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Aim and objectives

Discuss about the Systematic Review for Journal of Advanced Nursing.

The main aim of the systematic review is to evaluate the experience of international nursing students during their studies in abroad. The main objectives of the systematic review are as follows:

  • The examine the live experiences of international nursing students of studying abroad
  • To identify negative and positive experiences of nurses related to studying in foreign countries
  • To assess the challenges or facilitators of pursuing nursing program or courses abroad.

To get relevant articles that can meet the key aim and objectives of the review, the search process was guided by the following inclusion criteria:

Type of research articles: As the main aim is to evaluate experience of international nurse, all types of qualitative studies, systematic reviews and quantitative studies should be included for the review.

Type of publication: Only those research articles need to be included in the review which is published within the year 2010 to 2018.  

Type of participants: The main sample of interest for all studies should be nursing students.

Intervention studied: The main intervention should be exposure to a foreign country for nursing education.

Language used in the study: Only those articles need to be taken in the review which are published in English Language.

Type of outcomes evaluated:  The main focus of all the included studies should be to evaluate the experiences of nurses studying in international countries. The main outcome of interest can be the quality of experience, satisfaction with the experience and quality of life.

There were certain exclusion criteria for the studies too. The studies were excluded if:

  • The participants for the research were registered or other nurses apart from the student nurses
  • Those studies would be excluded where study or experience were evaluated in home countries of nursing students and not in foreign countries
  • Research articles published before 2010 were excluded
  • Research studies published in other languages were excluded 

The search strategy is guided by the use of PRISMA checklist where all relevant information sources or database has been used to retrieve relevant articles related to the study topic. Full electronic search strategy for the database has been presented with the use of specific data collection and data abstraction process. The advantage of the use of PRISMA while writing the systematic review is that the PRISMA checklist has all the items deemed necessary for transparent reporting of a systematic review. The PRISMA flow diagram is an effective process to review and segregate articles for analysis and systematic review. The different phases of systematic review such as identification, screening, eligibility and inclusion provide a good overview of the search process. Use of the checklist ensures transparent and complete reporting of systematic reviews (Liberati et al. 2009). The discussions mentioned below gives an overview about database used, key search term, number of hits achieved and a summary of the search process by going through the four phases of systematic review.

Inclusion and exclusion criteria

 A comprehensive search process was used to select all research articles that are related to the topic of the systematic review. The databases that were searched to select research articles for the systematic review included CINAHL, ProQuest and PsychINFO. The rationale for selecting the above database is that all of them published peer-review research literature in the field of biomedical and health care and there are high chances to get maximum number of hits from these databases. With the availability of peer-reviewed research studies in thee databases, the reliability of the work can be high. The search process in all the databases were limited by setting the publication date from 2010 to the current data. Other limits used during the search process include age and language. For example, as the main population of interest were nursing students, the age limits of participants that were necessary for all research articles were 19-44 years. English was used as one of limits to narrow down the search process.

Several keywords and other terms were used in various combinations to retrieve high quality and suitable research articles for the review. Boolean operator ‘AND’ was applied in along with several groups of similar search terms to retrieve research articles. The key search terms included ‘experience’ or ‘attitudes’, international’ or ‘foreign’ or ‘overseas’, ‘nursing students’ or ‘student nurse’ or ‘undergraduate nurse’, ‘academics or education’ and ‘In Abroad’. The eligibility criteria for selection of articles were determined by comparison with inclusion and exclusion criteria. The number of hits achieved for each databases, specific key terms used and details of key resources and action has been provided in Table 1 in appendix.

The process of identifying articles from database search and the number of articles excluded or included with rational has been provided by the PRISMA flow diagram. It gives clear idea about the identification stage by giving details on the records identified through data base search and other articles retrieved from other sources. The screening of articles has been done by removing duplicate. This section gives an overview of the screening stage of the systematic review. The number of articles assesses for eligibility and the final selection of articles based on the eligibility criteria has been provided in the form of PRISMA flow Diagram below:

PRISMA flow diagram for the selection of research articles.

