Exploring Barriers to Attending Zhengzhou University from the International Nursing Students’ Viewpoints in China: A Qualitative Study

1. Background

Students go from all continents to pursue mid &/or higher education programs and diplomas. Pupils who enroll at colleges outside of their home nation of citizenship for either on-shore or off-shore programs are referred to as "overseas learners" in the higher education sector (1). Globally, universities and governments acknowledge that international student education is a significant source of revenue (2).

According to the Chinese Ministry of Education report, about 492,185 international students from 205 countries and regions were studying there in 2018, and China is now Asia's top destination for overseas studies. The country's approach to teaching international students has undergone constant change in response to the country's swift social transformation (3).

International nursing students strengthen and diversify the professional nursing workforce with significant cultural and economic opportunities. The organization promotes international collaboration in research, international higher education, and student mobility around the world as a means of empowering pupils to learn (4). The language, religion, race, and nationality divides within society often make studying in China challenging for foreign professionals and students (5, 6).

According to a study, language hurdles, cultural difficulties, social isolation, navigating foreign teaching and learning styles, and experiences of prejudice are frequently mentioned as difficult challenges (7). A systematic review underlined the importance of valuing and acknowledging differences in academic, clinical, and social contexts to improve the experience of international students (8). International students are prone to psychological stress because they are adjusting to a new country (9). Overseas nurses must adjust to the culture, values, environment, principles, and behaviors of the new educational society to advance and flourish in their educational program (10, 11).

Furthermore, foreign students from collectivist societies may prefer to maintain cultural norms and values. In contrast, international students may want to adapt or change their perspectives to fit the culture of their host country (12, 13). The educational method, which focuses on international students' educational and academic experiences at universities, is another way to examine their experiences. The language of instruction, pedagogy, lack of opportunity to engage in faculty research, and academic relationships between students and faculty/students are thought to impact the learning and development of international students. Many studies have suggested that further support from the larger university/school systems is needed (14, 15).

Even though some studies have shown that studying abroad can be stressful and challenging (1, 10, 12, 15). Information regarding the barriers international nursing students face and how students might overcome them is scarce and fragmented. Studies such as these are no longer as current as they once were, as infrastructure and programs evolve rapidly, mainly due to the increased mobility of international students. A more recent and comprehensive study is needed to explore the current barriers experienced by international nursing students.

2. Objectives

The present study explored the barriers to attending Zhengzhou University from the viewpoints of international nursing students in China. The study's findings could help to improve or minimize the obstacles experienced by international students’ nurses regarding cultural differences, language difficulties, learning difficulties, and the overall well-being of international students.

3. Methods

The investigator utilized the qualitative research approach to determine the techniques and methods for data collection and analysis. The present research concentrates on the personal experiences and extensive understanding shared by international nursing learners in Zhengzhou University (ZZU), China, in December 2023. The thorough exchanges, societal insights, individual comprehension, and educational experiences were gathered through qualitative instruments like interviews. Thus, the researcher chose to use the qualitative research method as an approach due to the type and purpose of this study.

3.1. Design of the Study

The investigator chose the qualitative approach for this research. A descriptive qualitative approach is ideally suited to comprehending the barriers experienced by international nursing students because the qualitative technique is intended to investigate the lived experiences of humans (16).

The researcher gathered qualitative information about foreign nurse students from the School of Nursing and Health at ZZU and their viewpoint (experienced) barriers to being at Zhengzhou University using the qualitative approach technique. Since this method's application focuses on international nurses, their background, learning experience, and sociocultural experience may differ from those of other students; therefore, all of those requirements are met.

3.2. Study Setting

The study was conducted at Zhengzhou University, School of Nursing and Health. The College of Nursing has been offering bachelor's, master's, and doctoral degree programs in nursing, which are available in Chinese and English. The college offers continuing education programs in nursing in addition to full-time instruction. These programs include adult education, contemporary open-distance education, and self-taught supporting examinations (17).

3.3. Study Population

This study involved international nursing students at Zhengzhou University, Henan Province, China. Around thirty international nursing students attend as postgraduate students at the School of Nursing and Health at ZZU. Every student was enrolled in a four-year doctoral program that required them to undertake original empirical research, which they subsequently presented in an English-language research project and assessed in an English-language viva.

