Psychological Wellbeing and Predictors of Early Help-Seeking Behaviours of International Students of Undergraduate Nursing Programs: A Scoping Review
Funding: The authors received no specific funding for this work.
ABSTRACT
Background
Australian Universities are the principal providers of nurse education for international students. While researchers have recognised the important issue of poor psychological well-being among nursing students, few have explored the factors which impact international nursing students.
Aim
This review aimed to map the reported factors impacting psychological health, wellness and early help-seeking behaviours of international students enrolled in Bachelor of Nursing programmes.
Methods
A scoping review with a five-stage methodological framework to interpret and synthesise the available literature was utilised. The following databases were searched: CINAHL Complete, PsycINFO, MEDLINE, ERIC and Scopus for studies published in English from 2012 to 2022. Additional sources were also sought through a review of the references of included studies. Four studies met the inclusion criteria.
Results
Results revealed that all included studies were from Australia and utilised a quantitative approach. Factors impacting psychological health and wellbeing, as well as help-seeking behaviours included but were not limited to migrating alone, language spoken, marginalisation and the COVID-19 pandemic. Published literature on this topic is limited, with a notable absence from other countries.
Conclusion
This review highlights a gap in evidence concerning ways to support international nursing students.
Patient or Public Contribution
There were no patient or public contributions in the design, conduct, analysis or preparation of this manuscript.
1 Introduction
The influx of international students to Australia has more than doubled in number since 2001 (Universities Australia 2020). In February 2024, Australia's international student enrolments reached 703,245 compared to 578,930 in 2019 (Department of Education 2024). In the 2022–2023 financial year, international education was worth $36.4 billion to the Australian economy (Australian Bureau of Statistics 2023). For international students, Australia is a popular destination, third behind the United States (US) and United Kingdom (UK) (Universities Australia 2020). Ammigan (2019) reported several benefits of studying abroad, including academic, social and cultural. Although there are opportunities to learn new cultures amidst improved educational systems with potentially wider career prospects, many challenges can present for these students.
Students in foreign countries, compared to domestic, are challenged in many ways. Studying in a new environment is likely to be an overwhelming experience for anyone, especially those from a background that is culturally or geographically diverse (Jones 2017). Learning to adapt to a new academic setting in the absence of family and friends can be stressful (Arias-de la Torre et al. 2019; Bista and Foster 2016). Learning new academic programme requirements and curriculums, for international students, means they need to learn new social and cultural norms, which can include dietary options, communication styles, living arrangements and making new friends (Ammigan and Jones 2018). Language barriers can present as another important challenge for students (Ammigan 2019). Furthermore, studying overseas can be an expensive option for families, which can result in additional pressure and expectations on international students (Ammigan 2019; Wu et al. 2015) leaving students feeling isolated, stressed and anxious (Khawaja et al. 2017).
The incidence of psychological wellbeing among students in foreign countries has been recognised as a concern (Forbes-Mewett and Sawyer 2011; Orygen 2017). Consequently, these students are identified as one of the high-risk groups, as they are often prone to a number of factors pre-disposing this group to developing mental health problems (Forbes-Mewett and Sawyer 2011; Orygen 2017). A study conducted by Forbes-Mewett et al. (2015) in Australia, the UK and the US found that even though mental health-related issues are common, international students often avoid counselling services. The above study also highlighted that those students were less connected to their host countries, especially those from non-English speaking backgrounds. The psychological wellbeing of students from East and Southeast Asia was more likely to experience depression and anxiety, which affected their studies (Forbes-Mewett et al. 2015) and low help-seeking behaviours (Aguiniga et al. 2016). This finding is particularly important as data show that most students that arrive in Australia are from China and India, making up 42% of arrivals up to September 2022 (Department of Education and Training 2022).
During the COVID-19 pandemic, there was increased incidence of psychological distress in the community, particularly in the 13-to-26-year age group in the US and UK (McGinty et al. 2020; O'Reilly et al. 2021; Pierce et al. 2020). Despite the pandemic being a factor, mental health disorders typically emerge by 25 years of age (Solmi et al. 2022). In 2015, the most common age range for international students in Australia in higher education was between 20 and 24 years (50.9%) (Department of Education and Training 2016). The consequences of poor psychological wellbeing can be distressing for international students and their families. Xu (2021) reported that the pandemic had an impact on psychological conditions on students as a result of various environmental reasons (lockdown, social isolation, lack of support). There is evidence of inability to cope with academic demands, poor engagement with studies, poor clinical performance and unhealthy coping strategies.