Figure 1: PRISMA flow diagram for the selection of research articles. 

The studies selected on the basis of eligibility criteria were extracted and summarized according to the following data extraction table.

Search strategy

Table 2: Summary of included studies

Author, year &

Country of study

Research question

or study aim

Research design

Data collection including research instruments

Sample details

Key findings and conclusion

Limitations

Comments on quality & significance of study to your review

Cruz et al. (2018), Saudi Arabia

To assess cultural competence among nursing students from nine countries

Descriptive cross sectional study design was used to collect data from nine countries like India, Chile, Africa, Iraq, Saudi Arabia, Phillipines, Sudan and Turkey

Self-administered questionnaire survey method was used to collect data from participants. The tool was used in two parts. The first part of the survey collected data related to participant’s characteristics and cultural related experience. The part 2 of the survey used 20-item Cultural capacity scale to rate the response of participants

The sample for the study included participants from nursing school in all the nine countries. The criteria for selection was that the sample for the study should be full time BSN student in the second to fourth year level and voluntary indication to participate.

The overall analysis revealed moderate range of cultural competence among students. The competence level differed based on country of residence, age, gender, year of study and attendance at culture related training

The sample size for the study was too large and recruitment from very few institutions limited the quality of the study.

The study is of moderate quality and the relevance of the article to this study is that gives idea about experience of nurse related to cultural competence developed as part of nursing education.

Long (2014), United States

The main aim of the study was to analyse the influence of two week medical service learning experience on cultural competence, self-efficacy and learning experience of student nurses travelling abroad to Belize, Central America.  

The research used mixed method study design to first expose the participants to the intervention and then collect data related to experience and self-efficacy.

Pre-intervention survey tools were used to collect data related to previous cultural diversity training, foreign language training and international travel experience. After intervention, quantitative data related to cultural efficacy was collected from Cultural Efficacy Self scale.

Quantitative data evaluated self-reflective journals of research participant.

The participants for the study include sixteen student nurse from the College of Nevada who participated in a 14-day international service learning health trip with a non-profit organization called International Service Learning to the Central American country Belize

The results from the study gave the idea that experience of nursing students varied. The themes related to the experience included culture shock, increased self-awareness, gratitude and feelings for the people they worked with.  

The limitation of the study included lack of consideration regarding the blinding to eliminate risk of bias.

The research is of moderate quality evidence. It gives implication regarding the need for cultural competence training of educators. The relevance of the study is that it provides insight about experience of student nurses related to travel abroad for study or training.

Gilliland et al. (2016)

The purpose of the study is to get an insight into the learning experience of nursing and pharmacy students during international travel to learn about the country, people and the health care.

Mixed method study design by experimental approach was used to collect data from research particioants.

Self-administered instruments like Clinical Cultural Competency Questionnaire and the researcher-designed demographic questionnaire was used to collect data related to cultural competence and demographics respectively. Qualitative data were obtained from demographic questionnaire.

Nursing students enrolee in the travel to China and travel to India were included in the study

The exposure to international travel improved knowledge related to culture and cultural practice significantly.

Small sample size and lack of randomization were some limitation of this research.

The study is of moderate quality and its relevance with current research topic is that the main emphasis of the study is on nursing student’s experience of travelling abroad.

Sealey and Hathorn 2014.

The aim of the study was to examine the lived experience of US nursing students  while collaborating with Honduran nursing during a study abroad program in Honduras

Qualitative research design was used with t use of transcendental phenomenology approach.

Data was collected from participants by the use of audio-recorded semi-structured interview method. Interview questions covered details on learning experience, self-examination of beliefs and values, personal development and international experience

The participants for the study included Honduran and American nursing students

Six themes related to communication, cultural environment and sharing and learning emerged. Evaluation of participant’s response revealed benefits of international program in developing cultural competence of nursing students.

