Health and Social Development, Faculty of (Okanagan)
Nursing, School of (Okanagan)
DSpace
UBCO
Crockford, Gail
Master of Science in Nursing - MSN
University of British Columbia
Background: Nurses are increasingly migrating to Canada for higher wages and better working conditions that exist in their own home countries. With this increase, higher education institutions across Canada have adopted education programs to facilitate the migration process for internationally educated nurses (IENs). However, nurse educators are challenged with teaching students of different cultural backgrounds and learning needs. Research Design: This qualitative study aimed to gather information on nurse educators' experiences who have taught international nursing students (INS) to improve teaching and learning practices. Semi-structured interviews of INS nurse educators were conducted at a rural Canadian college that adopted a program to support international nurses to gain a nurse specialty. An Interpretive Description methodological approach was used to examine and apply the data to ensure the findings applied to the nursing discipline. Findings: Four thematic statements were constructed from these interviews: learning the learner, experiencing moral uncertainty in my role, inviting reciprocal relationships, and finding our way. Described in these themes were: the experiences of participants as they were trying to understand who their new learner was and how to effectively teach them when confronted with issues related to cultural safety; the uncertainties participants had about integrating INS into the school, community and workplace; the benefits experienced by educators by becoming better global citizens through the cultural knowledge gained and relationships they built with their INS; and the nurse educators’ determination and dedication to the program, students, and themselves. Discussion: This study's findings indicate that INS nurse educators at a Canadian college felt unprepared to teach INS. They experienced moral uncertainty in witnessing equity issues faced by INS, such as inadequate academic and psychosocial supports, discrimination, and de-skilling. The desire to ensure INS were given value in their education was necessary for educators to overcome the moral uncertainty from INS's equity issues. Furthermore, educators also sought to overcome challenges to bring forth the intercultural exchange potential that a nurse program for INS may bring to Canada and the students’ home countries.
EXPERIENCES OF NURSE EDUCATORS OF INTERNATIONAL NURSING STUDENTS: AN INTERPRETIVE DESCRIPTION STUDY by Gail Crockford BS in Biology, Eastern Washington University, 2000 BAE, Eastern Washington University School of Education, 2002 BSN, University of Alberta School of Nursing, 2006 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in THE COLLEGE OF GRADUATE STUDIES (Nursing) THE UNIVERSITY OF BRITISH COLUMBIA (Okanagan) June 2021 © Gail Crockford, 2021 ii The following individuals certify that they have read, and recommend to the College of Graduate Studies for acceptance, a thesis/dissertation entitled: Experiences of Nurse Educators of International Nursing Students: An Interpretive Description Study submitted by Gail Crockford in partial fulfillment of the requirements of the degree of Master of Science in Nursing. Dr. Barb Pesut, Faculty of Health and Social Development Supervisor Dr. Katrina Plamondon, Faculty of Health and Social Development Supervisory Committee Member Dr. Randy Janzen, Faculty of Health and Human Services, Selkirk College Supervisory Committee Member Marie Tarrant, School of Nursing University Examiner Barbara Astle, School of Nursing, Trinity Western University External Examiner iii Abstract Background: Nurses are increasingly migrating to Canada for higher wages and better working conditions that exist in their own home countries. With this increase, higher education institutions across Canada have adopted education programs to facilitate the migration process for internationally educated nurses (IENs). However, nurse educators are challenged with teaching students of different cultural backgrounds and learning needs. Research Design: This qualitative study aimed to gather information on nurse educators' experiences who have taught international nursing students (INS) to improve teaching and learning practices. Semi-structured interviews of INS nurse educators were conducted at a rural Canadian college that adopted a program to support international nurses to gain a nurse specialty. An Interpretive Description methodological approach was used to examine and apply the data to ensure the findings applied to the nursing discipline. Findings: Four thematic statements were constructed from these interviews: learning the learner, experiencing moral uncertainty in my role, inviting reciprocal relationships, and finding our way. Described in these themes were: the experiences of participants as they were trying to understand who their new learner was and how to effectively teach them when confronted with issues related to cultural safety; the uncertainties participants had about integrating INS into the school, community and workplace; the benefits experienced by educators by becoming better global citizens through the cultural knowledge gained and relationships they built with their INS; and the nurse educators’ determination and dedication to the program, students, and themselves. Discussion: This study's findings indicate that INS nurse educators at a Canadian college felt unprepared to teach INS. They experienced moral uncertainty in witnessing equity issues faced iv by INS, such as inadequate academic and psychosocial supports, discrimination, and de-skilling. The desire to ensure INS were given value in their education was necessary for educators to overcome the moral uncertainty from INS's equity issues. Furthermore, educators also sought to overcome challenges to bring forth the intercultural exchange potential that a nurse program for INS may bring to Canada and the students’ home countries. v Lay Summary With a significant increase of international nursing students (INS) into Canada, nurse educators are challenged with teaching students from different cultural backgrounds and learning needs. This study aimed to explore the experiences of nurse educators of (INS). Findings indicate that INS nurse educators at a rural college in Canada experienced challenges related to student equity issues and educator unpreparedness, and benefits in the reciprocal relationships built with students from other countries. This study highlighted the need for INS nurse educators' professional development and further research on creating inclusive pedagogy and inclusive and responsive learning environments for INS. vi Preface This thesis is an original, unpublished, independent work by the author, Gail Crockford. This study was granted ethical approval by the University of British Columbia Behavioural Research Ethics Board – Certificate Number: H19-03079. This study was also granted ethical approval by Selkirk College Research Ethics Board – Project Number: REB 2020-002. vii Table of Contents Abstract ..................................................................................................................................... iii Lay Summary .............................................................................................................................. v Preface ....................................................................................................................................... vi Table of Contents ....................................................................................................................... vii List of Tables .............................................................................................................................. xi Acknowledgments ...................................................................................................................... xii Dedication ................................................................................................................................ xiii Chapter 1: Introduction ............................................................................................................... 1 1.1 Background ................................................................................................................ 1 1.1.1 Increase of international students in Canada ............................................................ 2 1.1.3 Overview of Internationally Educated Nurses in Canada ............................................ 7 1.1.3.1 Increase of IENs in Canada………………………………………………………….9 1.1.3.2 Education Programs for IENs in Canada ..........................................................11 1.2 Purpose .....................................................................................................................13 1.3 Definition of Terms ....................................................................................................13 Chapter 2: Literature Review ..................................................................................................... 16 2.1 Overview ..................................................................................................................16 2.2 Search Strategy ..........................................................................................................16 2.3.1 INS Perspectives and Experiences ............................................................................17 2.3.1.1 Language Barriers.........................................................................................18 2.3.1.2 Recipients of Discrimination and the Harms of Cultural Ignorance .....................21 2.3.1.3 Transitional Needs .........................................................................................25 2.3.1.4 Summary of Study Recommendations and Related Literature Reviews ...............26 2.3.2 Nurse Educators’ Perspectives and Experiences of Teaching INS ...............................29 2.3.2.1 Language and Cultural Barriers ......................................................................29 viii 2.3.2.2 Cultural Competency Among Nurse Educators .................................................31 2.3.2.3 Lack of Time and Knowledge ........................................................................33 2.3.3 Comparison of INS and Nurse Educator Perspectives ...............................................34 2.3.3.1 Language and Culture ...................................................................................34 2.3.3.2 Teaching and Learning Strategies ...................................................................36 Chapter 3: Methods ................................................................................................................... 