Attending higher education can be a challenging period for many students. However, there is an added complexity for those undertaking an undergraduate nursing program. Training in nursing involves theory, practice and clinical experience (Khawaja et al. 2017). Nursing students need to learn to express themselves articulately and negotiate academic and clinical environments. It is widely accepted that nurses experience higher levels of depression and stress because of high-pressured clinical environments, resulting in anxiety or depression (Graham et al. 2016; Ng et al. 2022; Okechukwu et al. 2023; Reverté-Villarroya et al. 2021; Tung et al. 2018). These impacts are observed with continued concerns related to ‘burnout’ among the nursing profession (Shahzad et al. 2019; Shamsikhani and Ahmadi 2023; Vincent-Höper et al. 2020). International nursing students are particularly vulnerable as they are in a situation where they are not only students but also health professionals, surrounded by unfamiliar territory. The workload associated with clinical experience has been recognised as the main source of stress in nursing students, followed by family issues and financial constraints (Lo 2002; McCarthy et al. 2018; Reverté-Villarroya et al. 2021).
It is widely accepted that tertiary institutions provide support services, such as psychological counselling and financial support (Yee and Ryan 2022). Many institutions provide services to groups of students who have specific needs, such as international students. However, even with these services, international students consistently underutilise this type of assistance, in particular psychological counselling (Yee and Ryan 2022). The development of interventions that are culturally appropriate to help improve the wellbeing of international students has been suggested as a consideration in mitigating problems associated with stress and anxiety (Atherton and Cornwall 2022). Atherton and Cornwall (2022) reported that Chinese students studying at a New Zealand university were less likely to utilise university-based counselling services but rather turned to parents for psychological support. A lack of engagement with university psychological services was found to be due to cultural differences and practical concerns, including being unaware of these resources and not knowing how to contact counselling services as being some of the main barriers to engagement with help services (Atherton and Cornwall 2022).
Many studies have reported the significant impact of undergraduate studies and personal issues on nursing students (Aedh et al. 2015; Asturias et al. 2021; Lu et al. 2019; Lundell Rudberg et al. 2022). Evidence of the impact of anxiety and stress on performance in the clinical setting leading to reluctance to communicate is growing (Rust et al. 2020). Acculturative stress is a term coined to define stress induced by adapting to a new cultural setting (He et al. 2012), while acculturation describes the process by which we learn our surrounding culture (Mitchell et al. 2017). There are many advantages for international students in the clinical setting, such as the ability to improve their English language; however, students report their stress in these settings limits' communication (Mitchell et al. 2017).
The importance of psychological wellbeing for nursing students in general has been established. However, less is known about the psychological wellbeing for specifically vulnerable subgroups such as international nursing students and their previously described challenges. Nursing students play a pivotal role in our healthcare system, as the future leaders (Schwartz 2019). Students enrolled in nursing programs were recognised as assets during the pandemic (Rasmussen et al. 2022) and subsequently invited to work in clinical settings as healthcare assistants (Dempsey et al. 2023). Educational faculties are obligated to guide nursing students to career placement and continuous learning opportunities (Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing 2011). Nurses play a critical role in upholding our essential services in times of disaster (Shin et al. 2022). The health and wellbeing of the nursing workforce is paramount, as it directly impacts healthcare services worldwide (Cuff and Forstag 2019). People working within educational systems need to be aware of the factors which can influence psychological wellbeing for international nursing students to best support them in their clinical and educational endeavours. This could provide valuable information to mitigate psychological distress for students in different years of their education and promote early intervention and help-seeking.
There is a growing concern regarding the psychological wellbeing of international students, yet the literature remains limited in its exploration of the specific challenges faced by this group, particularly within the context of nursing education. To date, there has been little research into the psychological wellbeing of international nursing students, leaving a significant gap in understanding their unique needs and experiences. This scoping review aimed to address this gap by summarising, synthesising and analysing studies on international nursing students. The aim was to identify and examine the factors influencing their psychological wellbeing, with a particular focus on early help-seeking behaviours among students enrolled in undergraduate nursing programs. By exploring these factors, this review will contribute to the broader international literature on student wellbeing and inform strategies to better support the mental health of international nursing students.