3.4. Participants

3.4.1. Inclusion Criteria

The participants should be enrolled at ZZU, School of Nursing and Health, as nursing students studying for at least one year (with an identification document that does not belong to China) and willing to participate in the study.

3.4.2. Exclusion Criteria

International nursing students who were currently studying at Zhengzhou University School of Nursing and Health but had been studying and living there for less than one year at the time of data collection were excluded.

3.5. Sampling Technique and Data Saturation

A purposive sampling approach was employed to select research participants. International nursing students were prepared to share their knowledge in detail and their perceptions of their socio-cultural and learning experiences at ZZU, the School of Nursing and Health. The sample size was determined based on the principles of saturation. When the research subjects provided no additional information, the sampling process was ended.

3.6. Data Collection Process and Procedure

A semi-structured interview guide was prepared for this research based on an evaluation of the available research and adjusted to meet the unique goals of the investigation. The interview guides were prepared in English, which was used for the interview to enhance a better understanding of research subjects. The purpose of the interview guide was to obtain comprehensive data regarding how students learned and the socio-cultural experiences and perceptions of the international nurse students attending the PhD nursing program at ZZU. Experienced qualitative researchers conducted the interviews.

The interview was conducted in a comfortable, private room on the hospital grounds to minimize external interference. In every interview, follow-up questions were used to get further details or clarification from the participants regarding their answers. English was used for data-gathering, and Tape audio recording was used for every interview. Non-verbal signals, for example, were complex for the Tape audio recorder to capture, so the primary investigator took field notes in the notebook. The length of the interviews ranged from thirty to fifty minutes.

Example of the interview guide questions:

(1) How do you feel about being a student at this school or university?

- Probe question: Why do you feel like….?

(2) How do you find the learning-teaching process at the School of Nursing and Health, Zhengzhou University, China?

- Probe question: Why, what makes a difference like….?

(3) Could you please share your experiences while studying as an international student in China?

- Probe question: How did you experience this…...?

(4) Could you share any experience of bias or discrimination because of your skin color and national origin outside the school or university in China?

- Probe question: How did it biased or discriminated……?

(5) As an international student, what challenges do you encounter?

- Probe question: How/why did you happen?

3.7. Data Process and Analysis

The content analysis model with the conventional content analysis approach was utilized to facilitate a more thorough comprehension and development of topics. Textual data are interpreted via content analysis, which applies a systematic coding and categorization technique (18). Conventional content analysis is employed when a study seeks to explain a phenomenon for which there is a shortage of existing theory or research literature. The categories and codes are generated directly from the data during the analysis phase.

Immediately following the initial interview, data analysis was started by transcribing the audio recordings of the data and entering them straight into the NVivo 12.0 software computer. The lead researcher studied each one iteratively and with an open mind to gain an overall view and a comprehensive knowledge of each transcript. Field notes were examined independently, and the resulting categories and patterns were contrasted with those from in-depth interviews. Data in the form of direct quotes supported the pertinent categories. It is essential to guarantee the validity and rigor of qualitative research. Similar to the quantitative ideas of validity and reliability, Lincoln and Guba provided a framework for evaluating qualitative research with four criteria to determine the reliability and credibility of qualitative research. Credibility, Transferability, dependability, and confirmability are these requirements (19). This research study addresses every criterion, specific example, and step taken to satisfy Lincoln and Guba's reliability standards. This methodical technique guarantees that readers can comprehend and assess the qualitative study's rigor.

3.8. Ethical Considerations

The study was ethically granted and approved by the School of Nursing and Health, Zhengzhou University, and Mekelle University College of Health, with approval number ERC1308/2023. Oral consent was obtained from the study participants after being informed that the information would be treated confidentially and used for scientific research purposes only. There was no penalty for participants who left the study at any time. The investigator gave each pseudonym to safeguard the participants' private information (e.g., Participant #1). Written transcripts, audio recordings, signed and unsigned personal contacts, phone records, written transcripts, and related materials were all secured in a password-protected cabinet. The information can only be read by the researcher. The researcher promptly erased and destroyed all relevant materials and data during the study to preserve privacy.

4. Results

In this study, ten international nursing students were interviewed. The samples consisted of all post-graduate PhD students and every study subject whose mother tongue is not English. Individual-based, in-depth interviews were employed at different times. Among the ten participants, there were positive and negative feedback and concerns about their learning and sociocultural experiences in China as international nursing students, as well as the challenges, prejudices, and discrimination experienced both inside and outside the academic setting (Box 1).

