Authors:
Rupali Mandpe, BSc Student, Bachelor in Healthcare, Nursing, Novia UAS
Anita Wikberg, Supervisor, RN, RM, PhD, Senior Lecturer, Novia UAS

Abstract

The nursing shortage is seen as a significant challenge in Finland. Furthermore, due to increasing immigration, multicultural care is also seen as a need of the healthcare sector. Retention of international students as nursing professionals could be one of the solutions. However, nursing students face complex situations of unbalance between the education they receive in a foreign language and the communicative demands of the nursing practice.

This article explores challenges nursing students face studying in a foreign country, for example, in Finland. There are multiple challenges; however, based on the first author's experience, the language and communication barriers were identified as significant challenges and are discussed further in this article.

Implementing a suitable curriculum strategy, for example, competence development in the language and communication in ‘Finnish’ and ‘Swedish’ during nursing studies, seems to be the optimal way to attract and retain international nursing students in Finland. This will further improve their attitude towards a positive integration experience.

Introduction

A study done in 2017 revealed an estimation of 50 million expatriates and more than 5 million international students worldwide. Moreover, these numbers are expected to rise in the near future due to the globalization of the academic environment. Conditions of migration due to studies are a little different from other reasons of migration, for example, the decision to stay for a more extended period for the work, new life partner relationships, family bonding etc. Although migration due to study seems temporary, getting used to a foreign culture is crucial in a student's life. During the past decades, many students have seemed to complete their education in a foreign country. So, it becomes vital to understand the physical and mental wellbeing of these individuals wherein foreign language plays an important role (Hofhuis, Hanke& Rutten, 2019).

This article was written by a nursing student who has ‘Marathi’ (one of the Indian languages) as a mother tongue, ‘Hindi’ as a national language in the home country, moved to Finland due to family ties, studying nursing program in ‘English’ where the verbal and written communication is bilingual namely, ‘Finnish’ and ‘Swedish’.

The article is written from international students’ point of view wherein, the nursing shortage in Finland is seen as an employment opportunity for these international nursing students but, language and communication are observed to be barriers for their retention as nursing professionals.

Foreign student, global and Finnish statistics

‘Foreign students’ typically involves both non-resident visa and permanent visa students, for example, children of a parent who moved to a destination country due to work etc. The first author of this article falls under this category, who moved to Finland with her family members. ‘Credit mobile students’ refers to those who migrate for an exchange study program or short stay. They are enrolled in their home country and get only part of their studies done in a foreign country. ‘Internationally mobile students’ are individuals who migrate from their home country to another foreign country (a destination country other than their home country) to study and complete their education, after which they are granted a foreign degree certificate. These ‘internationally mobile students’ hold a student visa (non-resident status), and they differ from ‘foreign students’ and ‘credit-mobile students’. The length of the stay for ‘internationally mobile students’ varies from 1 year to 7 years (Migration Data Portal, 2021).

This article does not relate to any specific students' group but generally refers to all those studying in a foreign country other than their own home country. In a way, these students are new to the foreign culture. They are studying for their benefits, for which motivation could be to get better career prospects, improve their financial status, or even just due to family ties.

There were more than 5.3 million international students worldwide in 2017. This was a huge increase from 2 million in 2000. It is estimated that more than half of this 5.3 million were enrolled in educational programs in Australia, Canada, France, Germany, the Russian Federation, the United Kingdom, and the United States of America. The U.S. counted 1.2 million in 2018, Australia had nearly 1.3 million in 2017, Canada had about 642,480 in 2019, and there were 556,625 during the 2019-20 academic year in the United Kingdom. These students had migrated mainly from China, France, Germany, India, Nigeria, Saudi Arabia, the Republic of Korea, and various Central Asian countries (Migration Data Portal, 2021). In 2017, over 57,000 expatriates and 48,000 international students were in the Netherlands (Hofhuis et al., 2019). According to FACTS (2018), the most common countries among foreign students coming to Finland are Russia, Vietnam, China, Nepal, India, Estonia, Pakistan, Bangladesh, Germany, and Iran. About one out of four foreign degree students in higher education are from the EU/EEA (FACTS, 2018). Furthermore, that means an increasing student population is international, so it is essential to understand the challenges these students face in a foreign country.

In Finland, it is feasible to study in ‘Finnish’, ‘Swedish’ and, in some cases, in ‘English’ language (info Finland 2020). Most of the higher-level education courses are offered in ‘Finnish’ or ‘Swedish’ language. The higher education system in Finland offers more than 400 English language curriculums in Bachelor and Master's degree programs. These are offered by about 13 universities and 22 universities of applied sciences. Over 20 000 international students are studying in several locations around Finland. About 9% of the international students are studying health and welfare related to the education field, for example, nursing (info Finland 2020, Study in Finland 2021, FACTS 2018).