2 Method
The topic being investigated lends itself to a scoping review, which provides the ability to present a broad understanding and synthesis of the literature available and is not restricted by research design or quality (Arksey and O'Malley 2005; Doody et al. 2020). Advantages of scoping reviews include the ability to explore the literature available on a topic of interest, identify gaps and report these findings (Arksey and O'Malley 2005; Doody et al. 2020; Levac et al. 2010). This review adhered to Arksey & O'Malley's five-step process, which included: (a) formulating a research question, (b) identifying studies that were relevant, (c) choosing the studies, (d) plotting the results, and finally (e) collecting, writing concisely and recording the results. As this was a scoping review, ethical approval was not sought.
2.1 Identification of the Research Question
The questions addressed within this review, in relation to international students, were: (a) What are the reported factors impacting psychological wellbeing of students enrolled in undergraduate nursing programs? (b) What help-seeking behaviours are reported of students studying in the undergraduate nursing program? (c) What gaps exist in the literature examining psychological wellbeing of these students enrolled in undergraduate nursing programs?
2.2 Identification of Relevant Studies
A librarian consultation occurred prior to running the database search. An exhaustive search of studies that had been peer-reviewed was conducted in the following databases: CINAHL, PsycINFO, MEDLINE, ERIC and Scopus. A range of search terms and key words were utilised in order to obtain a broad range of peer-reviewed papers (Arksey and O'Malley 2005). The search terms utilised were all in relation to ‘international nursing students’. The databases' thesaurus were used, when possible, to control the search terms. An example of terms in Medline were: ‘Undergraduate’ or ‘International’ or ‘Nursing’ and ‘Psychological’ or ‘Wellbeing’ or ‘Well-being’ or ‘Help’ or ‘Stress’. Results were imported to EndNote and Covidence respectively (The EndNote Team 2013; Veritas Health Innovation, n.d.).
Inclusion of studies was guided by the ‘Population, Concept, and Context’ format (PCC) (see Figure 1), adapted to allow a broad search ensuring different methodologies (Peters et al. 2015). The population included international undergraduate nursing students, the concept was psychologicalwellbeing and help-seeking. The context related to those enrolled in undergraduate nursing programs worldwide.
International peer reviewed studies that utilised qualitative, quantitative, or mixed methods that were published in the English language in the previous 10 years were included (2012–2022). The time frame was limited to capture contemporary data, defined as research that reflects current trends, challenges, and developments within undergraduate nursing systems, student support services, and the experiences of students in a rapidly changing academic environment. All authors were involved in screening the studies for inclusion. Exclusion criteria included: clinical staff or educators who were not undergraduate students and students who were not enrolled as international students. Other exclusions included studies not focused on international undergraduate nursing students, editorials, discussion papers, position papers and reviews.
2.3 Study Selection
References were imported into vidence for management of the studies throughout the review process (Veritas Health Innovation, n.d.). developed by Cochrane Collaboration, Covidence is an online platform which assists with the production of reviews (Peters et al. 2015). An exhaustive database search was conducted and then combined with a Covidence reference chain search. Covidence software was utilised by all reviewers independently to not miss any relevant references. Duplicates were removed and studies were screened by all reviewers with inclusion and exclusion criteria in mind. Conflicts or disagreements were discussed at weekly meetings for a consensus to be reached. Results were presented in the ‘Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews’ (PRISMA-ScR) flow diagram (Tricco et al. 2018). Once included studies were identified, reviewers screened the list of references for each study to ensure no relevant studies were missed.
2.4 Plotting the Data
All papers included in this scoping review met the inclusion criteria. A standardised charting spreadsheet was used to extract relevant data on the main characteristics of each study (Arksey and O'Malley 2005). Information extracted from each study included: year and country of publication, the author, the study aims, methodology and findings. The data extracted is presented in Tables 1 and 2.
| Author(s) (year) | Selection bias | Study design | Confounders | Blinding | Data collection method | Withdrawals and drop-outs | Global rating |
|---|---|---|---|---|---|---|---|
| Asturias et al. (2021) | 2 | 2 | 2 | 3 | 1 | 2 | Moderate |
| He et al. (2012) | 2 | 2 | 2 | 3 | 1 | 2 | Moderate |
| Khawaja et al. (2017) | 2 | 2 | 2 | 3 | 1 | 2 | Moderate |
| Rasmussen et al. (2022) | 2 | 2 | 2 | 3 | 3 | 2 | Moderate |
- Note: Strong (1), moderate (2), weak (3).
