Experiences of Chinese nurses studying for master’s degree in the UK: a qualitative study?

Jun-Jun M, Jie Zhou, Ting-Jun Li, Li-Li Wng, Xio-Fei Tin*

aGeneral Surgery Department, Shenzhen Qianhai Shekou Free Trade Hospital, Shenzhen, Guangdong 518067, China

bDepartment of Nursing, The Second People’s Hospital of Futian District Shenzhen, Shenzhen, Guangdong 518049, China cDepartment of Pediatrics, Shenzhen Nanshan People’s Hospital, Shenzhen, Guangdong 518052, China

dDepartment of Nursing, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, Guangdong 518107, China

Abstract: Objective: To explore experiences of Chinese nurses who study for Master of Science in Professional Practice (health care) in the United Kingdom.Methods: A qualitative approach was applied, consisting of semi-structured telephone interviews (n = 8). The Colaizzi seven-step framework analysis method was used to extract themes.Results: The themes that emerged are as follows: (1) gains from studying overseas, (2) difficulties during studying, and (3) impacts of learning experience on work. The gains for nurses studying overseas include the improvement of scientific research capabilities, reconstruction of critical thinking, and development of reflection ability. Difficulties while studying mainly include language barrier, strict assessment, and boring life.Conclusions: The education of nursing postgraduate attaches importance to the cultivation of thinking. Nurses are very interested in nursing research including qualitative and quantitative methods. Nurses encountered language barriers in their study and life even though they knew a certain level of English.

Keywords: Chinese nurse ? experience ? graduate students of nursing ? nursing education ? qualitative study ? study abroad

1. Introduction

British nursing pedagogy has a long history. It originated from Florence Nightingale opening the world’s first regular nursing school at St. Thomas Hospital in the United Kingdom (UK) in 1860. Her ideas on school administration and studies have a far-reaching impact on the development of nursing globally.1Presently, there are nearly 200 professional and 500 vocational education colleges in the UK, providing nursing courses at the undergraduate, graduate, and postgraduate levels. Additionally, the training time of nursing postgraduate students is shorter in China.2The Master’s in Nursing education program in China, which began relatively late, aims to train high-level, applied, and specialized nursing talents who directly participate in clinical nursing practice. In recent years, nursing postgraduate education has been paid more and more attention for the development of medicine.3

A quantitative study4has found that 86.7% of nurses want to obtain a master’s degree in nursing. Moreover, 86.8% of nurses believe that a master’s degree plays an important role in their personal career development. Yu et al.5understood nurses’ psychological experiences and discussed the training mode of nursing postgraduates through in-depth interviews with 12 part-time graduate nurses. Studies6,7applied the qualitative method to explore and analyze the stress, real thoughts, coping strategies, and suggestions of graduate nurses. However, the qualitative research on the overseas study experiences of domestic nursing postgraduates has yet to be conducted.

In this study, a total of 37 nurses from the fourth graduation batch of the China–British cooperation project in Guangdong Province who pursued a full-time Master of Science in Professional Practice (health care) in the Birmingham city university were selected as research objects. The purpose of this study is to explore an indepth understanding of nurses’ experiences in the UK and recommendations for future overseas nurses getting graduate nursing education.

2. Methods

2.1. Study design

Husserl’s phenomenology was that the initial understanding of the phenomenon studied is with those who experienced this phenomenon.8In this study, Husserl’s descriptive phenomenology provided the philosophical underpinnings to explore the Chinese nurse’s experiences who study in the UK to get a master’s degree. Throughout the research process, it is consistent with consolidated criteria for reporting qualitative (COREQ) guidelines that has been followed.9

2.2. Participants

The purposive sampling approach was used to select nurses who studied to obtain a master’s degree at a university in the UK. The sample inclusion criteria were as follows: participants who had obtained the master’s degree and who worked in nursing positions at the previous hospital. All participants voluntarily participated in the study and agreed to the recording. Following the data saturation principle, the number of participants was based that no new themes appeared.

The first author recruited participants via WeChat from February to March, 2020. The first author explained the purpose and method of this study when nurses were invited. A total of 13 nurses were invited, but 8 nurses agreed to an auto-record interview on the telephone because of COVID-19. The first author sent informed consent forms via email to nurses who agreed to participate. The participants were aged between 24 and 38 years of age with a mean age of 31.86 years (SD = 4.70). Seven participants were females, and one was male. Information on the participating hospitals is shown in Table 1.

Table 1. Characteristics of participants (N = 8).