Two major categories were identified from the student data: Situations outside and inside the school/university. The details of the categories and sub-categories are described in the following (Box 2).

- Category 1 - situation outside school/university: Some study participants reported experiencing varying degrees of discrimination and judgment from Chinese individuals in the neighborhood based on their skin color, country, and spoken languages. These prejudices and discrimination caused the individuals severe challenges and distress. More importantly, these challenges greatly impacted their education and daily lives as international students in China.

(1) Sub-category - my skin color in China: Even though most study participants did not experience any barriers or pressure related to their skin color, some participants did experience some barriers or pressure because their skin color was different from that of the community people, especially when they walked outside the school or university campus for shopping, enjoyment, and other purposes.

‘‘I always go outside the campus to go shopping, and I used to walk on foot. Then, when I was passing through the road (way), everyone seated and walking around the road looked at me because my skin color differed from theirs, and I was always afraid of passing that way. Some people asked about my skin, ‘‘were you born like this color?’’ Many asked me to take pictures of myself and have pictures with me, so all these experiences relate to my skin color’’ [(code of participants: Ns)#1].

One study participant claimed that because of their skin color, they experienced barriers when going out from campus shopping. While using public transport like a train (subway metro station), many people looked at him when he entered and got off the train.

‘‘While going to the market in the middle of the city to buy clothes, I always use the subway-metro station (train). When I enter the train, everyone looks at me and surprises me, and they fear me. Most of them, if I am seated in a chair, the one beside me immediately stands up and goes to another chair, especially those younger boys and girls and children looking at me, and they may consider me an odd one’’ (Ns#2).

Most study participants explained that they did not experience any barrier or pressure related to their skin color everywhere in China while studying as international students.

‘‘I always go outside alone, and I am living outside campus. I have not faced any problems with the color of my skin because my skin color is similar to that of the Chinese people. This idea was shared with most of the participants’’ (Ns#3, 5, 6, 8, 10).

(2) Sub-category - spoken language: When the study participants came to China for the first time as first-year international students, they experienced some language barriers while communicating with local people because most of them had not learned how to use a dictionary translator about the Chinese language, especially during the first week of life.

‘‘I cannot speak and listen in Chinese because this is the first time in China, and my native language does not have these voices and different mother tongue languages... However, Chinese folks like making fun of and repeating my faults; some claimed they couldn't comprehend my sentence’’ (Ns#8).

A single study participant, who was in their first week of the first year, stated that they encountered some linguistic barriers when utilizing the postal service on campus due to their inability to use a mobile dictionary translation.

‘‘When I was a newcomer (a first-year student), I went to the postal station (taboo) to collect the goods I bought online. I did not have a mobile dictionary translator from English to Chinese then. I found it difficult to communicate with Chinese people who provide services here. Hence, one of the people here was very angry, and she spoke at me rudely (loudly) because of my language problem, and I could not speak Chinese’’ (Ns#4).

One study participant experienced the same language barrier as the other participant. After going to some place, they got confused because their mobile battery was off, and they failed to explain their concern with the local language.

‘‘When I was a first-year student, I went somewhere, and my mobile had finished the charger (battery off). I have been unable to listen and speak Chinese, and I have tried to understand my concern, but he failed to understand me. The person spoke to me loudly, but I do not know the word’’ (Ns#6).

(3) Sub-category - socio-cultural difference: Some respondents felt lonely, had no Chinese friends, and had inferior and minimal social connections with locals and domestic students. Additionally, a few individuals clarified that locals are misinformed about the cultures of other nations.

‘‘While I was walking outside the campus, many people asked me, ‘‘where did you come from?’’ When I told them I came from Africa, they said, ‘‘there are many thefts in Africa, and they said that even during the day, people can steal from you if any foreigner goes to Africa.’’ ‘‘I am not happy with this situation because of my identity and place of birth’’ (Ns#4).

A single participant explained that they are always afraid to speak to local people and domestic students because they fear making mistakes related to their culture.

‘‘I used to be too afraid to talk to people since I was from another country and had a distinct culture and poor local language speaking capacity; maybe I would make a mistake. I always go and walk and play alone, and also I do not have any Chinese friends with me, and I always feel lonely because the Chinese students do not want to interact with me because of poor social and cultural interaction with those people’’(Ns#2).