39 3.1 Overview ..................................................................................................................39 3.2 Study Design: Interpretive Description .........................................................................39 3.2.1 Study Setting ........................................................................................................41 3.2.2 Situating the Researcher........................................................................................42 3.2.3 Sample ................................................................................................................43 3.2.3.1 Sample Universe, Size, and Strategy ...............................................................44 3.2.3.2 Sourcing the Sample .....................................................................................45 3.2.4 Data Collection Strategies .....................................................................................46 3.2.4.1 Demographic profile of study participants ........................................................47 3.2.4.2 Interview process ..........................................................................................47 3.2.5 Data Analysis Procedure .......................................................................................51 3.3 Methods to Ensure Credibility in Interpretive Description ...............................................52 3.3.1 Epistemological Integrity ......................................................................................52 3.3.2 Representative Credibility .....................................................................................53 3.3.3 Analytic Knowledge ..............................................................................................54 3.3.4 Interpretive Authority............................................................................................54 3.4 Knowledge Translation ...............................................................................................55 3.5 Research Ethics Board and Approval ............................................................................55 Chapter 4: Findings ................................................................................................................... 57 4.1 Introduction to Findings ..............................................................................................57 ix 4.1.1 Sample Description ..............................................................................................59 4.2 Learning the Learner ..................................................................................................60 4.2.1 A New Classroom, a New Realization .....................................................................61 4.2.2 Cultural Differences and Assumptions ....................................................................66 4.3 Experiencing Moral Uncertainty in My Role .................................................................72 4.3.1 Ethical Issues in INS Integration ............................................................................73 4.3.2 Professional Boundaries in the Grey .......................................................................78 4.3.3 Advocating for Student Well-being .........................................................................80 4.4 Inviting Reciprocal Relationships .................................................................................82 4.4.1 Collaborative Relationships: Learning from Each Other ...........................................83 4.4.2 Becoming a Better Global Citizen ...........................................................................86 4.5 Finding Our Way .......................................................................................................88 4.5.1 Shifting “on the fly”: Unpreparedness ....................................................................88 4.5.2 Recommendations for Faculty Support ....................................................................91 4.6 Summary ..................................................................................................................95 Chapter 5: Discussions, Recommendations, and Conclusions ....................................................... 97 5.1 Introduction to Discussion ...........................................................................................97 5.2 Summary of Findings ..................................................................................................97 5.2.1 Unpacking Equity Issues in Teaching INS ...............................................................98 5.2.1.1 INS Recruitment in Higher Education: Capitalistic vs. Humanistic .....................98 5.2.1.2 We Aren’t Seeing Them Become Nurses in Canada ........................................ 101 5.2.1.3 INS Learning and Personal Needs: Who’s Responsible? .................................. 103 5.2.2 Faculty Preparedness: Building Strength and Capacity to Teach INS ....................... 106 5.2.3 Learning to See One Another ............................................................................... 111 5.3 Summary of Discussion ............................................................................................ 113 5.4 Limitations .............................................................................................................. 113 x 5.5 Recommendations .................................................................................................... 114 5.5.1 Education .......................................................................................................... 114 5.5.2 Practice ............................................................................................................ 115 5.5.3 Research ........................................................................................................... 117 5.6 Conclusion .............................................................................................................. 118 References ............................................................................................................................... 119 Appendices .............................................................................................................................. 134 Appendix A: Recruitment Bulletin ....................................................................................... 134 Appendix B: Recruitment Script .......................................................................................... 135 Appendix C: Informed Consent Fom .................................................................................... 136 Appendix D: Demographic Questionnaire ............................................................................. 139 Appendix E: Semi-Structured Interview Guide ...................................................................... 140 Appendix F: Field Notes ..................................................................................................... 141 Appendix G: Summary of Cognitive Processing .................................................................... 142 xi List of Tables Table 1: Definition of Terms……………………………………………...……………...…….14 Table 2: Interview Segments…………………………………………………….……………..48 Table 3: Thematic Statements of Themes and Subthemes………………………………….…..59 Table 4: Instructional Strategies for CALD Nursing Student Learning………………….…...110 xii Acknowledgments First and foremost, I would like to thank my thesis supervisor Dr. Barb Pesut of the School of Health and Social Development at the University of British Columbia-Okanagan. Dr. Pesut’s consistent guidance and care made the completion of this thesis possible. She was always there with words of wisdom to help guide my writing and personal expressions of understanding to build my strength and motivation to complete this project. I will be forever grateful for the time and work she invested in me. Many others made the writing of this thesis possible, whom I would like to acknowledge: To my supervising committee, Katrina Plamondon and Randy Janzen; I am so thankful for your mentorship and encouragement. The feedback you provided was appreciated and utilized every step of the way. I would also like to thank my running partner and friend, Tammy, who always listened to me process readings for this project and who always kept telling me, “you can do it!”. Finally, to my husband, Peter, and my children, Naomi, Levi, and Caleb, thank you for your ongoing patience, love, and support. You are the most precious people in my life. xiii Dedication This thesis is dedicated to the nursing faculty at the college under study, who have given so much of themselves for their students' future. I would also like to dedicate this to the international nursing students who were the inspiration for this work. 1 Chapter 1: Introduction 1.1 Background With the increase of internationally educated nurses (IENs) in Canada, there has been a concurrent increase in Canadian higher education institutions implementing nursing programs to educate IENs. The majority of these programs are designed to support IENs in obtaining nursing licensure and integrating into the Canadian health care system. However, many nurse educators of IENs are at a loss on appropriately delivering nursing knowledge in both the classroom and clinical settings to culturally and linguistically diverse learners (Donnelly et al., 2009a; L. Newton et al., 2016; Wilson et al., 2010). Exploring nurse educators' experiences of international nursing students (INS) can reveal the specific challenges and barriers they face, enabling a deeper understanding of how to improve faculty supports, program curriculum and policies, teaching and assessment strategies, and student support services. This chapter will provide an overview of the historical and current landscape of IENs and INS in Canada. To frame the purpose of the thesis, it is important to understand the context from which it is derived. Therefore, knowledge of the increase of international students in Canada is presented over the past 20 years. This is followed by a description of the context of nurse migration. Next, an overview of IENs and INS's increase will explain how these topics have merged and created specialized education programs in higher education institutions across Canada. This background knowledge provides relevant context and some historical perspective to the topic of INS nurse educator experiences. The chapter will end with the purpose and significance of this study and a table of the definitions of frequently used terms. 