2.3. Data collection

After reviewing the literature, the research team discussed about drafting a preliminary interview guide. Two nurses were invited to conduct the trial interview. The research team also invited nurses who were experts in qualitative research to discuss, revise, and finalize the interview guide. The questions were open-ended, semistructured, and nonjudgmental. The main questions are as follows: (1) What did you gain from studying in the UK of psychological expectations? (2) What difficulties did you encounter while studying in the UK and how did you overcome them? (3) What is the impact of studying overseas on your work after returning? For further information during interviews, the following questions were used: “Tell me more about it,” “How do you feel about that?” or “what do you mean?.”

The second author who had ample experience in qualitative research independently completed the semistructured interview form from March 2020 to June 2020 and recorded main points during the interview. The interviews lasted for approximately 30–45 min each. During the interview, the interviewees were given sufficient time to think, and interview skills such as questioning, listening and responding were used. The interview ended when there are no more new themes. The interviewer assured the use of codes instead of names to protect the interviewers’ privacy.

2.4. Data analysis

Within 24 h after the end of the interview, iFLYTEK Hearing Software was used to transcribe the recorded data to serve as preliminary text data and was listened to by the two research team members and corrected to form the final text data. The Colaizzi seven-step analysis method was used to refine the following themes: (1) read the interviewed materials repeatedly; (2) refine effective information; (3) code recurring opinions; (4) summarize coded opinions into the topic; (5) write detailed and complete descriptions; (6) summarize similar ideas and extract themes; (7) and clarify ambiguous analysis results with the participants if necessary.

2.5. Ethical considerations

Participants were informed about the purpose of this study, the confidentiality of interview data, the risks and benefits of their participation, and their rights to refuse or withdraw. Once they agreed to voluntarily participate in the study, each participant obtained a signed written informed consent form. In the report of findings below, all identifiable characteristics have been removed.

3. Results

3.1. Gains from studying overseas

3.1.1. Improvement of scientific research capabilities

All interviewers mentioned improvements in nursing research abilities and believed in the systematic study of quantitative and qualitative research methods and writing of systematic reviews in evidence-based nursing. However, some contents have failed to meet expectations because this study was conducted for only 1 year, and the courses were hastily arranged.

“I studied undergraduate in an ordinary university, and the education I received is more inclined to the three basics (basic theory, basic knowledge, basic skills); there is no scientific research course, and graduation from university is not required to write a thesis.”

“The nursing research of the domestic master’s program focuses on the importance, and qualitative research receives minimal attention. The foreign qualitative research methods are more diverse and more rigorous.”

“The methods of scientific research are very good, but I can’t study well in one year. My graduation thesis is a qualitative system review, so I don’t know much about quantitative system reviews.”

3.1.2. Reconstruction of critical thinking

Although nursing schools in China offer critical thinking-related courses introduced from overseas, nurses concurred that studying in the UK has enabled them to obtain a profound understanding of critical thinking.

“It turns out that there are specific methods to develop critical thinking. Before listening to the teacher, I always felt unpredictable.”

“In fact, critical thinking is simply the ability to discern. We all have the ability to think subconsciously, but it’s not connected with theory.”

“Critical thinking is everywhere. I used to listen to what my parents and leaders said. Now I will objectively consider my own ideas.”

3.1.3. Development of reflection ability

The use of reflective journaling is viewed as an effective tool for promoting reflection and learning in nurses and for self-assessment and evaluation of a clinical learning experience. Nurses are required to write reflective diaries in hospitals in China, but many people think it is self-reflection. The reason is that they have insufficient knowledge of reflection logs. Real reflection logs have different theoretical models, and reflection can promote self-growth and career development.

“When an adverse event occurs, the head nurse often asks us to write reflections. We will write the course of the event carefully, and then write what was wrong and how to correct it in the future; it feels more like reflection.”

“Now, through the academic writing course, I know that there are many theoretical frameworks for reflection, and it is not that difficult to write reflection with a theoretical framework.”

“Now at work, I often reflect on whether I can improve the conventional nursing methods. For example, I improved the fixation method of the drainage tube to reduce the occurrence of decoupling. Reflection has prompted me to continue to think about work and life.”

3.2. Difficulties while studying

3.2.1. Language barriers

All eight participants said that they had, to some extent, experienced a range of obstacles to their learning. Language deficiency was a major concern. Language difficulties were encountered in the areas of oral communication, reading, and writing. English is the only language to communicate with local students and teachers when studying in the UK. Even for nurses with high IELTS scores, there is still language pressure in the classes or communication. Interviewees mentioned the influence of language on them from different angles.