Few research participants have terrible social lives because they don't interact with local students and people. This could be related to how openly foreign students and domestic students communicate with one another.

‘‘Chinese students have always ignored me, and they do not want to speak to me because it may be related to my origin and place of birth differences, socio-cultural differences. I'm unsure why the Chinese students are unwilling to converse with us. Individuals seem trying to keep from talking to me” (Ns#3, 9).

- Category 2 - situation inside the school/university: International nurse students have had some positive and negative learning experiences at the School of Nursing and Health at Zhengzhou University. Different expectations and reality experiences, teaching styles, and learning styles were another significant theme in the research.

(1) Sub-category: Expectations and Reality of the teaching-learning process in the school

This sub-category explains that almost all participants feel good or happy being students at this School of Nursing and Health. All students explained that nearly all teachers were very nice in providing lectures because all teachers were prepared very well and used smart teaching methods in the class, except for some difficulty in the English language. Some students had to modify their expectations about the content and structure of the PhD program to fit the reality they experienced. Some participants had anticipated different teaching and learning processes, prioritizing theoretical and clinical practicum coursework and research—more aligned with a professional doctorate.

‘‘When I came to pursue my PhD, I never imagined that completing a PhD would be entirely up to the student and with the supervisor only providing heads or directions; instead, I imagined that it would be more like a whole program. However, being a student in this school gives me good happiness and opportunities to explore the teaching-learning process of school, university, and the whole of China’’ (Ns#1).

Study participants were surprised to learn that they could only have theoretical coursework and academic research. Still, most expected to have some professional nursing clinical practice in hospitals.

‘‘Firstly, when I started my course, I was surprised to learn that their program placed practically all the emphasis on research. I had anticipated that it would emphasize professional nursing research, course, and practicum, even though much time would be given to research. According to their own experiences, some students had anticipated taking specialized courses with a clinical focus in addition to clinical practice’’ (Ns#5).

Few participants explained that they experienced barriers and concerns about sharing essential issues related to healthcare practice, technology utilization, knowledge, and health facility setup from Chinese hospitals in their home countries because they had no opportunity to watch and visit Chinese hospitals and health facilities.

‘‘When I return home if my colleagues ask me about the Chinese healthcare system and nursing practice, I do not have the opportunity to watch and enter the hospital. We simply conduct our research in our field alone, in an office. Therefore, we are seeking international comparisons, which would be very helpful, notably for me as a catalyst for transformation. My nation dispatched me to China, and since I'm expected to make some changes when I return home, I'd like to study more about China's current events so I can apply that information there'' (Ns#3, 10).

(2) Sub-category - Concern with supervisor: Some students explained their concerns about communication, the time of supervisorship, and the challenge of meeting supervisors in person; most of them met online with the help of WeChat and email. This web-based meeting is not as good as in-person supervision.

‘‘When I came to the school during the first month my course started, I tried to meet my supervisor, and I texted her on WeChat, but I did not get any response for more than two weeks. I went to her office many times, but I did not find her in the office. Lastly, I have contacted her through a WeChat contact. So this delay in contacting my supervisor made me late in deciding on my dissertation title’’ (Ns#8).

A study participant experienced that their supervisor did not give them enough time after helping to select the research title. Most of the time, he/she met his/her supervisor through WeChat and email, and they explained that in-person supervision is much better than web-based supervision.

‘‘After I came to China, I immediately met my supervisor, who helped me to select my dissertation title. But later, after I selected my title, my supervisor did not give me enough time because she was always busy. We always communicate with the help of WeChat and email, but this is not as good as in-person supervision’’ (Ns#6).

However, most study participants have outstanding supervisors and are very happy to have such a supervisor. They always meet their supervisors when they need help, have concerns, or have questions about their dissertations.

‘‘My supervisor met me in person one day every two to three weeks, and she is perfect and helped everything; I want to say her thank you (Ns#3, 4,7, 9,10)’’.

(3) Sub-category: Lack of supportive service for international students during first-year student

The School of International Education (SIE) of Zhengzhou University: As first-year students, the advisors helped us as much as possible, and all participants were satisfied with their help and support. However, although they helped us in different ways in some rooms (office) of the SIE, they lacked some support, like in language and other services.