Language barrier and communication

The duration of the nursing degree programme is three and a half years and consists of 210 European Credit Transfer and Accumulation System (ECTS) credits. Out of these, 90 ECTS credits are for clinical practice that is the real-life experience of becoming a professional nurse (NOVIA, 2021). The clinical practice is an essential part of the nursing studies that provide better exposure to become safe practitioners. During practice, the student receives guidance from teachers and the assigned supervisor at the workplace. The nursing studies curriculum mainly focuses on academic studies and vocational development to make students professional nurses after graduation (Suliman & Tadros, 2011). However, studies indicate two significant issues concerning foreign nursing students and correspondingly to future international nurses. These issues are language and communication barriers. To become a competent nurse, it is imperative to have competence in language and communication skills. Nursing students encounter this as a significant challenge to become competent nurses (Eames, 2014).

The increasing challenge of language and communication barrier is twofold viz., one is the communication between healthcare staff that includes native language speakers and international students as future nurses, and the second is the communication between nurses and patients when both are from different cultural backgrounds. The study “A comparison of migrant and English‐speaking Australian‐born cancer patients” was done in Australia (Hyatt et al., 2017). Participants were oncology patients: English‐speaking Australian‐born or born in a country where Arabic, Greek or Chinese is spoken. This study aimed to investigate the communication barriers and challenges experienced by Arabic, Greek and Chinese (Mandarin and Cantonese) speaking patients. The results from the study found that limited English proficiency of patients was related to reduced levels of medical comprehension and reduced communication of crucial medical information (Hyatt, Lipson‐Smith, Schofield, Gough, Sze, Aldridge, & Butow, 2017). It is, therefore, crucial for nursing students to understand the diversity where language plays an important role. This makes it easy for them to work with patients from different foreign backgrounds (Dos Santos, 2021). Although the referred studies concern ‘English’ as a foreign language, any other foreign language, for example in Finland, 'Finnish’ and ‘Swedish’, raises the same concerns.

Learning a foreign language and culture is thus very important when nursing students want to pursue additional job security and treat native patients with good quality care. In addition, it further helps in personal and professional development. However, the curriculum of nursing studies typically has a schedule that makes it a challenging experience for students to get motivation and interest in learning the foreign language. It is also observed that many of the programs do not have a strong focus on developing language skills (Dos Santos, 2021). Furthermore, when the language of instruction is different from the student’s own language, studies are done without understanding and mainly based on memorizing the content (Suliman & Tadros, 2011). “Therefore, nursing students are not ready for globalization due to a lack of language and cultural knowledge of the foreign country” (Dos Santos, 2021). An ongoing primary concern, especially with multicultural foreign students and future healthcare staff, is about effective verbal and written communication in the foreign language. Despite completing academic goals, coping with a foreign language is stressful (Suliman & Tadros, 2011).

More than 150 languages are spoken in Finland; however, ‘Finnish’ and ‘Swedish’ are two official languages. Approximately 4.9 million speak ‘Finnish’ as a first language, more than 0.5 million speak ‘Finnish’ as a second language, and approximately 296 000 are ‘Swedish’ speakers (Institute for the Languages of Finland, 2021). According to Finnish law on the patient’s position and rights (FINLEX), patients have a right to seek information in ‘Finnish’ and ‘Swedish’ languages. Although interpreters can be arranged if a health care professional or patient does not speak the same language, this makes it evident that competence in language and communication becomes the primary factor of becoming a professional nurse after graduation. That is a minimum requirement from Finnish employers' point of view. Dos Santos (2021) states that learning a language help student to further decide on continuing the study or service in a foreign country. According to the first author of this article, active learning during clinical practice is limited by a lack of competence in the 'Finnish' or 'Swedish' language.

Communication is one of the essential parameters in a healthcare setting that improves patient care quality and leads to a better life for an individual. There would be an increase in patient's healthcare costs and adverse outcomes without effective communication (Ratna, 2019). Effective communication with patients in their native language increases their understanding and confidence in providing the treatment. Typically, medical sites are utilized for translation purposes; however, patients prefer to have face-to-face communication to avoid misinterpretation of the subject of discussion (Dos Santos, 2021). In the context of intercultural communication, language challenges might lead to misunderstandings about medical terminology. So, an immigrant must get support from someone who can translate these medical terms and explain the situation. The negative consequence of language barriers in intercultural communication in healthcare was discussed in several studies (Hyatt et al. 2017, Kale & Syed, 2010).

According to Migration Data Portal (2021), the total number of international migrants globally in mid-2020 has reached 280.6 million. The same portal reported about 386 thousand international migrants in Finland at mid-year 2020. Being healthy is a fundamental precondition for migrants to work, be productive, and contribute to the socio-economic development of the society both in-home and host country (Migration Data Portal, 2021). Healthcare literacy, language barriers and cultural competency are observed to be a few main components for effective communication (Ratna, 2019). Lack of communication competence may seriously affect the student's ability to practice as a competent nurse. This affects providing care, getting along with the team, and further developing a professional career (Eames, 2014). Therefore, it is crucial from an international nursing student's point of view to consider the aspects of awareness and understanding of a native language in a foreign country where they would like to get employment.