“The biggest difficulty is the reading of English literature and books. My reading level is limited, and I need to spend considerable time and energy on determining the meaning of sentences.”

“The teacher in the class speaks very quickly, and sometimes I don’t understand it very well, so I record it every time I go to class and listen to it again after class.”

“My spoken English is not good, and I rarely communicate with the tutor. If I communicate with the tutor for more for help, I won’t miss the exam the first time.”

“Because my English writing ability is limited, sometimes the content written does not express the true thoughts, which makes me very troubled.”

3.2.2. Strict assessment

The educational philosophy of “l(fā)enient entry and strict exit” in foreign countries has a strict assessment system. Although the assessment is an open-ended self- proposition with a 50-point pass, the instructor will only provide the results needed. The solution steps should be explored by the students themselves and the instructor will guide them, but the considerable emphasis is placed on students’ independent study and extensive reading abilities. Under the rigorous assessment system, nearly one-third of students failed their first exams. Hence, exam preparation has become the main theme of studying overseas.

“I don’t understand the requirements of the exam very well. When preparing for the exam, I always feel very nervous and often suffer from insomnia...”

“I asked the teacher how I wrote the essay before the exam. He said it was excellent, but I still failed. I can’t understand this point.”

“I was too nervous to sleep before my PowerPoint presentation to recite my lines over and over again.”

3.2.3. Boring life

In other countries, academic pressure is causing life to lose its luster and become boring. This situation is particularly true for nurses who have given birth, explaining that they often miss their children.

“I feel like I’m busy with courses and exams during my study abroad, and I don’t have time to go out to play. Now, I think I should go out and play more and experience life abroad.”

“My personality is relatively introverted. I rarely communicate with my classmates, and my interaction with my tutors is not smooth. Sometimes, I don’t know how to do my homework, and I often stay up late to prepare for exams until 3 am. I feel so helpless and lonely.”

“I think about my family, especially the children, at night, I feel that I have fewer opportunities to contact the outside world, and my life is so boring!”

3.3. Impact of learning experience on work

The majority of the interviewees indicated that they would focus on the development of nursing management and scientific research in the future. Two interviewees have already received an offer for Doctor of Nursing program, and two nurses interviewed were transferred from the ward to work in the nursing department (from clinical nursing to nursing management).

“I found that I like academic research, and daily clinical work is too boring...”

“After returning to China, I was transferred from the ward of the hospital to the nursing department to assist in the management of clinical nursing quality, and I felt that I was valued.”

“I am now a head nurse. Although I am under a lot of pressure, I am very happy.”

4. Discussion

The study findings highlight that different learning approaches and strategies are needed for international students to succeed in the British educational system. Most students identified both positive and negative experiences related to their academic, social, and cultural needs.

4.1. Academic gains

The gains of graduate students in the UK are mainly reflected in improvements in nursing research and critical thinking abilities. Nursing research is a significant part of postgraduate nursing education. Domestic nursing research on weight measurement has provided statistical software courses for quantitative research data analysis, while qualitative research rarely offers independent data analysis courses. Given the popularity of qualitative research methods, increasing results of qualitative nursing research have received considerable attention. The nature of courses in the UK is based on philosophical theories, including development history, research methods, and application examples that trace origins and provide vivid images. Philosophy is rarely connected with nursing research in China. Students think that they are two independent disciplines. This belief is consistent with the experience of scholars in Ireland.10The recommendation is that philosophy and nursing should be closely linked; the former is used as support of the latter to enhance the theoretical nature of nursing research. Additionally, master’s degree education in the UK attaches immense importance to cultivating students’ independent thinking and reflection skills. The curriculum contains critical thinking and reflection-related content, uses heuristic and interactive teaching methods to improve students’ thinking skills, and focuses on the life and clinical applications.11In clinical work in China, nurses are often considered to have limited critical thinking. The possible reason is that there are only a few reflective courses in postgraduate nursing education in China. Therefore, postgraduate nursing education in China is recommended to enhance students’ autonomy, individuality, and ability to think independently.12,13

4.2. Difficulties

Language acquisition and education acculturation are major challenges for international nursing students in achieving optimal student learning.14,15Students who do not fully master the language and/or the new education culture will not progress as well as those who do. Similarly, a study16found that language mastery and adaptability are crucial for international nursing students studying overseas. The respondents believed that words affect the results of their assessments, and cultural differences cause them to communicate poorly with their mentors. Adaptation refers to the process by which individuals or groups adopt or adapt to the cultural characteristics of another group, which may eventually lead to new or integrated cultural patterns or behaviors.17Moreover, Evans and Stevenson18believed that, for international nursing students, experiencing isolation, communication, and adaptation problems are inevitable. While studying overseas, the interviewees also experienced the process of adapting to life in another country. The strict assessment, boring life and missing family members are experiences they need to overcome. Although international students prepare for the language in advance, they should also be prepared for language communication challenges that will make learning more difficult. It is important to strive for the support or strategies that were helpful for English language development. In addition, it is equally important to develop the courage and the confidence to express themselves in the learning environment.