‘‘The first time I came to the university, immediately when I went to the SIE office, I did not know her as my advisor before. I entered one room to ask for the availability of a dorm on campus, and I communicated with the person in the room (office-SIE), but we failed to communicate (introduce) each other because I was speaking English and the person spoke Chinese’’ (Ns#1, 8).

Some research participants stated that, despite receiving full scholarships, they were not paid for their accommodations or stipends because of a bank account processing system delay. They asked to pay a dorm fee during registration for the first semester. Some students may not have the money to cover these costs before receiving a scholarship.

‘‘I experienced that when I first came to this university; I came with a scholarship, and they asked us to pay a dorm payment for six months immediately during registration. I was surprised by this situation because we had not received the stipend and accommodation payment then. So when we come for the first time as an international first-year student, we need money for the settlement, and the international school of education should consider this situation for the future’’ (Ns#7, 10).

Almost all study participants are pleased with their advisor. They explained that the student advisor in the SIE office is very dedicated and works for the safety of international students. They even visit the student dormitory on a schedule to confirm the safety of student life in and outside school.

‘‘Our advisors in SIE are very dedicated and concerned about the international student case; they are doing very carefully to solve the issue of international students. I want to say thank you, and I appreciate them; they have helped us’’ (Ns#2, 3, 4, 5, 6, 9).

5. Discussion

This study explored the barriers experienced by international nursing students attending a single Chinese university, the School of Nursing and Health, Zhengzhou University. This study identified several barriers to international nursing students' education and socio-cultural experiences, including skin color, the Chinese language spoken, socio-cultural differences, expectations and reality in school teaching-learning, supervisor concerns, and a lack of support from the school or university.

The findings of this study were consistent with a survey conducted among international nursing students in the world (5, 7, 20). The reason for this is that international nursing students come from all over the world and have different societal divides based on languages, religions, races, and nationalities. Foreign professionals and students frequently face similar challenges when studying in China. Most international students find Chinese culture difficult to learn and adapt to, and it takes time and practice to speak with the local Chinese people. Language is the most frequent obstacle students face wishing to study in China or anywhere else. Studying in China forces one to confront the task of learning one of the most complicated languages on earth, i.e., Chinese. As a result, interacting with Chinese students and conversing with Chinese individuals would be easier.

This study indicated that an international nursing student found the School of Nursing and Health Zhengzhou teaching-learning process for the PhD program different from their expectations in that the school did not include the clinical nursing practicum courses. This finding was consistent with a study conducted in other countries (1, 10, 12, 15). Since all countries have different curricula (teaching-learning methodology) for nursing education, students are expected to have a clinical nursing practicum. In some cases, the curriculum includes one for PhD nursing students.

This study revealed that some international nursing students, but not all students, find it challenging to meet their supervisor on time and that their supervisor gives them less time. This study is similar to a survey in the UK among international nursing students, in which they classified supervisors as excellent and poor quality supervisors (15). Some supervisors might be too busy and have too many duties and responsibilities besides helping and advising students.

This study showed that almost all international nursing students experienced different barriers, such as language barriers, socio-cultural differences, and poor social interactions. This finding was consistent with a survey conducted in various parts of the world (4, 7, 21). International students may have different socio-cultural backgrounds, languages, and educational curricula from those in their home countries. Globalization may have contributed to these barriers.

The limitations of this research were due to the small number of study subjects and the fact that the study participants were only from one university, which cannot be generalized to students at other universities in China. This study only included PhD nursing students; it would be better to include master's and undergraduate nursing students.

5.1. Conclusions

This study showed that the barriers experienced by international nursing students at Zhengzhou University were identified in two categories, including situations outside the university or school and situations inside the school or university, and six subthemes, i.e., skin color, language, sociocultural difference, expectation and reality in learning, supervisor concern, and lack of some support from the school. All categories are associated with international nursing students' positive and negative learning, teaching, and socio-cultural experiences.

Most college students need assistance in their first few months to help them adjust to the unfamiliar academic environment and make the transfer. Furthermore, establishing relationships between international and domestic students is crucial for forming future nurse-researcher communities of practice. International students should enroll in Chinese language courses to overcome the language barrier. Additionally, they maintain contact and become friends with Chinese students, and they will improve their linguistic abilities with this method.