| Author(s) (year) | Country | Aim | Research design | Measures used | Sample size (n) | Response rate | Summary of findings | Considerations |
|---|---|---|---|---|---|---|---|---|
| Asturias et al. (2021) | Australia | To measure perceived stress for undergraduate nursing students, to identify coping strategies and to also identify if there is a link with socio-demographic factors | Quantitative |
Demographic. Perceived Stress Scale. Coping Strategy Inventory |
377a | 62% | Majority experienced moderate stress, maybe due to impending assessments of clinical placement at the time of collection. Adaptive coping strategies were directly related to lower stress levels. Those born outside of Aust, International students utilised cognitive restructuring and problem avoidance coping strategies. Those who spoke a language other than English at home utilised problem avoidance and wishful thinking coping strategies | Stress levels for participants may have been influenced by impending assessments and month of data collection. Some students were also undertaking clinical practice at the time. Participants surveyed once, which might introduce some bias. This study includes a subsample of international students |
| He et al. (2012) | Australia | To investigate Chinese international undergraduate nursing students' level of acculturative stress and sense of coherence | Quantitative |
Demographic. Acculturative Stress Scale for International Students. Sense of Coherence Scale |
119 | 37.8% |
Level of acculturative stress was only moderately high. Could be due to the thought that by admitting that they have acculturative stress it will be perceived as a weakness. Worried about losing face and embarrassment, therefore unlikely to share experience and may have implied personal failures. Sense of coherence was negatively correlated with level of acculturative stress |
Data was collected when most students' first assignments were due. Self-report measures and recall. The measures in this study were validated in the US, which might limit relevance and validity for other countries and international students. Sampling limitations (one cohort of Chinese international students) |
| Khawaja et al. (2017) | Australia | To examine the relationship between second language anxiety and international nursing student stress after taking demographic, cognitive and acculturative factors into account | Quantitative |
Demographic. Second Language Speaking Anxiety Scale. Second Language Writing Anxiety Inventory. Dysfunctional Perfectionism Subscale (Frost Multidimensional Perfectionism Scale-Revised). Brief Fear of Negative Evaluation Scale. Marginalisation and Separation (East Asian Acculturation Measure) |
152 | Not reported | International nursing students encounter second language anxiety particularly in the spoken form. Interventions are required to assist international nursing students' resilience, coping and management of second language issues | Response rates could not be tracked. Sample size was small. No causal relationships could be determined. Sample in Australia, limited generalisability for international students in other countries. Apart from the stress scale, validation of the utilisation of the other measures with the international student population is still limited |
| Rasmussen et al. (2022) | Australia | To explore the impact of COVID-19 on psychosocial well-being and learning for nursing and midwifery UG students in an Australian University | Quantitative | Survey based on Manual for Depression Anxiety Stress Scales | 437 |
22%. 288 provided a response to one of the three open ended questions. |
Three major themes: 1. Psychosocial impact of the pandemic. 2. Adjustment to new modes of teaching and learning. 3. Concerns about course progression and career. International students indicated that they felt isolated from family in a foreign country, and they raised concerns about their inability to make connections with fellow students in the on-campus setting having moved to the online space |
The study focused on the impact of the Covid-19 pandemic with undergraduate nursing students. International students were a subsample |
- a N was not always achieved due to incomplete surveys.
Quality appraisal of the studies included was conducted using the ‘Quality Assessment Tool for Quantitative Studies’ (Armijo-Olivo et al. 2012; Effective Public Health Practice Project 2009; Thomas et al. 2004). The tool provides an overall global rating for each paper based on an assessment of eight domains relating to any bias in selection, design of the study and if any confounding factors exist, methodology including blinding and collection of data, participants withdrawing or dropping out, integrity of any interventions and finally analysis of the data. Quality assessment for each study was conducted by two reviewers, and any discrepancies were discussed (see Data S1). The assessment of quality was utilised to further structure and provide knowledge synthesis for evaluation of the studies and did not result in exclusion (Arksey and O'Malley 2005).
2.5 Collation and Summary of Results
The PRISMA-ScR checklist was adhered to, ensuring transparency in our reporting and the ability to identify gaps in the literature warranting further investigation and research (Tricco et al. 2018). Papers were therefore selected and analysed to answer the research questions posed. This manuscript presents the results in narrative form with accompanying tabulated or charted results included (Arksey and O'Malley 2005; Levac et al. 2010).
