Phenomenological inquiry on nursing science international students’ experiences in a non-native English pre-clinical learning environment

Article history: Received 19 November 2019 Received in revised form 22 February 2020 Accepted 24 February 2020 Pre-clinical learning in nursing science introduces unique terminologies, abstractions, and activities needed in foundational knowledge. The language, culture, and pedagogical differences within the non-native English-medium instruction result in more complex situations for international students. The study aimed to reveal the lived experiences of international nursing students in a non-native English pre-clinical learning environment. Utilizing phenomenological design, interviews gathered data from purposively sampled participants, from four different Asian countries enrolled in an international program. Thematic analysis was done to reveal their experiences. Four major themes emerged from the participants’ narratives. Their lived experiences began with idealized expectations defined by family influence, guided opportunity, and inspiration. It evolved into a communicative struggle with the divergence of reality from their expectations. Their shaken idealizations and disrupted learning process due to language barriers had an emotional toll. The satisfactory laboratory experiences with unmet expectations brought out ambivalence in them. Communing with others, adaptive response and introspection helped them towards reality reorientation and recalibration, the last two themes to emerge. Different aspects with varying impact within the learning environment defined the experiences of the nursing science international students. These students process and develop their own adaptive responses within their evolving experiences in the non-native English pre-clinical learning environment. Policy development, continuing English language support, student development and support programs for nursing science international program students in the context of pre-clinical training are needed.


Introduction
*International student mobility has been on the rise with globalization. The growing internationalization of education has to the convergence of learners and instructors of different nationalities in the international programs having English as a medium of instruction (Hu, 2019;Choudaha, 2017;Kirkpatrick, 2017). Teachers, university staff, and the students' primary language are not English, yet the medium of course instruction and measurement of outcomes are in English adds to the complexity of this phenomenon (Jenkins, 2019).
Nursing science is among those programs in which these students enroll. Changing demographics and growing trend of medical tourism are some factors are just some of the factors in the increasing global demand for nurses Dalen and Alpert, 2019;Drennan and Ross, 2019). ICN (2013) believed nurses should culturally and linguistically communicate to patients, according to their needs. To prepare these nurses, one must first take a look at the international nursing science students' experiences in their pre-clinical learning environment. Studying nursing introduces a student to a whole new range of terminologies, jargon, and verbal representations uniquely found in the health care system, gradually establishing familiarity to the highly technical use of professional language in English (Gattud et al., 2019). The international nursing science students are expected to able to integrate these terms and concepts into their understanding within a non-Native English speaking environment.
The learning environment is a complex construct in a particular setting defined by culture and contextual circumstances, where people learn clearly has an impact on the learning process and its outcomes (Gruppen et al., 2018;Nguyen, 2019). This context includes numerous factors at the personal, social, and organizational levels that will shape the totality of the learning experience.
This study aimed to describe the lived experiences of the international nursing program students in non-native English learning environment. The researchers were interested in being able to describe the totality of the experiences of international nursing students within a distinct academic environment that will generate responses depending on each of their unique backgrounds. There are aspects within the learning environment that can possibly characterize and define how the lived experiences of the international nursing program students are shaped. Moreover, how they respond to their experiences further develop how their succeeding experiences are subsequently viewed and processed. The research was conducted among students enrolled in a Thai private university Bachelor's Nursing Science international program during the academic year of 2561. They have not yet received hospital or community training. Returning students from leave were not part of the study. International students from other schools were not considered. The international students are taught by international lecturers whose primary language is not English.

Study design
Descriptive phenomenology was utilized to lived experiences of the international nursing students in a non-native English-medium instruction learning environment enrolled in the nursing science international program of a private university in Thailand.

Setting and sample
The study was conducted at a Thai private university campus situated in the locality of Don Yai Hom district, province of Nakon Pathom, Thailand. The 10 international students are non-native English speakers from Bhutan, China, Cambodia, and Thailand enrolled in a nursing science international program. The participants were recruited using the inclusion criteria of a) presently enrolled international nursing program; b) international nursing program students without hospital-related experience.