2 1.1.1 Increase of international students in Canada Student demographics in many classrooms across Canada have changed with the increase of international students. Governments from many countries value the importance of international education, both embracing international students into their countries and sending their students abroad. It is often viewed that this exchange of students will enrich relationships between governments and better position countries in succeeding in the global economy. According to the Canadian Bureau for International Education (Canadian Bureau for International Education [CBIE], 2018), there was a 119 percent increase in international students studying in Canada from 2010 to 2017. This increase reflected the Canadian Government's International Education Strategy's efforts to double the international student population from 239,131 in 2011 to more than 450,000 by 2022 (Canada, 2014). Schools have successfully met this goal and reached an international student population of 494,525 students by 2017 (CBIE, 2018). Economically, the value of international students has positively impacted Canada. In a financial report on the years 2017 and 2018 provided for International Affairs Canada, it was found that international students in Canada spent 18.4 billion in 2017 and 22.3 billion in 2018 on tuition, accommodation, and discretionary spending (Currie, 2020). This translated into 16.2 billion in 2017 and 19.7 billion in 2018, contributing to Canada’s GDP. Students from India contributed most to the increase between 2017 and 2018. In 2018, the highest number of international students from Ontario contributed 55.3% to the GDP, followed by British Columbia with 19.8% and Quebec with 11.9%. Furthermore, the jobs created in Canada by international students in 2017 and 2018 amounted to 180,141 and 218,577, respectively. These statistics, 3 provided in the International Affairs Canada financial report, demonstrate the high economic value that international students bring to Canada (Currie, 2020). The recognition of both the educational and economic advantages of increasing international students and sending students abroad to higher educational institutions has been a catalyst for the internationalization of Canada’s higher education campuses over the past two decades. According to a new rendition of the term internationalization in educational institutions, it is “the intentional process of integrating an international, intercultural or global dimension into the purpose, functions, and delivery of post-secondary education, to enhance the quality of education and research for all students and staff, and to make a meaningful contribution to society” (de Wit et al., 2015, p. 29). Garson (2016) suggests that the concept of internationalization in higher education needs to be reframed. The need to blend economic rationales with the social and academic outcomes for student success must support an ethical, inclusive, and equitable approach to internationalization. In the past, many colleges and universities claim to ‘internationalize’ their campuses by increasing their international student enrolment. However, Garson (2016) argues that the answer is not simply increasing enrolment but reframing the concept of ‘internationalization at home’ informed by critical global citizenship education. Regarding critical global citizenship education, Garson says, “educators must take care to encourage critical thinking by presenting multiple perspectives for consideration so students can grapple with the complex issues of our times” (Garson, 2016, p. 30). This rapid increase of international students and internationalizing post-secondary campuses has conjured ethical concerns about the capitalistic motives of recruiting and retaining international students. In the 2019-2024 International Education Strategy, it was said in a 4 message from the Minister of International Trade Diversification, “Competitor countries in this sector recognize the long-term benefits of international education. They have upped their game, and to remain competitive, we upped our game too” (Canada & Global Affairs Canada, 2019, p. 3). The International Education Strategy gained a budget allocation of $147.9 million for 2019 over five years, followed by $8 million per year of ongoing funding. This money is intended for Canadian students to gain skills through study and work abroad opportunities, international students to come to Canada, and increase support for Canadian education sector institutions to grow their export services. This budget increase, along with statements made about the economic benefits of international education, may contrast with higher education institutions' portrayals of the goodness of internationalizing their campuses. This section provided background knowledge about the increase of international students in Canadian educational institutions and the evolution of internationalized classrooms. It informs the reader of the need for further knowledge on the issues and challenges educators and administrators have encountered throughout this demographic change in schools across Canada. More specifically, this study will be addressing how this rapid growth of international students has affected nurse educators of international nursing students (INS) since an increase in INS has also followed the trend of international students' overall increase. The following topics on the global context of nurse migration and the rise of IENs in Canada will provide context for the influence nurse mobility has had on increasing IENs entering Canada as international students. 1.1.2 Global Context of Nurse Migration The global marketing of nurse labour has conjured many international debates of the consequences on healthcare systems worldwide. As nurses move among countries, there are legal, economic, cultural, social, and educational ramifications that affect the profession of 5 nursing, health care organizations, communities, care to populations, and the nations (Jones & Sherwood, 2014). Questions about sustainability, justice, and social accountabilities have arisen with the liberation of global markets, which have allowed healthcare workers to seek employment in countries other than their own origin (Aluttis et al., 2014; Jones & Sherwood, 2014). There is a general consensus that health worker migration has adverse effects on the sending country and its people, while the receiving country and the healthcare worker benefit (Aluttis et al., 2014). It is well documented that healthcare workers benefit through better working conditions, higher wages, better career opportunities, and the recipient country benefits through an adequate supply of healthcare services and tax savings by reducing training and education costs. While others argue that sending countries benefit from receiving financial remittances from nurses living and working in high-income countries (HICs), this does not meet the higher costs the government has invested in nurse training (Castro-Palaganas et al., 2017). Often nurse migration occurs from low and low-middle-income countries (LMICs) to HICs. This pattern of the migration of healthcare workers from the Global South to the Global North has also been derided as a ‘brain drain’ (Siyam & Dal Poz, 2014). Global health agencies, such as the World Health Organization (WHO), International Labour Organization (ILO), International Organisation for Migration (IOM), and international medical and health professional councils have developed, and continue to develop, strategies and solutions for ethical health care worker migration while also strategizing for health care worker retention of sending countries (Siyam & Dal Poz, 2014). Alongside these international agencies, several HIC governments have developed policies to promote ethical recruiting practices. However, Connell and Buchan (2011) have found that these policies to manage health care worker migration have had limited influence on equitable incorporation of workers into the receiving country systems. 6 Furthermore, nurse emigration has caused adverse impacts to LMICs regarding the transfer of resources in training and the loss of professional nurses exiting the national health system (Aluttis et al., 2014). India and the Philippines are both leading countries in the supply of nurses for global markets. In both countries, nursing education systems have been influenced by the increased number of nurses desiring to emigrate and the migration processes of sending and receiving countries. This has led to increased private nursing schools established to recruit students for nurse emigration (Garner et al., 2015; Thompson & Walton-Roberts, 2019). Private nursing schools can capitalize on the push factor of nurses' desire to emigrate and benefit through the high enrolment and tuition costs of nursing students. Consequently, this surplus of nurse graduates has left nurses open to exploitation in their own countries before arriving in destination countries. Even though it is reported that there are increased nurse graduates, literature still shows there is an inadequate supply of nurses in these two countries, especially in rural areas (Castro-Palaganas et al., 2017; Garner et al., 2015; Thompson & Walton-Roberts, 2019). This occurrence is often due to the underfunding of their healthcare systems. Both India and the Philippines healthcare systems cannot absorb the costs of employing all their nurse graduates even though there is a demand for nurses. Therefore, with the large increase of nurse graduates needing nursing experience before destination countries will admit them under student or work status visas, hospitals have been known to exploit nurses for their labour in both India and the Philippines (Thompson & Walton-Roberts, 2019). Other areas that have left nurses vulnerable are the quality of nursing education and increased costs associated with private education. However, on a positive note, the increase of nurse migration in India has created a shift toward positive transformation for nursing status, 7 resulting in increased respect for individual nurses and the nursing profession (Garner et al., 2015). Challenges associated with questionable recruiting practices, differing scopes of practice encountered after migration, and experiences of racism and cultural differences have also been found (Garner et al., 2015). Even though the nurse training capacity has increased in India and the Philippines, their health care systems still struggle to serve their populations' needs. This has led to a call for nursing reform and change in both these countries' healthcare infrastructure (Thompson & Walton-Roberts, 2019). India and the Philippines are major exporters of health care professionals, but both countries find it challenging to ensure adequate availability within their own home countries. This raises important questions on how nurse migration can be responsibly managed and how sending nations can retain nurses. This section has provided some aspects of global nurse migration, which is a complex and rich discussion that falls beyond the scope of this thesis. Even though this controversial topic of ‘brain drain’ largely falls outside of this thesis's scope, the relativity to the study is important for the reader to understand. Information has been provided to understand the larger picture of some of the ethical and systematic issues that have affected nurse migration for nurses from India and the Philippines, which are the largest group of IENs in Canada. The following section will inform the reader of the context of IENs in Canada. 