As the sample for the study were taken only from two universities, it influenced the generalizability of research. The findings cannot be applicable for other setting.

The research is of high quality as it gives in-depth idea regarding student nurse experience. The study is also relevant to the systematic review topic as it highlights international travel experience of nursing students.  

Charles et al. (2014)

The aim of the study was to examine the lived experience of third year undergraduate Australian nursing students regarding participation in a 5 week cultural immersion program in India

Qualitative descriptive research design was used to evaluate participant’s response

Reflective journal were used to collect data for the study.

The participants for the study include Australian nursing students taking part in cultural immersion program in Tamil Nadu

The result gave rise to five theme of Focus on self, focus on difference, recognition of validity of different system, working within the cultural infrastructure, and application and transferability. Overall, the study underscored the importance of international travel experience in cultural competence development among nursing students

The study is limited by its small sample size.

The study is of moderate quality as it gives inconsistent result related to learning experience of nursing students. As it evaluates an international travel experience of nursing students, it is relevant to the systematic review topic.

De Natale, M.L. and Waltz, C.L., 2015

America

The aim of the research is to analyse the planned learning experience of the international nursing students (California) in Ireland where they participated three-week summer immersion training program

Qualitative: thematic analysis of the open ended questionnaire  directed towards the international students

Qualitative data collection approach. The themes were generated from the personal reflection of the international nursing g students

15 master degree nursing students from the University of California were included in a interview of three open ended questionnaire. The reflection was collected after two years

The findings of the study suggested that the three week summer immersion program helped the nursing students to generate cultural awareness and increase knowledge about the healthcare system

The interview questionnaire avoided questions like the what are the challenges if any that were experienced by them during their course of training in Ireland

Poor sample size

This study will help to analyse the positive aspect of the obtaining study in abroad by the international nursing students

Maltby et al. (2016)

The aim of the research was to evaluate the experience of American nursing students who completed a study abroad trip to a low income country Bangladesh and Netherland

Quantitative research by the use of hermeneutic or interpretive phenomenology approach

The lived experiences of participants were collected by the use of reflective journals. The journals were analysed using the g Lindseth and Norberg's (2004) phenomenological hermeneutical methodology of text interpretation

The participants for the study included 45 undergraduate nursing students who participated in study abroad program for four years in Bangladesh and Netherland

The findings of the study revealed that student’s cultural conciousness increased after the travel experience and this was independent of the place visited.

The conclusion from the study was to revise nursing curricula so that nurses can develop their cultural competence

The limitation found in the study is the use of small sample size

The significance of the study is that it highlights the fact that perception of all nursing students change whether they travel to high income or low income country. It suggested the need to enhance cultural consciousness by encouraging nursing students to engage in reflective journaling

Philips, L., Bloom, T., Gainey, T. and Chiocca, E., 2017

The aim of the study was to elucidate the importance of the very short study abroad programs among the under graduate nursing students.

Qualitative study via the instrument of interview questions

The narratives of the students were recorded as per the pre and post travel semi-structured yet open-ended prompts dealing with the expectations and the subsequent perceptions of the culture, happiness and healthy. The data analysis was done on the basis of qualitative descriptive style approach.

The focus group: 62 senior baccalaureate nursing students who travelled for 2 weeks to the Cape Coast, Ghana in between their semesters for a special faculty-led community health clinical experience.

The key findings of the study indicated that the student perceptions of culture demonstrated a progression through the numerous stages of the cultural competence. The analysis of the themes like culture, relationships with the community and proper definition of the health and happiness lead to the elucidation of the fact that the training or study in aboard help to increase the overall adaptability from different cultural background. Even under the short term study, the adaptability quotient was high

The main limitation of the study is, it mainly highlighted the themes from the response of the African American students (n=3). Since the sample size is low, the generated themes may lead to the generation of biased results.