2.6 Quality Appraisal
The quality appraisal of the studies included is presented in Table 1 (Effective Public Health Practice Project 2009). Two authors assessed the papers for quality. Although there were minor discrepancies because of differences in interpretation of criteria, both assessors reached consensus and agreed on a global rating of moderate for each paper.
3 Results
The initial search yielded 2578 studies (see Figure 1). Following the removal of duplicates, 1924 studies were independently screened with the criteria for exclusion and inclusion in mind. Following this process, an examination of titles and abstracts was conducted, with 27 studies identified for full-text review. Twenty-three studies of the 27 were excluded; reasons for exclusion are outlined in Figure 1 leaving four studies that met the criteria for inclusion.
3.1 Study and Sample Characteristics
Tables 2 and 3 provide the characteristics of the studies included in terms of research design, sample and key findings. All of the included studies were from Australia (n = 4) and published between the years 2012–2022. All of the studies utilised a quantitative research design.
| Author(s) (year) | Sample description | University year | Sample age | Sample sex | Country of birth N (%) | Residential status N (%) | Marital and family status | Employment or volunteering status | Primary language N (%) | IELT scores | Years in host country |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Asturias et al. (2021) | 2nd and 3rd year BN students at one University | Second (71%) and third (29%) |
18–24: 174 (47%). 25–29: 88 (23.8%) |
81.9% female. 18.1% male |
Australia 155 (41.1%). Philippines 55 (14.6%). India 55 (14.6%). Other 112 (29.7%) |
Citizen/Permanent Resident 322 (85.6%). International Student/Temporary Visa 54 (14.4%) |
Single 277 (60.9%). Married 146 (39.1%) |
Employed 291 (79.5%). Unemployed 75 (20.5%) |
English 218 (58.8%). Non-English 153 (41.2%) |
Not reported | Not reported |
| He et al. (2012) | Chinese international undergraduate nursing students enrolled in one Australian University | First (31.9%), second (25.2%) and third (42.9%) |
< 24: 66 (55.4%). 25–29: 27 (22.7%). 30 <: 26 (21.9%) |
108 (90.8%) female. 11 (9.2%) male |
Not reported | Not reported | Not reported |
Employed 93 (78.2%). Unemployed 26 (21.8%) |
Not reported |
7.0–8.0: 13 (10.9%). 6.0–6.5: 49 (41.2%). < 5.5: 24 (20.2%) |
Not reported |
| Khawaja et al. (2017) | Enrolled in nursing or midwifery programs across Australia. | First (29.3%), second (32%) and third year (38.7%) | Mean = 26.23 (SD = 5.60) |
129 (85%) female. 23 (15%) male |
Not reported | Not reported | Not reported | Not reported | Not reported | Not reported |
1–3 (42.1%). < 1 year (34.9%). Years studying English as second language Mean = 10.31 SD = 6.69 |
| Rasmussen et al. (2022) | Undergraduate nursing and midwifery, public health and health promotion (single or double degree) students in a Victorian university (3 campuses). | First (24.3%), second (33.2%), third (13.3%) and fourth (6.4%) | Mean = 25.15 (SD = 7.35) |
408 (93.4%) female. 24 (5.5%) male. 2 (0.5%) non-binary. 3 (0.7%) did not disclose |
Australia 375 (72.5%). Philippines 29 (6.6%). China 17 (3.9%). India 11 (2.5%). Other 63 (14.4%) |
120 (34.2%) were not born in Australia. Of these (n = 79) held international student status (65.8%) |
Living alone: Yes (42/9.6%). No (395/90.4%). Living with dependent children: Yes (51/11.7%). No (386/88.3%) |
Employed 314 (71.9%). Unemployed 123 (28.1%) |
Not reported | Not reported | Not reported |
3.2 Summary of Results
The summary of results is presented in Table 4 addressing the research questions. Two studies surveyed undergraduate nursing students, and international students were a subsample (Asturias et al. 2021; Rasmussen et al. 2022). These studies were included as the available research in this area is limited. Furthermore, the inclusion criteria did not identify international students only as a population.