1.1.3 Overview of Internationally Educated Nurses in Canada The proportions of foreign-born doctors and nurses are highest in countries such as Australia, Canada, Israel, New Zealand, and European countries such as Luxembourg and Switzerland (World Health Organization [WHO], 2017, p. 85). In 2011, 22.5% of practicing nurses in Canada were foreign-born (p.89) and in 2012-2014, 7.5% were foreign-trained. India 8 and the Philippines account for the largest shares of migrant doctors and nurses in OECD countries (p 96). Decision-making factors for nurses migrating to Canada from lower and middle-income countries include improved working conditions, higher wages, family salience, desire for knowledge and adventure, and personal enrichment (Garner et al., 2015). In 2018, there were 39,189 internationally educated nurses licensed to practice in Canada, representing 8.5% of Canada’s nursing workforce (Canadian Institute of Health Information [CIHI], 2019). Evidence has shown many benefits of receiving healthcare provider migrants into OECD countries, especially as the aging population rapidly increases. These trained healthcare providers are needed to meet the shortfalls in countries’ workforces (Dumont & Lafortune, 2016). Canada has been proactive in anticipation of economic and labour shortages. It has developed policies and initiatives to support foreign-born professional health care workers in its health care system, as evidenced by the Canadian Internationally Trained Workers Initiative established in 2005 (Canada, 2010). This initiative invests 18 million dollars per year in integrating internationally educated health professionals into the Canadian health care workforce by increasing access to assessment and training programs. IENs experience significant challenges when practicing their profession in foreign countries. In a literature review titled The Migration and Transitioning Experiences of Internationally Educated Nurses: a global perspective, authors found the overarching theme to the question, “What are the experiences of IENs when migrating to and transitioning into health care systems of the destination country?”, was cultural displacement (Newton et al., 2012). In this review’s context, cultural displacement refers to the reasons for the transition and migration issues that IENs experience entering the nursing workforce in a new country. Here, cultural displacement largely stemmed from communication and language differences, feelings of being 9 an outsider, and differences in nursing practice. This cultural displacement inhibits the development of relationships between staff and IENs and may promote feelings of inadequacy in IENs, which may harm their psychosocial well-being. Other themes identified in this review included IEN’s experiences of difficulties obtaining credentialing, which leads to de-skilling and experiences of discrimination (e.g., marginalization, minimal peer and superior support, unfair treatment, stereotyping, and rejection by patients and peers). The home country which the nurse comes from may influence how well the nurse will gain employment and integrate into the Canadian healthcare context. IENs from high-income countries have been more smoothly integrated into the country than those from low-income countries (Christine L. Covell et al., 2017). There have also been barriers for IENs trying to enter Canada as nurses. These challenges include the inability to pass language proficiency and nursing exams, lack of nursing experience, and transfer of credential challenges. Therefore, some IENs gain entry into Canada as international students, spouses of migrants, or through a two-step migration process (Thompson & Walton-Roberts, 2019). Two-step migration occurs when nurses migrate to less attractive markets, such as the Middle East, to gain nursing experience to qualify for more desirable markets (e.g., Australia, UK, Canada, USA). Alongside government-financed programs to successfully integrate healthcare professionals into the healthcare workforce, Canadian higher education institutions have adopted nurse bridging programs or specialized post-degree programs. These programs have been developed to prepare IENs to become nurses in Canada. 1.1.3.1 Increase of IENs in Canada. IENs bring value to the Canadian healthcare system. They are skilled professionals who contribute to the stable and sufficient supply of nurses in Canada. It was anticipated in 2011 that there would be a shortage of 60,000 nurses by 10 2022 if recruitment and retention actions were not taken (Tomblin Murphy et al., 2012). With international nursing shortages, it is essential to ensure that IENs have the opportunity to practice in their trained professional field of nursing in Canada. The International Council of Nurses (ICN) recognizes that international nurse migration has risen rapidly due to a global need to fill and prevent nurse shortages. In ICN’s position statement on international career mobility and ethical recruitment, it is stated that “ICN respects and supports the rights of nurses to pursue professional achievement through career mobility and to better the circumstances in which they live and work” (ICN, 2019, p. 1, para.1). The “migration of nurses offers potential beneficial outcomes including multicultural practice and enhanced learning opportunities” (p.1, para. 1). Another advantage IENs bring is that they may help reduce the health care inequities among visible minorities by providing a nursing workforce representative of Canada’s population. Canada’s population growth is currently largely supplied by immigrants, with twenty-two percent of the population being foreign-born (Government of Canada, 2017). Globally, nurses account for almost 50% of the health workforce (WHO, 2017). In 2018, there were 431,769 licensed nurses in Canada, and registered nurses alone comprise almost three-quarters of the regulated nursing workforce and are the country’s largest single group of healthcare providers (CIHI, 2019). Since nurses make up the largest portion of the health workforce and work directly with patients, nurses could have the most impact in creating accessible, safe, and equity-sensitive care environments. To represent ethnic and culturally diverse populations and provide culturally safe care, it is more than fitting that Canada should diversify its healthcare professionals to be more representative of its population. Diversifying the nursing workforce to represent the population it serves may help reduce inequalities that minority and marginalized populations have experienced in the Canadian health 11 care system (Maio & Kemp, 2010). Partly due to the strict selection process and required medical clearances set by Canadian immigration policies, the health of immigrants to Canada upon arrival has been better than that of the Canadian-born population (Perez, 2002; Beiser, 2005; Laroche, 2000, & Hyman, 2004). However, based on the Longitudinal Study of Immigrants to Canada (n=7720), visible minorities and immigrants who experienced discrimination or unfair treatment were most likely to experience a decline in self-reported health status (Maio & Kemp, 2010). The findings revealed that discrimination and inequality partly drive immigrant health transitions. Similarly, Phillip and Malone (2014) found that visible minorities experienced more healthcare disparities and poorer health outcomes than their naturalized USA citizen counterparts. These authors write that “the projected growth in minority populations, coupled with the growing disparities in healthcare and health outcomes underscores the need to recruit and retain a diverse nursing workforce that mirrors the nation’s culturally diverse population” (Phillips & Malone, 2014, p. 129). The nursing representation that mirrors Canada’s culturally diverse population could also be a strategy to address the inequalities of minority populations. IENs may help in building nurse representation to Canada’s population demographics. 1.1.3.2 Education Programs for IENs in Canada. Meeting nursing competencies in a different country in which the nurse was trained has its challenges. Challenges meeting Canadian nurse competencies among internationally educated nurses was a problem for nurses, regulatory bodies, and employers (Neiterman & Bourgeault, 2013). In this study, 71 IENs and 70 stakeholders in Canada were interviewed to explore how international nursing models are different from Canada’s and how these differences bring challenges to the integration of the IENs. One solution to this challenge was to provide bridging and post-degree diploma programs 12 where IENs can upgrade their nursing and communication skills in the Canadian health care system context. A pan-Canadian study on the integration of IENs was conducted in 2015 (St-Pierre et al., 2015). This study, funded by the Internationally Educated Health Professionals at Health Canada, was performed to identify factors that support the integration and retention of IENs in the health care system. It included 2,693 IENs who immigrated to Canada from 1957 to 2014. The researchers found that nurse bridging programs helped aid nurses in their success as Canadian nurses. Therefore, the study's authors recommended that the government and regulatory colleges explore ways to increase the accessibility of bridging programs (e.g., geographical location, delivery methods, and financial support). Bridging programs and post-degree diploma programs for international nurses have been adopted to meet nurse competencies set by regulatory bodies in both public and private institutions across Canada. Covell, Primeau, and St-Pierre (2018) examined the perceived benefits of IENs who participated in bridging programs and how they impacted IEN’s nursing preparation in Canada. Bridging programs were moderately helpful in learning nursing roles and responsibilities and knowledge about the Canadian health care system. However, they were less helpful in perfecting language skills and understanding employment conditions. In response, in 2018, the Canadian Association of Schools of Nursing (CASN) has established accreditation for IEN bridging programs. As this introduction has indicated, there are compelling reasons for recruiting and supporting IENs. However, nurse educators are challenged with teaching students of different cultural backgrounds. These challenges are discussed further in the literature review. It is vital to recognize these challenges so strategies can be developed to assist faculty in teaching excellence. 13 Over the past decade, literature has primarily examined international nursing students' learning needs from their perspective. However, limited research examined learning and teaching needs from the instructor’s perspective. 1.2 Purpose The purpose of this qualitative research project is to explore the experiences of nurse educators of INS in both the classroom and clinical context. This study contributes to developing new knowledge addressing nurse educators of international nursing students. As the literature reviewed next will suggest, studies of this topic have primarily been conducted outside of Canada. Research done in the Canadian context is necessary to properly inform Canadian stakeholders and guide future nursing education, practice, and research. The study will help address the gaps of missing knowledge related to INS education. 1.3 Definition of Terms Table 1 includes a definition of terms used throughout this paper. 