningful clinical learning experi-
ences. This included being required to wait for foreign patients to care
for, being ignored, being called names and receiving remarks about
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International Journal of Nursing Studies 74 (2017) 85–94
Sample quotations
(Malau-Aduli, 2011; p.5).
I found that it is hard to make Australian friends. Maybe we are
too different in many ways. (Wang et al., 2008, p. 145).
I’m in every day, but only a few people even know my name.
(Malau-Aduli, 2011; p.503).
their ethnic backgrounds.
4. Discussion
While much has been written about the experiences of international
students in higher education, much of this has covered generic groups
of students and academic experiences. There are increasing numbers of
international students studying health professional courses. These
courses add complexity to international students’ experiences through
clinical practice requirements and engagement with local health care
systems. This scoping review was conducted to explore research ex-
amining factors impacting on psychological wellbeing for international
students in the health professions. Findings suggest there are specific
issues faced by international students in health professional courses that
are not necessarily experienced by those in traditional, classroom based
courses, and that directly impact on psychological wellbeing.
The need to negotiate various structures and systems was found to
be broadly reported in the studies included in this review. The nature of
higher education systems being different and requiring different types
of student engagement has been well documented in the literature on
international students (Smith and Khawaja, 2011) and emerged in this
review as stressors capable of impacting on their psychological well-
being. However, this review additionally found that undertaking clin-
ical placements in health care systems for which students have not been
adequately prepared, can be particularly stressful and further com-
pounding potential risk for these students. Hence, there is a need to
examine how international students are prepared for their clinical
placements, and how clinical support staff are prepared to assist them
to navigate new systems of health care and care delivery.
A range of communication issues impacting on learning were
identified through the reviewed studies. Studies in this review suggest
that different types of English language, including slang, is problematic
for many international students. English proficiency has been raised as
an important aspect in success in nursing studies, and low English
language acculturation has been found to be associated with low aca-
demic performance in nursing (Salamonson et al., 2008). While a few
studies highlighted communication issues for international students,
only one (Attrill et al., 2015) specifically explored this, suggesting more
research is needed in this area. This need is further supported by Koch
et al. (2015) who conducted a literature review on clinical placement
experiences in diverse nursing students, and concluded more work was
needed in relation to ethnicity and clinical placement experience. Such
research is needed to inform the development of support systems for
effective clinical learning outcomes for international health profession
students (Edgecombe et al., 2013).
Quality of life and issues surrounding self-care emerged through the
reviewed studies. Feelings of loneliness for international students has
been well acknowledged. Sawir et al. (2008) interviewed 200 interna-
tional students studying in Australia, finding 65% of students had ex-
perienced loneliness or isolation during their studies. Of these, 88%
reported turning to personal or social networks, both in and outside of
Australia. They reinforced a cross-cultural aspect of loneliness and
identified the concept of cultural loneliness as important, whereby
loneliness was initiated when there was an “absence of preferred cul-
tural and/or linguistic environment” (p.171). Sawir et al. (2008) re-
commended improving relationships with local students, by enabling
L. McKenna et al.
sharing and encouraging curiosity about international students and
their contexts. The current review, however, identified that local stu-
dents were perceived as not willing to engage or befriend international
students. This is clearly an aspect that demands attention.
Clinical placements make health professional courses different from
those of other disciplines. The current review identified aspects where
international students confronted discrimination such as patients re-
fusing their care, verbal abuse and being isolated by clinical staff and
other students. Interestingly, a recent narrative literature review of
Chinese nursing students studying in Australia did not identify issues
for these students related to clinical placement (Wang et al., 2015). It is
likely that international students are encountering such attitudes but
they are not being recognised by clinical educators, nor reported by
students. Furthermore, it is unclear how students are managing such
situations. With increasing international student numbers, universities
have a responsibility to effectively manage clinical learning experi-
ences. This area requires urgent attention through further research and
the development of appropriate support mechanisms, as well as edu-
cation for clinical educators and clinicians in supporting them.
This review has highlighted areas where there is a need for further
research in order to better understand psychological wellbeing of in-
ternational health profession students, and mechanisms for supporting
them in this regard. While many of the identified challenges are not
unique to this group of students, the clinical component of their courses
adds unique elements such as requirements for complex communica-
tion, having to face cultural, systems and social differences and po-
tential discrimination issues that may directly influence their psycho-
logical wellbeing. Only a small number of studies were found that dealt
with clinical issues. There is a need for research seeking to understand
students’ experiences, the personal impact of these and necessary sup-
port mechanisms.
This scoping review has some limitations that need to be acknowl-
edged. It sought to explore what is known about international health
professional students and factors impacting on their psychological well-
being. Only English language reports were reviewed and, while the
review was broad, some relevant studies may have been omitted.
Furthermore, all of the included studies involved students studying in
Western countries. No research could be sourced on international stu-
dents in other settings. In addition, studies obtained only covered three
disciplines: nursing, medicine, and speech-language pathology.
Nevertheless, the review has found that there are particular issues for
international students in health professional courses that are not iden-
tified in general studies on students in higher education, and indicate
areas where future research is needed.
5. Conclusion
International students in the health professions face many similar
issues to international students studying in other disciplines. For those
enrolled in health profession courses, however, it appears that the
stresses and strains of their studies are compounded by having to
function in unfamiliar health care systems, and communicate verbally
and non-verbally in culturally appropriate and effective ways. Available
research suggests that these students are also exposed to discrimination
and social isolation from other students, clinical staff and patients.
Further research is needed to explore specific clinical practice factors
impacting on international health professional student mental health
and well-being, and how these students can be most appropriately and
effectively prepared for and supported in their studies. In addition,
there is a need for education for clinicians and educators in appro-
priately supporting these students in practice. Universities are enrolling
increasing numbers of international students. Clearly, they have a re-
sponsibility to support these students throughout their studies, not only
academically, but also around factors potentially impacting on their
psychological wellbeing in order to minimise associated risk.
93
International Journal of Nursing Studies 74 (2017) 85–94
Conflicts of interest
There are no conflicts of interest declared.
Funding
No specific funding was received to undertake this study.
Ethical approval
No. Not applicable for a literature review.
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