| Author(s) (year) | Research question 1: factors impacting psychological health and wellbeinga | Research question 2: factors impacting help-seeking behaviours | Research question 3: gaps in the literature on psychological wellbeing and help-seeking |
|---|---|---|---|
| Asturias et al. (2021) | Socio-demographic factors impacting stress (diversity in background, migrating alone, without family and support) gender, age, marital status, country of birth, ‘residential status’ and ‘language spoken’ |
Engagement coping strategies were preferred over disengagement coping strategiesb. Male participants tended to use problem solving, self-criticism and social withdrawal coping strategies. Female participants tended to use social contact coping strategies. Participants born outside Australia tended to use cognitive restructuring and problem avoidance coping, while participants whose primary language is not English tended to utilise problem avoidance coping strategies. Participants who spoke other language than English at home utilised problem avoidance and wishful thinking coping strategies. Married and single participants tended to utilise either cognitive restructuring, problem avoidance or social withdrawal coping strategies. International students more likely to utilise cognitive restructuring. Lower levels of stress help with adaptive coping strategies |
Future research needs to evaluate strategies to reduce stress for undergraduate nursing students. Students for whom English is their second language may require specific support. Factors such as employment and family responsibilities should be explored further. Compare stress levels between the start and end of teaching periods. Qualitative or mixed-methodologies to examine student's experiences in more depth. Further studies to understand the causative factors of stress among undergraduate nursing students. International students were a subgroup |
| He et al. (2012) | University year | No help-seeking behaviours reported in results |
Individual interviews with international nursing students identifying types of stress experienced and how they coped. Additional validated questionnaires to investigate students' coping strategies and examine their accessibility to social support networks. Presence or severity of depression could be further investigated. A comparable group of Nepalese students-replication of the study with international students from other countries and cultures |
| Khawaja et al. (2017) |
Marginalisation, Separation. Years studying English, Years in Australia, Fear of negative evaluation, Spoken and Written Second language anxiety, Academic stress |
No help-seeking behaviours reported in results | Comparing levels of stress and second language anxiety with other international nursing student populations. Utilising measures that have been well validated with the nursing student population. Qualitative methods to explore the lived experience |
| Rasmussen et al. (2022) |
The Covid-19 pandemic (reduced motivation, impact of isolation and the global pandemic on student's mental health, competing concerns affecting ability to focus and engage in teaching and learning, increased resilience). Adjustment to new modes of teaching and learning (flexible teaching and new strategies, improved study techniques, fewer face to face classes, quality of teaching strategies and techniques). Concerns about course progression and career (worries about assessment, preparation for being a registered nurse and new graduate). Isolation from family and support networks |
Covid-19 helped build resilience, use available resources that can help with studies. Isolation-No energy to reach out for help |
The University provided frequent simulation learning opportunities in comparison to other University settings. Potential bias due to voluntary participation. Data collected during early stage of the pandemic. International students were a subgroup |
- Note: Disengagement coping strategies (social withdrawal, problem avoidance, wishful thinking and self-criticism).
- a For studies 1–3, factors were reported which had a statistically significant association with psychological health and wellbeing.
- b Engagement coping strategies (cognitive restructuring, social contact, problem solving and express emotion).
3.2.1 Factors Impacting Psychological Wellbeing
Several factors impact the psychological health and wellbeing of students. Socio-demographic variables, such as gender, age, marital status, country of birth and residential status, can significantly affect stress levels. Migrants, especially those who have moved alone without family support, face additional challenges. Language barriers and the years spent studying English and in Australia can heighten anxiety, particularly concerning academic pressures and the fear of negative evaluation.
Academic stress, including concerns about course progression, assessments and preparation for future careers (e.g., becoming a registered nurse), further contributes to mental health challenges. The COVID-19 pandemic exacerbated these issues, reducing motivation and increasing isolation, which disrupted students' ability to focus on studies. Despite this, many students developed resilience in response to these challenges.
The transition to new teaching methods, including fewer face-to-face classes, flexible learning options and new strategies, has been a mixed experience. Some students found improved study techniques, but others struggled with the quality of teaching. Isolation from family and support networks continues to be a key stressor, especially for those in a new country. Marginalisation and separation also contribute to feelings of disconnection and increased psychological strain.
3.2.2 Factors Impacting Help-Seeking Behaviours
Help-seeking behaviours were influenced by a range of factors, including coping strategies and socio-demographic characteristics. Students generally preferred engagement coping strategies, such as problem-solving, over disengagement strategies. Male students often used problem-solving, self-criticism and social withdrawal, while females were more likely to engage in social contact as a coping strategy. Students born outside Australia tended to favour cognitive restructuring and problem avoidance, with those whose first language is not English showing a particular tendency towards problem avoidance. Additionally, individuals who spoke a language other than English at home were more likely to use problem avoidance and wishful thinking strategies.