The significance of the study is, it helped to identify the importance of short aboard study among the international students towards building the cultural sensitivity along with a special focus on the importance of adaptability of the international nursing students on the exposure of the aboard training

Gower, S., Duggan, R., Dantas, J.A. and Boldy, D., 2017

Australia nursing students

To study the level of understandings of the prevailing global health issues among the nursing students after they have  taken active participation in an international clinical placement during the tenure of their pre-registration university level nursing education

A retrospective cross-sectional design. This particular design was employed via using an exploratory, descriptive style qualitative approach

Data collection was done via the use of the individualised semi-structured interview questions. The respondents mainly recorded their lived experience. Data analysis was done via thematic data analysis

25 pre-registration nursing students from Western Australian universities who undertook their clinical placement across five difference countries.

The key findings of the study indicated students who underwent clinical placements abroad during 2014 developed new understandings about their health care systems including the concept of fragility of the resource access, differences about their clinical practise methods and variances in their respective nursing roles in different settings.

The study concluded that the international clinical placements can help to develop greater awareness and help to the nursing students in the domain of the realistic strategies via employing their global nursing skills obtained through the international training. The study also highlighted that the pre-placement training in the domain of cultural awareness and in the health system realities plus strong supervisory support is important for the overall success of the nursing students.

The main limitation of the study is its poor sample size that may lead to the generation of biased results

The challenges and the benefits which are experience by the international nursing students will help the researcher to develop a critical analysis of the international training of the nursing students

Hilde, C., Marion, W. and Marianne, N., 2018

The main aim of the study is to critically explore the lived experience of the Flemish midwifery students who are undertaking an internship in the Suriname.

Qualitative research design via Hermeneutic phenomenological method

Qualitative data collection. All the interviews were audio-taped and then transcribed verbatim and then they were analyzed thematically

Seven midwifery nursing students from one University College were selected purposefully for an in-depth interview during the course of their abroad internship from October to November 2014.

The key findings of the study indicated students who underwent clinical placements abroad during 2014 developed new understandings about their health care systems including the concept of fragility of the resource access, differences about their clinical practise methods and variances in their respective nursing roles in different settings.

The study concluded that the international clinical placements can help to develop greater awareness and help to the nursing students in the domain of the realistic strategies via employing their global nursing skills obtained through the international training. The study also highlighted that the pre-placement training in the domain of cultural awareness and in the health system realities plus strong supervisory support is important for the overall success of the nursing

The main limitation of the study is its poor sample size that may lead to the generation of biased results

The challenges and the benefits which are experience by the international nursing students will help the researcher to develop a critical analysis of the international training of the nursing students

The initial number of studies that were selected via the search of the keywords from the databases was screened for the removal of the duplicate. The selected unique studies were then screened on the basis of their tiles. The shortlisted articles which have qualified on the basis of their titles were then screened via study of the abstract. The detailed of the study of the abstract of the short listed articles lead to exclusion of the some articles. The articles which were selected after the short listing of the abstract are then analysed in a standard tabular format. The Data from the selected studies were systematically extracted via the use of the standard tabulated format (as discussed in table: 4). In order to stringently address the aims and the objectives of the research, the data were extracted on the basis of the aim of the selected study, the research design, the process employed for the purpose of the data collection, the sample details (focus group selected), the key findings of the research, the associated research limitations and the interlinkage of the chosen study with the aims and objectives of the research (Miles, Huberman, and Saldana 2013). The finally selected articles were then passed through the quality appraisal tool, AMSTAR. 