14 Table 1 Definition of Terms Term Definition Cultural Competence Cultural competence is the ability of nurses to self-reflect on their own cultural values and how these impact the way care is provided. It includes each nurse's ability to assess and respect the values, attitudes and beliefs of persons from other cultures and to respond appropriately when planning, implementing and evaluating a plan of care that incorporates health-related beliefs and cultural values, knowledge of disease incidence and prevalence, and treatment efficacy (Lavizzo-Mourey & MacKenzie, 1996). This is the definition used in the CNA Position Statement: Promoting Cultural Competence in Nursing (Canadian Nurses Association [CNA], 2018). Cultural Safety Cultural safety surpasses cultural sensitivity, which recognizes the importance of respecting difference. Cultural safety is predicated on the understanding of power differentials inherent in health-service delivery and redressing these inequities through educational processes (Canadian Indigenous Nurses Association [CINA], 2011, p. 2). This is the definition used in the CNA Position Statement: Promoting Cultural Competence in Nursing (Canadian Nurses Association [CNA], 2018). Inclusive Pedagogy Inclusive pedagogy is a student-centered approach to teaching that pays attention to the varied background, learning styles, and abilities of all the learners in front of you. It is a method of teaching in which instructors and students work together to create a supportive and open environment that fosters social justice and allows each individual to be fully present and feel equally valued (Center for New Designs in Learning & Scholarship [CNDLS], 2021). Internationally Educated Nurses (IENs) Nurses who have graduated from an international nursing program of study. International Nursing Student (INS) Nursing students born outside of the host country. 15 Table 1 Definition of Terms Internationalization (in education) The intentional process of integrating an international, intercultural or global dimension into the purpose, functions, and delivery of post-secondary education, to enhance the quality of education and research for all students and staff, and to make a meaningful contribution to society (de Wit et al., 2015, p. 29). Moral Uncertainty Moral uncertainty occurs when a nurse feels indecision or a lack of clarity, or is unable to even know what the moral problem is, while at the same time feeling uneasy or uncomfortable (CNA, 2008. P.6). Other Terms used for INS Culturally and linguistically diverse (CALD), English-as-a-second-language (ESL), English-as-an-additional-language (EAL), foreign-born Nurse Bridging Program A nurse bridging program is any program designed to address gaps and/or differences in education and competencies so that the internationally educated nurse may become registered to practice in Canada and facilitates successful integration into the Canadian healthcare system (CASN, 2012). Post-Degree Nursing Program A post-degree nursing program encompasses a range of qualifications that require an undergraduate degree to be considered for entry into the nursing program. 16 Chapter 2: Literature Review 2.1 Overview To understand the knowledge that has been generated about INS and nurse educators of INS, a literature review was conducted. The literature review included experiences and perspectives from both the INS and nurse educators, focusing on challenges and issues within nursing programs. These views are essential in understanding the context and the persons impacted by educational institutions' learning environment. Nurse educators in academic institutions are fundamental in preparing INS for meeting competencies set by nursing regulatory bodies. Findings from this review will demonstrate the need to understand INS nurse educators' experiences and offer reflections from international nursing students' perspectives. 2.2 Search Strategy The review was focused explicitly on international nursing students (INS) and nursing educators of INS. A combination of the following keywords was used in the CINAHL, Medline, Embase, and ERIC databases: international, nursing, student, foreign-born, instructor, educator, supervisor, and facilitator, English as a Second Language (ESL), English as an Additional Language), Cultural and Linguistically Diverse (CALD). After searching CINAHL, Medline, Embase, and ERIC databases and cross-referencing hand-searched studies, 198 studies were retrieved. The title noted 55 duplicates, and 87 studies were excluded after reviewing the title and abstract for various reasons, including lack of specificity to nursing, publication date outside search timeframe, and relevance to the research question. The remaining 56 articles were further assessed for inclusion by reviewing their abstract or full text, and of these, most were excluded because they were not describing original research studies. After screening against inclusion and exclusion criteria, 25 studies were included for the review. Inclusion criteria included articles 17 that were: published between 2009-2020, peer-reviewed, abstract included, written in the English language, focusing on INS and nurse educators of INS. Articles were excluded if they were not specific to international nursing students and INS nurse educators. 2.3 Findings of the Literature Review Twenty-five articles were identified and grouped under three main categories by the author. The three categories presented are INS perspectives and experiences (n=11), nurse educators’ perspectives and experiences of teaching INS (n=7), and comparison of INSs’ and nurse educator perspectives (n=7). Fifteen studies used qualitative methods, five mixed-method studies, two quantitative method studies, and three literature reviews. The majority of the research included in the review was studied from Australia and the United States. The literature reviews were placed in the introduction or the summary of each category, not to confuse them among the empirical studies. Each category will further be described by themes that characterize each category's findings. Throughout this literature review, nurse educators will also be referred to as supervisors, facilitators, mentors, and instructors, depending on how it was used in the article. However, all terms were used to describe an educator who teaches and assesses students. There are also many different terms that researchers have used to describe INS. These terms include English as a Second Language (ESL) student, English as an Alternative Language (EAL) student, foreign-born student, and Culturally and Linguistically Diverse (CALD) learner. 2.3.1 INS Perspectives and Experiences Nine empirical studies and two literature reviews looked into INS perspectives and experiences in nursing programs at higher education institutions. After analyzing the literature, I 18 organized the data into three overarching themes: language barriers, recipients of discrimination and the harms of cultural incompetence, and transitional needs. 2.3.1.1 Language Barriers. Four studies found language barriers a critical issue that INS experienced that challenge their academic learning. In a qualitative inquiry study exploring INS learning and acculturation experiences in the School of Nursing and Midwifery at an Australian University, the themes Expressing Myself and Finding My Place were discovered (Mitchell et al., 2017). After interviewing 17 INS, ten undergraduates, and seven post-graduates, they found English language confidence takes time and creates stress among INS. In this study, the students were mindful of the extra time it took to read and understand the content, especially having difficulty with colloquialisms and abbreviations compared to domestic nursing students. They also voiced their concerns about how stressful environments, such as large classroom groups and clinical settings, decrease their communication skills, as demonstrated in this statement, “stressful times make translation more difficult” (Mitchell et al., 2017, p. 18). Participants did attribute these same stressful environments as beneficial in recognizing how important language proficiency is for clinical and classroom settings and that it was necessary to practice in these environments for language acquisition. It was concluded that creating safe learning environments for INS to become more proficient in their communication and language skills is necessary for INS learning success. Similarly, in a descriptive qualitative Australian study of international students (n=24) in health programs and the attitudes of domestic students (n=11) to the cultural issues faced by international students, Gilligan and Outram (2012) found language barriers as a key theme. Domestic student views were congruent with international student comments in both groups finding that language was a cultural barrier to social interaction and discussion. Other key 19 differences between Australian educational systems to international student home institutions included differences in professional roles and expectations, cultural and religious practices, and teaching and learning methods. Both Mitchell et al.’s (2017) and Gilligan and Outram’s (2012) studies recognized the challenges language barriers created for INS. They were at a disadvantage in their academic performance and classroom participation than their domestic counterparts. In another Australian study, it was found that the stress caused by language barriers may psychologically and emotionally impact INS (Khawaja et al., 2017). This quantitative correlational study providing an in-depth understanding of INS's stress factors was conducted with international undergraduate nursing students (n=152) across Australia. Respondents participated in an electronic survey including six measures widely used in international student research. They found that INS experience second language anxiety (SLA). It is a significant factor in their stress, having an even greater impact than other psychological factors associated with international student stress. SLA refers to performance-related anxiety, impacting the students' well-being and academic achievement. Difficult second language communication and marginalization were significant predictors of INS stress in both the academic and placement environment. There were several implications from this study's findings to help reduce SLA. It was recommended that nursing schools factor in coping and management of second language issues, introduce activities that promote INS interactions with domestic students, and educate supervisors in understanding the SLA associated with performance at a clinical placement. All three of the previous studies (Gilligan & Outram, 2012; Khawaja et al., 2017; Mitchell et al., 2017) point to the importance of providing institutional supports to reduce second-language related stress and anxiety and provide environments that will build student confidence in their English language communication skills. 