4.3. Impact of career development

The majority of overseas nurses have received the attention of their work units after returning to their countries, such as being transferred to management positions or studying for specialized nursing fields. With the development of postgraduate nursing education, an increasing number of postgraduate nursing students engaged in clinical nursing work, which has gradually become a global nursing development trend.19This development is important for optimizing the academic structure of clinical nursing staff and applying nursing theory. Moreover, playing positive roles are guiding the nursing practice, improving the social status of nurses, expanding the role of nurses, and promoting patient health, among others. During the interviews, postgraduate nurses indicated that they hold considerable hope for their own professional development. They believe that current hospital systems lack management methods and incentive policies related to highly educated nursing talents, and the existing hierarchical training and management system for nurses restricts their development. This situation reminds managers to communicate with postgraduate nurses in a timely manner and understand their views and expectations on their own career planning, resistance, and difficulties encountered in their work. Employers provide nurses with reasonable development and training opportunities. Nurses have clear development direction, which help them become the backbone of nursing as soon as possible.20

4.4. Advice for studying overseas

Although studying overseas requires nurses to pass a language test, language remains the main obstacle to their learning. During the study period, the school offers English support courses. However, given the limited English tutorial time and that some Chinese students are restrained in class, the learning effects vary from one person to another. Some nurses said that difficulties encountered while studying overseas are not simply caused by language communication but also by cultural differences.21For example, some nurses said that they could not completely understand assessment questions and requirements, and they could not communicate well with the instructor. Consequently, they were unable to prepare for the exam, thereby adding to the academic pressure. Additionally, longing for their family members often makes them feel lonely, and the pressure is indirectly amplified, resulting in a vicious cycle. Therefore, nurses studying overseas should strengthen their foundation in English before going to other countries, systematically learn knowledge related to nursing research, and continuously communicate with classmates to make progress together.22Hofstede et al.23also recommend small group learning to increase teacher-to-student and student-to-student interactions.

4.5. Implications for clinical practice

The following four recommendations are provided for students who will study overseas in the future. (1) Do a good job of time management, and on the basis of completing your studies, travel or make more local friends, to broaden your horizon, and enrich your experiences. (2) Understand the school curriculum in advance and learn about curriculum-related knowledge, such as nursing research, before going overseas. Zero-based learning is difficult, and pressure resulting from exams is high. (3) Be prepared to improve language proficiency. English proficiency not only directly affects the learning effect but also affects all types of communication in daily life. Particularly, English proficiency can considerably integrate into the local life and make the experience of studying in a foreign country smoother and richer. (4) Continue communicating with classmates and teachers. Communicating with teachers can provide a substantial understanding of course contents, assessment key points, and methods and effectively discover and comprehend challenges in learning. Communication with classmates and group study, among others, can address learning difficulties.

5. Conclusions

This study explores experiences of Chinese nurse students studying for master’s degree in the UK. The study results support for some identified findings such as language barrier and acculturation which are important for international students. The study found that the Chinese students are not good at teamwork and communicating with teachers. In addition to assessing students’ learning ability, teachers of international students should also pay attention to their psychological state. This study highlights that good time management, good study plan, and positive attitude are important factors for a successful study abroad.

Limitations

This study has a number of limitations. It was a small study, with a purpose of sampling of 8 participants. The research team only recruit the nurses from a China– British cooperation project. The experiences of this particular group of students may not be representative of all nurses studying in the UK. There are 3 participants who were interrupted during the telephone interview. They needed a short pause before continuing the interview to organize their thought.

Ethical approval

This study was approved by the ethics committee of Shenzhen Qianhai Shekou Free Trade Hospital (No. 2022-111(shen)-01K).

Acknowledgments

The authors would like to thank all participants and the financial support of the Shenzhen Nanshan District Science and Technology Bureau for the study.

Conflicts of interest

The authors have each completed the International Committee of Medical Journal Editors Form for uniform disclosure of potential conflicts of interest. All contributing authors declare no conflicts of interest.