Instrument
The researchers utilized open-ended interviews as it allowed participants to discuss their opinions, views, and experiences fully in detail. An interview guide consisted of six open-ended questions that helped focus on the nature of the inquiry to be covered with each participant.

Data collection procedure
Approval of the Institutional Review Board of the Christian University of Thailand was secured prior to data gathering. Informed consent was provided to the participants, which included a brief description of the study, the significance of the study, rights of the participants, such as the right to withdraw, anonymity, and confidentiality. Interviews were done from January to April 2019.

Data analysis
Data coding was initially done. The formulation of meanings and clustering subsequently followed. Thematic analysis ensued to clarify. Member checks were also done to assure conformability and transferability. Rigor instituted throughout the study through adherence to a philosophical perspective, thoroughness in collecting data and consideration of all of the data Table 1 presents the participants' lived experiences of the international nursing program students in a Non-native English instruction learning environment. The subthemes of guided opportunity, family influence, inspiration from experience, and others were revealed. Altogether these sub-themes emerged into the main theme of idealized expectations. Subsequently, their lived experiences unfolded with the identified subthemes of shaken idealization, disrupted learning process, ambivalence, and emotional toll. Thus, the second theme of communicative struggle with the divergence of reality and expectations surfaced. Further, the uncovered sub-themes of communing with others, adaptive response, and introspection evolved into the third theme of reality reorientation. Lastly, affirming determination emerged in the lived experiences characterizing recalibration, the last major theme to be uncovered.

Discussion
The following presents the discussion of the four major themes that emerged in this study.

Theme 1: Idealized expectations
The students were guided to take the opportunity to study at an international nursing program by their family inspiration and pieces of advice (Mooney et al., 2008). Further, contributing to stepping towards this particular learning environment are their own experiences and employability considerations. The participants were not largely guided by a single factor but rather combinations of their own and family consideration and circumstances (Nguyen, 2019). This denotes the complexity and amount of information processing and consultation that was made for the students to be able to attend an international nursing program, offered in an Englishmedium instruction learning environment. The chance to pursue a nursing degree in an international program, especially for students who are not from Thailand, has become more than just their own choice of the study program. The representation of their very own expectations for themselves and their families, hoping for perceived quality education and improvement of the English language, facilitated their much-idealized expectations. Their higher expectations are not too dissimilar from a larger Australian sample (Crisp et al., 2009). They arrived at the university with relatively realistic visualizations of what their learning environment should be done (Hassel and Ridout, 2018).

Theme 2: Communicative struggle within the divergence of reality and expectations
The international students gradually discovered how certain elements within their non-native English preclinical learning environment were far from their expectations, resulting in disappointment and frustration. This defining subtheme of shaken idealizations echoes (Kim and Feldman, 2011) unrealistic expectations and the mismatch in the expected availability of assistance or related support service (Smith and Hopkins, 2005).
More verbalizations came to describe the disrupted learning process and unmet learning needs with communication differences playing the bigger role. Teachers unable to communicate well in terms of the English language and in their teachinglearning activities become a factor in the disruption of the learning process. The learning environment then becomes less conducive to learning when the crucial link, (i.e., language) (Bolton et al., 2017) between the learning constructs comes across as distorted and confusing. The unhelpful curriculum, pedagogy, and context end up fostering learner resistance (Huang, 2018). This experience draws a sharp contrast from what was observed that teachers need to understand the nursing students to facilitate teaching (Yeop et al., 2016).
Some students expressed their difficulties in language translating, understanding, and retranslating the process of learning. Clearly, learning in a language that a student does not know well also fails to give them adequate skills in that language, despite its intent to do so. This splits the learner focus between context topic understanding and literal understanding. It has to be acknowledged, however, that English medium instruction does allow opportunities for language practice (Zhang, 2018;Chang et al., 2017;Hernandez-Nanclares and Jimenez-Munoz, 2017) which some of the participants' value. This also demonstrates the ambivalent feelings among some of the international students in this given learning environment.
There is an expressed preference in clinical laboratory learning than classroom didactics. Participants generally expressed ambivalence in their learning environment, especially in appreciating laboratory classes more. This mirrors Haraldseid et al. (2015) description of student nurses valuing clinical practice in the process of becoming a nurse and a professional. For others, there is both an appreciation and disappointment of how they were learning inside the classroom. The motivational learning ambivalence inside the class reflects more the teaching-learning activities the teachers are employing inside that specific part of the international nursing program learning environment. Student nurses have shown that feedback from lecturers and peers influence learning (Ismaile and Alhosban, 2018). The unraveled experience shows that this process is disrupted by language barriers. The recognized appreciation of the international students towards some of their classes may also be reflective of the different strategies of narrative pedagogy in nursing (Brown, et al., 2008) as well as applied pedagogy that can address the diverse needs of the students (Pagnucci et al., 2015;Starkey, 2015).
Given the language barrier between the international and local students, some intentionally limit their interactions due to the communication struggle of translating and retranslating. Some of the participants went on to the extent of isolation to avoid experiencing that stressful part of their learning environment (Wu et al., 2015). This is contrary to the purpose of having an Englishmedium instruction where Kim and Tatar (2017) found a negative correlation between the students' performance and their interaction between the local and international students. There is no language gain enhancement as well as reinforcement of nursing concepts. This only highlighted the dissimilarities in the educational systems in their home countries resulting in emotional responses like loneliness, homesickness, language difficulty, discrimination, financial problems, and confusion (Crisp et al., 2009;Wu et al., 2015).