20 In a Canadian research study, English-as-an-additional language (EAL) nursing students (n=14) identified limited language skills as a major barrier to good academic performance (Donnelly et al., 2009b). In this qualitative study using mini-ethnography, students explained that their lack of English skills interfered with every learning process. Students reported difficulty understanding textbooks, lectures, teacher expectations, test-taking, APA formatting, and expressing their thoughts and opinions through writing assignments. Even though these students had to achieve minimum English proficiency test scores for admittance into the program, students felt it did not guarantee English proficiency for academic purposes. Students felt language barriers prevented them from communicating clearly and effectively while recognizing this as an essential competency for providing competent nursing care. One student voiced, “I don’t know some of the common words that Canadians talk with each other…when I talk to the RN, there are lots of words I don’t understand” (Donnelly et al., 2009b, p. 135). When critically analyzing the Canadian (Donnelly et al., 2009b) study and the three Australian studies (Gilligan & Outram, 2012; Khawaja et al., 2017; Mitchell et al., 2017), two of the studies (Donnelly et al., 2009b; Mitchell et al., 2017) were specific in identifying that language challenges were confounded by the use of jargon and colloquialisms that were used in the classroom and professional environments. Furthermore, both Donnelly et al. (2009b.) and Gilligan and Outman (2012) found that INS and international health professional students needed not only to support basic English language skills but specific discipline-related language support. All four of the studies (Donnelly et al., 2009b; Gilligan & Outram, 2012; Khawaja et al., 2017; Mitchell et al., 2017) recognized that English language challenges were hindering INS and other international health care professional students’ academic and social success and institutional supports are necessary to support these students. 21 2.3.1.2 Recipients of Discrimination and the Harms of Cultural Ignorance. Seven studies described INS experiences of isolation, exclusion, loneliness, and or discrimination. In the qualitative inquiry study exploring INS's learning and acculturation experiences mentioned in the previous theme, Mitchell et al. (2017) also identified otherness and discrimination themes. The 17 participants of the study shared stories of experiencing otherness and discrimination in the classroom, clinical placement, and community. Comments by participants included demonstrating these themes included, “It’s something that I don’t understand why the Australian students don’t want to work with me”; and “I have experiences of being spoken to rudely by students…An Australian student said…Can you understand English? Just move. This was because…the Australian student wanted her seat”; and “We did not have a way to resolve this” (Mitchell et al., 2017, p.19). In Donnelly et al.’s (2009b) mini-ethnographic qualitative study, it was also found that EAL nursing students were challenged by cultural differences and perceived inferiority and discrimination. Students viewed that success in the nursing program was highly dependent on their cultural knowledge since curriculum and appropriate interpersonal interactions were often based on Canadian culture. They also spoke of being discriminated against by both instructors and peers in their struggle to learn to nurse. They believed instructors practiced discrimination through avoidance, negative tone of voice, impatience, distancing, failure to make contact, reluctance to communicate, negative comments, and spending little time with them. Both qualitative studies (Donnelly et al., 2009b; Mitchell et al., 2017) provided experiences of cultural differences causing discriminatory behaviours towards INS. Foreign-born nursing students reported patterns of stress, strain, and cultural ignorance from a Bachelor of Nursing program at a Texas University. In this interpretive phenomenological 22 mixed-methods study, researchers analyzed qualitative and quantitative data to discover the essence of foreign-born nursing student stress and perceived faculty support (Junious et al., 2010). Through focus groups, individual interviews (n=10), and quantitative surveys measuring nursing student stress and faculty support, an overarching theme was the Desire to be Valued and Accepted. The students desired to be accepted and valued by classmates, faculty, and the educational institution. Two patterns of Stress and Strain and Cultural Ignorance were related to this overarching theme. The students verbalized their experience of stress and strain in personal relationships, financial issues, feeling as though they have no life, and feeling the academic institution had made no accommodations for them. Students perceived that faculty recognized them as foreign-born, but no special efforts outside the classroom were initiated to assist with their learning. All students experienced cultural ignorance in the forms of language barriers, stereotyping, discrimination, or cultural incompetence by the dominant culture. For example, one participant described cultural insensitivity by a faculty member, In my culture, when you talk to someone….that has authority above you, we try to show respect…I will just look down. I’m listening, but I don’t have to necessarily look into {his/her} eyes, but when my teacher does this—literally do this (participant demonstrated how the instructor pulled her chin up)—looks at me and gets so close, I’m so uncomfortable” (Junious et al., 2010, p. 266). Despite the amounts of stress, strain, and cultural ignorance these participants endured, they still held onto a strong desire to be valued and accepted. Incongruently, in a descriptive qualitative study of lived experiences of the transitions of INS, Vardaman, and Mastel-Smith (2016) found that the INS participants (n=10) did not feel isolated by faculty but appreciated the nursing faculty and felt they were more than just instructors but also supportive persons who 23 offered guidance and advice. Both these studies (Junious et al., 2010; Vardaman & Mastel-Smith, 2016) were conducted in USA higher education institutions, but there could be a difference in student attitudes toward faculty since there were six years between the two studies. Faculty and institutions could have improved their attitudes and behaviours toward international students in this six-year timeframe as they gained a better understanding of student needs. Another interesting descriptive qualitative study on the cultural competence of nurse faculty interviewed 11 nursing students who had immigrated to the United States within 20 years but spoke a language other than English for the first ten years of their lives (Morton-Miller, 2013). The interviews were aimed at gathering suggestions to give instructors; the suggestions included understand the cultural background of the students, reflect on own cultural histories and worldviews to increase self-awareness, understand the impact of faculty perspectives in shaping curriculum and policies, role model curiosity about culture, take steps to enhance cultural knowledge, incorporate culture into nursing assessments and interventions, and seek opportunities to engage in interactions with diverse clients and diverse health care providers. This study was initiated by the nurse educators acknowledging their need to be culturally competent when teaching a diverse nursing student body. It provided a unique perspective of nursing student immigrants who lived in the culture under study long enough to have a strong understanding of the host country and lived experiences of being a second-language student. Unfortunately, the methods of this study were not well documented, so limitations and the methodology of data analysis were not described, so one should be cautious when applying the findings. The previous studies (Donnelly et al., 2009b; Junious DL et al., 2010; Mitchell et al., 2017; Morton-Miller, 2013; Vardaman & Mastel-Smith, 2016) all reveal discrimination or 24 culturally incompetent behaviours that students experienced from their peers and faculty, but studies have also shown that discrimination or cultural ignorance also comes from patients in the clinical setting. In a Participatory Action Research (PAR) study, De (2010) examined whether INS faced disadvantages when caring for patients in the UK. De compared results of 13 INS and 12 home students, all Welsh Caucasian, enrolled in the same Bachelor of Nursing Program. Results showed that 69% of INS reported mistreatment from patients, with five students reporting unfair treatment, four were unsure, and four felt racially abused. Out of the 12 home students, 33% reported an incident of mistreatment, and four reported unfair treatment of being punched or sworn at. However, in two of these incidents, home students felt the patients involved were too unwell to be aware of their actions. A large discrepancy between the two groups was that 46% of the INS incidents were easily described as racially-related incidents, with patients referring to the INS with terms such as, ‘foreigners’, ‘second class citizens’, and ‘poor country folk’. These students received unfair treatment, but did not complete clinical incident forms. In contrast, none of the home students felt personally insulted, but if they did receive any unfair treatment they submitted clinical incident forms to the ward managers. This demonstrates that home students are able to self-advocate and ensure unfair treatment is reported. In contrast, INS did not report unfair treatment through clinical incident forms. It would be interesting to replicate this PAR in different healthcare contexts to examine if unfair treatment from patients is experienced in the different contexts. One other study looked at INS experiences in clinical practice and presented both positive and negative INS experiences. In this descriptive, qualitative, and Finnish study, researchers explored acculturation experiences that facilitated student belonging (Mattila et al., 2010). INS (n=14) described experiences that influenced acculturation and student belonging. 25 In the positive experiences, students reported feeling welcomed when given a thorough orientation, improved their independent working skills, and included when staff members’ and students’ positive attitudes were bridged together. The negative experiences reported included restricted learning due to language-related problems, discrimination from patients and staff, and exclusion when not accepted as a member of the social environment. These studies (De, 2010; Donnelly et al., 2009b; Junious DL et al., 2010; Mattila et al., 2010; Mitchell et al., 2017; Morton-Miller, 2013; Vardaman & Mastel-Smith, 2016) reported discriminatory behaviours from peers, faculty, and patients towards INS. Several of these studies recommended that academic institutions need to increase practices of cultural safety (De, 2010; Junious et al., 2010; Morton-Miller, 2013; Vardaman & Mastel-Smith, 2016). 