However, language is not the only factor that affects communication. Language is one medium to communicate, but different aspects of nonverbal communication should also be studied and implemented in a healthcare setting. This includes body movement, gesture, touch, personal space, eye contact, body language, tone of voice etc. (Universal class 2021, LaFrance & Mayo 1978).

Nursing shortage situation in Finland

In Finland, about 13 000 nurses are expected to retire by 2030, and about 30 000 new nurses are estimated to be needed in the coming decade to care for an ageing population. The problem of recruiting enough nurses for elderly care has been reported already by more than half of Finnish municipalities. Finnish authorities are expecting to cope with this shortfall by attracting nurses and nursing students from abroad (Yle news, 2021). Although there are already nursing programs offered by Finnish institutes, the Finnish or Swedish language skills are often observed as barriers in recruitment and retention (Yle news 2021, Helsinki Times 2021).

To get 75% of immigrant nurses to stay in Finland, Metropolia University in Helsinki, and Tampere University of Applied Sciences (TAMK) has begun a pilot program to help foreign nursing students secure employment once their studies are completed. In addition, these universities will emphasize teaching the 'Finnish' language in nursing theory courses and the development of communication competence for work placements (Yle news 2021, Helsinki Times 2021).
According to Päivi Rimpioja, patients’ approach towards immigrant nurses is positive. Immigrant nurses seem to be respectful towards older people. Communication in local language knowledge could be an added advantage. Sanna Laiho further adds that it is essential to express yourself in a working language for an emotionally stressful nursing job. The joint program set up by two universities is expected to address the issues concerning language and communication barriers as well as employment. According to Mäenpää, it is essential that immigrant students need to be employed and stay in Finland. It is not affordable for Finland to lose these nursing staff (Yle news 2021, Helsinki Times 2021).

Summary and suggestions

The article aimed to understand the main challenges students face in nursing programs in foreign countries and the necessity of their retention to find the solution to the nursing shortage.

Education in ‘English’ as a medium of instruction is beneficial in coping with the global crisis of nursing shortage. It helps recruit skilled foreign nurses competent in ‘English’ as a second language and is mainly seen as a recruitment option from developing countries to developed countries. In addition, English as a language of instruction for nursing studies makes nurses more competitive and appealing in the international market; wherein English is acceptable as a communication language. However, there seem to be difficulties in retaining culturally diverse nursing students in a foreign culture. One of the main reasons is a lack of competence in language and communication in a foreign country. For example, the research carried out in Saudi Arabia indicates that the country has become one of the most significant importers of nursing staff from various regions of the world, exceeding about 80% as non-Saudi nurses. This means, nearly all the patients are native Arab speaking, whereas the nursing staff is culturally diverse and hardly speak or knows the Arab language. Therefore, the hospital management decided to make written and verbal communication among staff in ‘English’ and then have arranged professional interpreters to establish communication between staff and patients in ‘Arabic’ language (Suliman & Tadros, 2011).

Developing the ability to take responsibility for coping with foreign language depends on the joint efforts of the student, teaching staff, and management (Suliman & Tadros, 2011). Foreign language and a culture course could be made mandatory to improve the professional competency of the nursing student. Nursing education in a foreign country mainly focuses on the development of nursing knowledge and practical skills. However, it is equally essential to develop nursing students' language and communication skills, which will help them effectively communicate with patients. In addition, the ability to speak a foreign language provides an additional advantage in job searching and career development (Dos Santos, 2021). This will provide an opportunity for these nursing students in a foreign country where ‘English’ is not considered a primary language of communication. This could further ease the situation of the nursing shortage.

Achievement of education and career goals, academic interest, interest in career development, financial and personal considerations are the main factors for motivation to learn the foreign language and culture. Therefore, it is essential to understand the student's motivation and then design the schedule according to the individual's requirement. Learning a foreign language and improving communication skills are of utmost importance to the nursing student regardless of age, cultural background, education, location, and motivation. It also improves the country's competitiveness when these international nursing staff can speak and understand foreign cultures and languages (Dos Santos, 2021).

Recruitment and retention are thus based on fundamental ways of teaching wherein improvement, and modification are expected in teaching strategies. The education institute management, teaching staff, the instructor must understand the need of these nursing students and develop the course curriculum accordingly that will help nursing students cope with the professional environment. It is essential that the education institute management, teaching staff, and instructor understand the need of these nursing students and develop the course curriculum accordingly to help the nursing student cope with the professional environment (Suliman & Tadros, 2011).

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