Married and single students showed similarities in coping, typically using cognitive restructuring, problem avoidance or social withdrawal strategies. International students were more inclined to use cognitive restructuring to manage stress. Lower stress levels were linked to more adaptive coping strategies. The COVID-19 pandemic, while challenging, also contributed to resilience, encouraging students to utilise available resources for academic support. However, isolation remained a significant barrier to seeking help, as students often felt they lacked the energy or motivation to reach out, further hindering their ability to access support when needed.
3.2.3 Gaps in the Literature on Psychological Wellbeing and Help-Seeking
The gaps identified from the studies revealed that future research on stress among undergraduate nursing students should focus on identifying effective strategies to reduce stress, particularly for those for whom English is a second language, as they may require targeted support. Factors such as employment and family responsibilities should also be further explored. Comparing stress levels at the start and end of teaching periods could provide valuable insights.
Qualitative or mixed-method studies are needed to examine students' experiences in greater depth and to understand the causative factors of stress. International students represent a specific subgroup that warrants further attention, with individual interviews needed to identify their unique stressors and coping mechanisms. Additionally, studies should include validated questionnaires to assess coping strategies and access to social support networks, as well as explore the presence and severity of depression. Replicating studies with international students from different cultural backgrounds and using well-validated measures would help strengthen the findings. Potential biases, such as voluntary participation and data collection during the early pandemic, should also be considered.
4 Discussion
This review summarises studies of international nursing students to understand factors which can influence their psychological wellbeing as well as early help-seeking behaviours of international students enrolled in undergraduate nursing programs. All studies were conducted in Australia, which is not surprising as Australia is a major nursing program provider for students from other countries (He et al. 2012). Findings suggest that there is much work to be done to improve the academic and clinical experience for undergraduate international nursing students. It is important to acknowledge that studies were excluded (n = 5) if there was a focus on international students but not nursing students in particular. Most of the studies (n = 3) were conducted in the last 7 years, which might indicate that interest has grown slightly. This could be the result of growing concerns related to the nursing workforce with potential impacts on current policy and practice. Furthermore, this could also be attributed to the substantial increase in international students as a whole and the need to support them.
Christensen et al. (2021) conducted an inductive content analysis of nursing academic experiences of contra-power harassment from undergraduate nursing students. One theme which emerged from this study was students, ‘Being set-up to fail’. Academics acknowledged the considerable pressure faced by international nursing students in particular with maintaining academic and professional standards in addition to student visa status and what failing would mean (Christensen et al. 2021). Some academics felt that some international students were, ‘prone to arguing that as English is not their native language, the normal conventions of academic writing should not be applied’ and should receive special consideration (Christensen et al. 2021). Christensen et al. (2021) also found that some academics were, ‘directly accused of grading international students lower than domestic students’. The need to support international nursing students is paramount, as ‘it is these students who know they hold the power of tuition fees’ and ‘fees the Universities desperately need’ (Christensen et al. 2021).
There are several diverse elements, which impact psychological wellbeing, some more prevalent than others such as ‘language’ and related anxiety. Number of years in Australia and/or University were also factors impacting psychological wellbeing. Other factors were socio-demographic such as gender, marital status and age as well as migrating alone, marginalisation, fear of negative evaluation and academic stress. The COVID-19 pandemic was a particular focus for one study. Despite only four studies identified, international students in nursing programs are experiencing a broad range of factors which are impacting their wellbeing. McKenna et al. (2017) explored the psychological wellbeing of foreign students in the health professions and the impacting factors. The review found four key elements, including the ability to negotiate components, systems of components to make structures, effective communication to exchange information and perception of their well-being, discrimination and being socially isolated. McKenna et al. (2017) reinforced the difficulties experienced by international health professional students and navigating different healthcare systems. The authors implored further research to explore these factors impacting wellbeing to appropriately prepare and support their encounters. One way of supporting international students is providing education on the university services available to them such as counselling or mentoring programs.