2.3.1.3 Transitional Needs. A single study focused on the transitional needs of INS. In a descriptive phenomenological study conducted in the United States, researchers described the transition experiences of INS (n=10), representing eight different countries of origin among prelicensure nursing programs in five states (Vardaman & Mastel-Smith, 2016). This study used the transitions theory (Meleis, 2010) to inform the analysis. Findings indicated that students’ expectations and experiences differed. “I was kind of imagining like a city life….just like from the media”, but found it “less fun.” As a result of these experiences, their expectations of living in the U.S. “went down” (Vardaman & Mastel-Smith, 2016, p. 38). Student participants in this study suggested that financial planning and adequate English skills were important things to consider when considering their transition to nursing school. Students described interaction with the nursing school environment to be “hard,” “heavy,” “challenging,” and “time-consuming,” but also a “home away from home,” and “fair” (Vardaman & Mastel-Smith, 2016, p.38). Emotionally, these students described themselves as 26 missing family and familiar surroundings, being homesick, and having difficulty coping. One student described the need “to change a lot…my whole style, how I live, how I study, how I used to sleep, everything like that and emotionally it was getting more frustrating, stressful” (p.39). Physically, a weight change was a primary finding. Both weight gain and weight loss were attributed to differences in diet and available foods. Students also reported that their general sense of well-being improved as they became more independent, mature, and culturally competent. However, the well-being of their interpersonal relationships decreased as they lacked time to stay well connected to their families and friends from their home countries. Relationships with classmates were not “close relationships” (p 40) but more academic. In comparison with previously mentioned studies emphasizing the need to support students in language barriers (Donnelly et al., 2009b; Gilligan & Outram, 2012; Khawaja et al., 2017; Mitchell et al., 2017) and institution and faculty cultural competency (De, 2010; Junious et al., 2010; Mattila et al., 2010; Mitchell et al., 2017), this study (Vardaman & Mastel-Smith, 2016) found that to promote academic outcomes faculty also need to be cognizant of the INS transition process and needs. 2.3.1.4 Summary of Study Recommendations and Related Literature Reviews. Many of these studies of INS experiences and perspectives resulted in recommendations for improving the learning environment, increasing student supports, and increasing the capacity and responsiveness of nursing educators. The following summarizes the implications and recommendations from the previous studies mentioned. Donnelly et al. (2009b) provided EAL students’ recommendations to future EAL students; these included being prepared for each lecture, look up anything you do not know, build knowledge, know your strengths and limitations before clinical, be honest with your instructor, get involved in Canadian culture, do not dwell on bad memories. The students from this study also provided recommendations for 27 how clinical instructors might support them better by minimizing weaknesses and maximizing strengths, providing academic and emotional support, being patient and allowing more time, and offering help and encouragement. For nursing faculty, they recommended building a support group for students, providing workshops and orientation programs, teaching APA formatting, building a course on cultural diversity, and nurturing language competency throughout the program. Gilligan and Outram (2012) recommended that academic institutions host cultural awareness events to promote appreciation and understanding between domestic and international students. In the classroom, academic staff should be aware of the pace of speaking, reduce slang terms and nuances of spoken English, form mixed groups, prepare materials for IS to help them understand the methods of learning that will be used, provide opportunities for students to enhance their English language proficiency through additional support and facilitate interactions with other students. Using Transitions Theory (Meleis, 2010), Vardaman and Mastel-Smith (2016) recommend that faculty examine their INS’s transitions and plan supports and teaching strategies according to INS’s transition needs. The study revealed a strong need for social supports, role models, and a curriculum that addresses the INS's academic language, pedagogical, clinical, social, and cultural needs. Acceptance and support from domestic students, faculty, and the educational institution would decrease foreign-born nursing students' stress (Junious et al., 2010). Group work and clinical placements were cited by INS as valuable strategies for acculturation, language, and learning (Mitchell et al., 2017). De (2010) implied that clinical mentors need to be made more aware of discrimination issues facing their students and more 28 efforts and actions by the clinical placement facilities need to be made in educating patients about the diversity of multidisciplinary health care teams. Two literature reviews focused on INS perspectives and experiences. One literature review explored issues that impact INS's clinical learning (Edgecombe et al., 2013). However, since the literature specific to INS was scarce, articles relating to international student experiences in clinical learning experiences across health disciplines were included, totaling 36 articles in the review. The review highlighted the need for supportive learning environments that develop a feeling of belonging. Recommendations to assist INS in integrating into clinical placements included developing institution-wide programs to address the communication and cultural needs of both students and staff, strengthening partnerships with the clinical settings to educate and advocate on behalf of INS, providing clear clinical expectations to INS, and developing and implementing strategies to increase cultural understanding and interactions with the domestic population. The literature review by Hansen and Beaver (2012) explored four main areas of concern for English-as-a-second-language (ESL) nursing students and presented many strategies to address language, learning models, test-taking, and cultural differences. These included strategies such as, high level of interactive communication with patients, family members, and other health care professionals; taping class lectures; role-playing; vocabulary notebooks; clear expectations; explaining learning models; study groups and tutoring services; extra time for tests; ongoing faculty support; and incorporating cultural information from students into courses. These strategies have been recommended because ESL nursing students come from educational systems with different learning models and teaching pedagogies. 29 In summary, research addressing INS perspectives and experiences is well-documented in Australia and the USA. These studies are primarily in Bachelor of nursing programs with a mix of both international and domestic students. INS's learning challenges include language barriers, isolation, discrimination, and unfamiliar teaching pedagogies. These studies will help inform this study, but none were conducted in the Canadian rural context. 2.3.2 Nurse Educators’ Perspectives and Experiences of Teaching INS Six studies and one literature review are included that focus on the perspectives and experiences ofINS nurse educators. I will discuss these three themes from the literature: language and cultural barriers, cultural competency among educators, and lack of time and knowledge. 2.3.2.1 Language and Cultural Barriers. Three of the seven studies focused on the language and cultural barriers that challenged INS nurse educators. Miguel and Rogan (2012) explored the expectations facilitators have when assessing ESL nursing students in their clinical communication assessments. The researchers used a descriptive interpretative qualitative approach to examine facilitators’ comments on all clinical assessment forms of student participants (n=10). These students took part in a pilot study of a clinical language support program. It was found that facilitators expected students to communicate well with patients and staff, have a good bedside manner, be proactive and assertive, and be self-directed learners. Through this study, facilitators' and universities' recommendations to be more explicit about their clinical expectations and improved preparation in language assessment for facilitators were made. In a later study, the same researchers evaluated English language proficiency guidelines for clinical facilitators designed off the previous study results (San Miguel & Rogan, 2015). 30 Interview data were gathered from 8 experienced clinical facilitators from 8 clinical settings, and results showed that the guidelines were a ‘good start’. Facilitators found the leveled assessment guidelines helpful in giving the students communication feedback and a learning tool for the students. The guidelines made language assessment more objective and provided the facilitators with the proper vocabulary to discuss expectations and made expectations explicit. However, this was a pilot study, and it was found that further evaluation needs to be done on the guidelines, especially the reliability when used by multiple assessors. Other inquiries that arose from this study were whether the good performance of clinical skills should override underperformance in English proficiency and how influential consequences of miscommunication influence facilitators’ decisions on language proficiency. Furthermore, facilitators found that similar guidelines for assessing INS writing and documentation would also be advantageous for students and clinical facilitators. In a USA study, Starkey (2015) conducted grounded theory qualitative research based on the philosophical underpinnings of symbolic interactionism and pragmatism to explore the critical factors that influence faculty attitudes and perceptions of teaching ESL nursing students. Thirteen nursing faculty teaching ESL nursing students were interviewed, and all participants emphasized language and cultural differences as the most prominent barrier in teaching. Nine out of the 13 participants revealed that they felt unprepared to deal with student diversity challenges. Starkey (2015) built a conceptual model around the critical factors influencing faculty attitudes and perceptions of teaching English as a Second Language (ESL) to nursing students. This model illustrates how nurse educators processed the barriers and challenges of teaching ESL nursing students and the feeling of unpreparedness that cultural diversity may bring, and how they altered their teaching strategies to adapt to ESL student learning needs through the concept 31 of ‘conscientization’. This ‘conscientization’ was the process that nurse educators used to develop a critical awareness of their beliefs, actions, and behaviours. It was discussed that “critical inquiry is needed by faculty to examine the social reality of the classroom and how power and influence can dominate the learning process” (Starkey, 2015, p. 723). Similarly, in my literature review findings, both INS and INS classroom and clinical instructors named differences in language and culture as barriers to teaching and learning success. The INS voiced how the struggles of language and cultural barriers inhibited their academic and social performance (Donnelly et al., 2009b; Junious et al., 2010; Mitchell et al., 2017; Morton-Miller, 2013) and the INS educators themselves voiced the language and cultural barriers between themselves and the students caused teaching challenges (San Miguel & Rogan, 2012; Starkey, 2015). Furthermore, Starkey’s (2012) study reveals that naming that there are language and cultural barriers is not enough, but the practice of conscientization may guide nurse educators to examine how power may influence the classroom of diverse nursing students. 