Theme 3: Reality reorientation
The vivid description of their lived experiences revealed how international students have navigated and are currently making sense of what they had been and were going through. Interacting with their fellow students in the form of student organizations have proven to be helpful in the adjustment of international students (Foubert and Urbanski, 2006;Wu et al., 2015). The participants were particularly appreciative of the freshman orientation program they went through. This reiterates the need for communication between students and staff to achieve a better alignment of students' expectations and the reality of university study and culture (Crisp et al., 2009;Brown et al., 2008). However, after the mentioned activity, they found themselves gravitating towards their fellow students from their own country in the absence of student organization activities. While this is helpful, it does not help much in assisting the students to create more connections with others outside their own culture contrary to student engagement (Foubert and Urbanski, 2006;Dorsett, 2017), which enables international students to be more serious about learning and promote awareness of where and how to get help. They also tended to be more social, open to diversity, and to venture out and explore the culture. This was reflected in some of the participants' experiences of having initiated and responded to social advances from others outside of their own nationality.
The formation of adaptive responses is inevitable. The experiences of being with others and selfreflection may have enabled them to develop adaptive responses and vice versa. The resulting experiences allow them to define or process the different aspects and implications of the pursuing their nursing science degree in English as a medium of the instruction learning environment (Gruppen et al., 2018). Suliman and Tadros (2011) found that students utilize positive reappraisal, plan problem-solving, self-controlling, as well as seeking confrontive coping and distancing investigated strategies used by nursing students in coping with English as a foreign language medium of instruction. Some participants were able to utilize those strategies by themselves or within their respective social circles. Further, these adaptive responses also prepare them to manage challenging situations in their senior year in nursing (Albagawi et al., 2019).

Theme 4: Recalibration
Student adaptation occurs when the environment allows the students to personally engaged with people as well as working to understand the cultural differences (Dorsett, 2017;Brown et al., 2008). Their experiences allow them to anticipate changes in their current learning environment. Their determination to move forward within the realms of their learning environment suggests their motivation to ultimately learn how to better care for a patient (Colbert-Getz et al., 2016;Wu et al., 2015;Sanner and Wilson, 2008). This suggests that the international students are eventually able to adjust in the initially relatively unfamiliar processes and aspects within the non-native English pre-clinical learning environment by using resources within their access and existing coping patterns.

Conclusion
There are many aspects with varying impacts in the non-native English pre-clinical learning environment that define the lived experiences of the international nursing program students. It was processed and understood in order to develop their own adaptive responses within their evolving experiences.
Thus, as demonstrated in this study, by having a better understanding of these students' academic challenges, the university faculty and staff can recognize students' needs and correspondingly offer supportive campus resources and services to facilitate a more effective learning environment.

Funding
This research was funded by the Christian University of Thailand.