Only two studies reported on help-seeking behaviours; however, the findings did not specifically relate to help-seeking behaviours but instead to ways of coping. One study identified differences between male and female participants in coping strategies. Depending on where participants were born, there were differences in how coping strategies were or were not adopted. In the remaining study, COVID-19 helped build some resilience; however, it contributed to further isolation experienced by international nursing students. Although not focused on international nursing students in particular, the relationship between help-seeking behaviours and the stigma attached with respect to mental health was examined by Maeshima and Parent (2022) in Asian American and Asian international college students. They found that help-seeking was impacted by stigma in Asian college students and that being an international student also impacts the strength of the relationship between perceived and personal stigma.
4.1 Implications for Research, Practice and Policy
Our findings can provide guidance for designing nursing programs and supporting students. Khawaja et al. (2017) provide recommendations in supporting international nursing students in academic and clinical practice. Resilience building for students should be the main aim of counselling services by the introduction of resources and interventions. Second language issues, such as communication, should be factored into nursing programs. Furthermore, activities which promote students' interactions with domestic students should be introduced. This could facilitate proficiency and confidence with the second language. Khawaja et al. (2017) suggested that academics should be aware, while teaching and examining students, that second language anxiety exists. In clinical practice, placement supervisors need to be mindful of anxiety that may be experienced by many international nursing students.
Sought after by many overseas students, Australian Universities provide high-quality nursing programmes (He et al. 2012). Student attrition and retention in these programmes, both undergraduate and postgraduate, can be impacted by continued exposure to severe stress (Asturias et al. 2021). Hence, there is a need to ensure Universities are continuing to support international students appropriately by developing and implementing interventions tailored to their needs. Interventions should aim to build resilience in the international nursing student cohorts, while also focusing on coping strategies and ways in which second language issues can be managed (Khawaja et al. 2017). However, based on the limited data available, Universities are likely less informed of international students' needs and how best to support them, particularly in nursing programs. Educational journeys need to be smoother, more successful and less stressful (He et al. 2012). There is a nursing shortage worldwide (Drennan and Ross 2019) and a priority for skilled migration (Cooper et al. 2020). Hence, there is a need to prioritise psychological well-being and help-seeking behaviours of international nursing students. Failing to act appropriately to their needs may preclude international students from being able to enhance their ability to strategise and develop their skills (Seyedfatemi et al. 2007).
4.2 Future Research
The aim of this review was to summarise the available information related to factors that may impact international nursing students' wellbeing. Continued research is warranted on international nursing students and how best to support them during their educational and clinical journeys. Longitudinal qualitative studies would be useful to understand the lived experiences of international students. Further quantitative research with validated measurement tools could contribute to the current literature gap concerning international nursing students. This review can be useful for university policy and practice development by identifying and finding ways to implement adequate support for students.
5 Limitations
Though this is the only scoping review of international nursing students in the last 10 years to our knowledge, there are limitations. The focus of this review was international nursing students. Therefore, other vulnerable population groups were excluded. This might limit the generalisability of findings. Keywords employed may have influenced the search. Studies published in English were only included, which could eliminate potentially relevant literature published in other languages. The findings from this review were from only four Australian studies, which might limit applicability to other countries and their university systems. Self-report measures were used, which can influence desirability bias, in addition to recall being a potential issue. The types of university settings are not known and could be a confounding factor. The search terms did not include terms such as ‘foreign students’ or ‘overseas-born’, which might have excluded relevant studies. Despite these limitations, this review provides valuable insight into understanding the challenges impacting international nursing students and potential ways to support them in both the educational and/or clinical setting. The present review advances our purpose of understanding the factors impacting psychological wellbeing of international students enrolled in undergraduate nursing programs.
6 Conclusion
The aim was to provide insight into reported factors impacting psychological wellbeing and early help-seeking behaviours of international students enrolled in undergraduate nursing programs. This review screened 2578 studies, identified and synthesised 4 studies. The suggested research, practice and policy implications could prove helpful for academic and clinical services. Further research is warranted to gain a more in-depth understanding of this phenomenon to prepare and support international nursing students and ultimately our healthcare systems. Such studies would be a welcome addition to the limited body of literature focusing on the wellbeing of international nursing students. More importantly, further research can help aid a smoother and more successful journey for international nursing students.
Author Contributions
All authors contributed to writing this manuscript.
Acknowledgements
Open access publishing facilitated by Federation University Australia, as part of the Wiley - Federation University Australia agreement via the Council of Australian University Librarians.
Conflicts of Interest
The authors declare no conflicts of interest.
Open Research
Data Availability Statement
Data sharing is not applicable to this article as no new data were created or analysed in this study.