The criteria used for accessing the finally selected study were mainly based on the AMSTAR quality appraisal tool. According to Harrison et al. (2016), the quality in the research included two main aspects that is methodological and reporting quality. Here quality is not associated with the importance of the topic or enjoys ability of the research but the term “quality” is associated with the values of the research. The methodological quality of the research is associated the research design and the manner in which the entire research is conducted and how the fundamental understandings of the results relates with the level of confidence in the findings of the research (Harrison et al. 2016). So in order to critically analyse the quality of the research, the researcher here will use AMSTAR critical appraisal tool. According to Shea et al. (2007), AMSTAR critical appraisal tool is a measurement tool that is used to assess the methodological quality of the systematic reviews. AMSTAR is an abbreviated from of assessment of multiple systematic reviews. This tool consists of 11 items that provides good face along with proper content validity for measuring the overall methodological quality of the systematic reviews. Proper analysis of the systematic reviews via the critical appraisal tools help in the quality assessment of the research papers based on the research design and the methodology used. This quality assessment helped the researcher to select quality rich paper that will help to stringently address the research aims and objectives. 

Search methods

Apart from analysis of research findings and results, evaluation of methodological quality of research article is also essential to understand the reliability and transferability of the research work. Bias is a systematic error found in results or other stages of research that can lead to underestimation of overestimation of the true intervention effect. Consideration of risk of bias in each study and differences in risk of bias may help to understand variation in the studies included in the systematic review. A research article with rigorous methodology are more like to provide results closer to reality that those with bias in sample selection or analysis method (Moher et al. 2015).

` To conduct risk of bias assessment for the included studies in this systematic review, the Cochrane Risk of Bias Assessment tool has been used. It is a tool that supports an appraiser to identify different kinds of bias in research such as performance bias, selection bias, detection bias, attrition bias and other kinds of bias (Sterne, Higgins and Reeves 2015). The following criteria have been used to consider an article to have the following biases:

Selection bias: Selection bias can be identified by the presence of systematic differences in baseline characteristics of research participants. By the use of Cochrane risk of Bias Assessment tool, two types of bias assessment can be identified. These include random sequence generation and allocation concealment. Risk of bias in allocation sequence is identified by analysing the method used to generate allocation sequence. Inadequate generation of randomized sequence means selection bias is present. Bias in allocation concealment can be identified by reviewing the method used to conceal the allocation sequence.

Performance bias: Performance bias may arise by identifying differences in the treatment of intervention and control group apart from the exposure to intervention. Effective blinding is the process to minimize performance bias. Blinding of participants and study personnel may denote that the study is free from performance bias.

Attrition bias: Attrition bias can be identified by events like poor follow-up and withdrawal from clinical trials. This may lead to incomplete data. The Cochrane risk of bias assessment tools supports researchers to identify attrition bias by analysing whether attritions and exclusions were reported in the study or not.  

Detection bias: Detection bias relates to identification of differences in groups by the method of measuring the outcome. Detection bias may arise when assessors have the knowledge about the allocated intervention.

Research summary

Other kinds of bias: Apart from the above mentioned sources, other forms of bias identified in research study may include risk of biasness in design or possibility of bias due to contextual issues found in clinical setting (Higgins et al. 2011).

The risk of bias assessment will be summarized in the form of following risk assessment table:

Table 3: Risk of bias assessment table

References

Sequence generation

Allocation concealment

Blinding of participants

Blinding of outcome assessor

Incomplete Outcome date

Other source of bias

Author et al. year

+

+

?

-

+

-

The symbols as mentioned above in the table denote the level of bias found in the studies. Positive signs in the table will indicate high risk of bias in the assigned section and negative sign will indicate low risk of bias. In addition, question mark sign indicates unclear risk of bias. 

The systematic review gave a summary about the methods used to retrieved articles related to experience of international nursing students regarding studying abroad. The PRISMA checklist was followed to report about the systematic review and cover important sections such as eligibility criteria, search strategy, data analysis and quality appraisal method. This chapter provides an insight into inclusion and exclusion criteria used to collect research articles. The search strategy and the process of screening and including research articles have been provided in the form of PRISMA flow diagram. The analysis of research articles is first done by the review of title and abstract. The second stage focus on review of full articles. Furthermore, the quality appraisal of the research article has been done with the use of AMSTAR tool and the Cochrane Risk of Bias assessment tool. The data extraction table gives an overview of the study and significance of the research findings. 

Reference:

Charles, L., Maltby, H., Abrams, S., Shea, J., Brand, G. and Nicol, P., 2014. Expanding worldview: Australian nursing students’ experience of cultural immersion in India. Contemporary nurse, 48(1), pp.67-75.

Cruz, J. P., Aguinaldo, A. N., Estacio, J. C., Alotaibi, A., Arguvanli, S., Cayaban, A. R. R., ...and  Idemudia, E. S. 2018. A Multicountry Perspective on Cultural Competence Among Baccalaureate Nursing Students. Journal of Nursing Scholarship, 50(1), 92-101.

De Natale, M.L. and Waltz, C.L., 2015. Reflections of nursing students travel abroad experiences in Ireland: A global nursing perspective. Nursing Education Perspectives, 36(3), pp.188-189.

Gilliland, I., Attridge, R.T., Attridge, R.L., Maize, D.F. and McNeill, J., 2016. Building cultural sensitivity and interprofessional collaboration through a study abroad experience. Journal of Nursing Education, 55(1), pp.45-48.

Gower, S., Duggan, R., Dantas, J.A. and Boldy, D., 2017. Something has shifted: Nursing students’ global perspective following international clinical placements. Journal of advanced nursing, 73(10), pp.2395-2406.

Harrison, J.K., Reid, J., Quinn, T.J. and Shenkin, S.D., 2016. Using quality assessment tools to critically appraise ageing research: a guide for clinicians. Age and ageing, 46(3), pp.359-365.

Higgins, J.P., Altman, D.G., Gøtzsche, P.C., Jüni, P., Moher, D., Oxman, A.D., Savovi?, J., Schulz, K.F., Weeks, L. and Sterne, J.A., 2011. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. Bmj, 343, p.d5928.

Hilde, C., Marion, W. and Marianne, N., 2018. The lived experiences of flemish midwifery students undertaking an internship in Suriname: A phenomenological study. Nurse education in practice, 30, pp.79-85.

Liberati, A., Altman, D.G., Tetzlaff, J., Mulrow, C., Gøtzsche, P.C., Ioannidis, J.P., Clarke, M., Devereaux, P.J., Kleijnen, J. and Moher, D., 2009. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS medicine, 6(7), p.e1000100.

Long, T., 2014. Influence of international service-learning on nursing student self-efficacy toward cultural competence. Journal of Nursing Education, 53(8), pp.474-478.

Maltby, H.J., de Vries-Erich, J.M. and Lund, K., 2016. Being the stranger: Comparing study abroad experiences of nursing students in low and high income countries through hermeneutical phenomenology. Nurse education today, 45, pp.114-119

Miles, M.B., Huberman, A.M. and Saldana, J., 2013. Qualitative data analysis. Sage.

Moher, D., Shamseer, L., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., Shekelle, P. and Stewart, L.A., 2015. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic reviews, 4(1), p.1.

Philips, L., Bloom, T., Gainey, T. and Chiocca, E., 2017. Influence of short-term study abroad experiences on community health baccalaureate students. Journal of Nursing Education, 56(9), pp.528-533.

Sealey, L.J. and Hathorn, D., 2014. The lived experience of Honduran and USA nursing students working together in a study abroad program. The Qualitative Report, 19(48), pp.1-20.

Shea, B.J., Grimshaw, J.M., Wells, G.A., Boers, M., Andersson, N., Hamel, C., Porter, A.C., Tugwell, P., Moher, D. and Bouter, L.M., 2007. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC medical research methodology, 7(1), p.10.

Sterne, J.A.C., Higgins, J.P.T. and Reeves, B.C., 2015. on behalf of the development group for ACROBAT-NRSI. A Cochrane Risk Of Bias Assessment Tool: for non-randomized studies of interventions (ACROBAT-NRSI), Version 1.0. 0, 24 September 2014. 2014-10-11)[2014-10-21] https://www. riskofbias. info.

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