2.3.2.2 Cultural Competency Among Nurse Educators Two quantitative studies from the USA have pointed out that nurse educators feel culturally incompetent in teaching INS. Esterhuizen and Kirkpatrick (2015) express the importance of nurse educators to familiarize themselves with intercultural and global competencies to serve a multi-ethnic population since meeting cultural competencies is an expectation among health professionals. In a pre-test and post-test designed quantitative study, Greenburg (2013) attempted to increase nurse educators' cultural competence by implementing a project to examine its effectiveness on nurse educators’ cultural competence. Ten full-time educators of ESL nursing students completed four computerized learning modules on teaching ESL nursing students. They took a pre and post-self-assessment tool to measure healthcare 32 professionals' cultural competence related to mentoring. All educators demonstrated increased cultural competence after receiving the education. Identified areas that were regarded as most helpful in the learning modules included: strategies to enhance ESL students’ success, identifying their own cultural biases, and classroom techniques to help students achieve academic success. It was also recommended that the modules include more examples of specific interventions and case studies. Similarly, a longitudinal quantitative study to measure the process of cultural competence over time in a group of nursing faculty and allied health faculty (n=28) was conducted (Wilson et al., 2010). An Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals (IAPCC) was administered before a cultural competence workshop, the same day after the workshop, and then at three, six, and 12 months. The scores indicated that all participants had improved in cultural awareness, knowledge, skill, and encounters over time and no faculty scored in the culturally incompetent range one year after the intervention. Interestingly, a decrease in the mean score of four items (20 items total) indicated that some faculty were still uneasy about personal cultural competence concepts, such as different values and beliefs differ from others, knowledge about world views, and personal stereotyping. Perhaps this statistic indicates the importance of Starkey’s (2012) Conceptual Model of Conscientization, designed for nurse educators to analyze their social processes while teaching INS. These quantitative studies (Greenberg, 2013; Wilson et al., 2010) demonstrated that nursing faculty or allied health faculty improved their cultural competency scores after participating in either a cultural competency workshop or online modules. However, it must be understood that the data was self-reported from faculty perceptions of their cultural competency in the Greenberg (2013) study with a small number of participants at the same nursing school. 33 The Wilson (2010) study may be more reliable with a larger number of participants and was taken over a one-year timespan at 3, 6, and twelve months. 2.3.2.3 Lack of Time and Knowledge. One relevant study in the Canadian context and one literature review address the lack of time and knowledge that nurse educators of INS experience. In this explorative qualitative study in Canada, Donnelly, McKiel, and Hwang (2009a) interviewed nurse educators’ (n=9) EAL nursing students. Participants were asked to describe their experiences teaching EAL nursing students, how they supported students’ language and cultural differences, what they believed to be strengths and barriers for the students to achieve success, and what supports they used to foster their teaching. Challenges for instructors included a lack of institutional resources specific to teaching EAL students, a lack of time and knowledge, and a lack of institutional policies. The faculty reported feelings of exhaustion related to addressing EAL nursing student needs. The participants in this study recommended: a more comprehensive screening process, a language course designed for EAL students, a formal support system for instructors, the hiring of more culturally diverse instructors, collaboration with local health regions, and advocation for EAL students. The new knowledge that this study brought forth was that nurse educators of EAL students were exhausted with the extra time and emotional investment required. Similarly to some of the previous studies (Donnelly et al., 2009b; Gilligan & Outram, 2012; Khawaja et al., 2017; Mitchell et al., 2017; Vardaman & Mastel-Smith, 2016) in this literature review, the need for institutional resources to support INS and INS educators was voiced. Key messages were found in an integrative literature review that aimed to discover the experiences and perceptions of RNs who supervise INS in the clinical and classroom setting (Newton et al., 2016). The review included ten studies and found that RNs and nurse educators 34 do not feel adequately prepared to meet the supervision needs of INS. It was also discovered that poor verbal and written proficiency often contributed to higher workloads and unsupported environments led to supervisors/educators feeling exhausted and dissatisfied. Inadequate or absent role preparation was attributed to this job dissatisfaction. Studies in this theme, Nurse educators’ perspectives and experiences of teaching INS, demonstrate that INS nurse educators feel unprepared to teach students from different cultural and language backgrounds. Cultural incompetence, lack of time, and lack of institutional resources leave nurse educators feeling frustrated and exhausted. Further research needs to be done to understand the areas nurse educators of INS need support to better support students, improve teaching practices, increase cultural knowledge, and decrease stress-related factors. 2.3.3 Comparison of INS and Nurse Educator Perspectives Seven studies included both INS and nurse educator participants to gather both groups’ perspectives on teaching and learning. These studies are themed into language and culture and teaching and learning strategies. 2.3.3.1 Language and Culture. As identified throughout this review, language and cultural barriers are key issues between INS and academic and clinical staff. Three studies investigated communication-related issues between students and educators. In a qualitative exploratory study exploring factors that impede or enhance the CALD students, and academic and clinical staff of CALD students, issues and strategies were identified (Jeong et al., 2011). CALD students (n=11), clinical facilitators (n=3), and academic staff (n=4) were interviewed in focus groups at an Australian university where 106 CALD nursing students were enrolled. Students reported feelings of rejection and isolation due to their English proficiency level. Simultaneously, academic and clinical staff questioned how CALD students were allowed to 35 commence the nursing program when their English language skills put them at risk for failing courses. The study also revealed that students did not feel that they had learning opportunities to advance their practice, and facilitators did not have the extra time needed to instruct CALD students in the clinical setting. Participants represented in each group voiced the need for university supports. Another language and culturally related descriptive qualitative study explored intercultural experiences of clinical nurses (n=19), nurse academics (n=7), and final year INS (n=10) and discovered profound ways in which cultural differences lead to incorrect assumptions and misunderstandings between clinical nurses, facilitators, academics, and student nurses (Henderson et al., 2016). Prejudice based on cultural diversity, unfamiliarity with cultural boundaries, stereotyping cultural behaviours, and difficulty speaking English were key communication barriers. Through participant focus groups and telephone interviews, strategies to mitigate these communication challenges included obtaining cultural validation through alliance building, proactively seeking clarification, and acquiring cultural knowledge. The third study evaluated a newly developed full-semester transition course for post-graduate international nursing students to reduce culture shock and develop clinical communication (Chiang & Crickmore, 2009). Through narrative, qualitative interviews of both faculty (n=unknown) and students (n=unknown), data showed this course was found effective in developing intercultural communication skills in clinical practice. The course was guided and evaluated on the intercultural competence framework (Byram, 1997) and the model of clinical supervision (Grealish & Carroll, 1998). It included 20 hours of classroom instruction, 5 hours in the computer lab, 18 hours in a clinical lab, and 32 hours in the clinical placement provided by clinical instructors, academic staff, and an English teacher. 36 2.3.3.2 Teaching and Learning Strategies. Four articles focused on teaching and learning strategies evaluated by both students and educators. The key learning and teaching strategies to improve group work were supported among INS and domestic students (Del Fabbro et al., 2015). This mixed-methods participatory action research (PAR) project included interviews from academic teaching staff (n=14) and international nursing students (n=12). Likert survey (1=’not very helpful’ to 4=’very helpful’) evaluations on the teaching strategies from domestic and international nursing students (n=108, 71% domestic students, 29% INS) were also analyzed. The initial planning phase interviews identified group work processes as a critical issue. Teaching staff planned and implemented enhanced group work strategies into one of the nursing courses, and respondents positively rated working in small groups (mean 3.42; SD 0.92), sharing nursing experiences (3.59; 0.60), and class discussions (3.5; 0.55). Through a collaborative and scholarly approach, both students and nurse educators identified an effective group work strategy that promotes student engagement and learning between INS and domestic students. Two of the studies addressed teaching strategies for international student writing assignments. Murray and Preston (2016), a librarian and a nurse faculty member, partnered together to provide evidence on how the students in a Bachelor of Nursing International Program in Ireland utilized the library compared to the expectations of their nurse faculty. In this small mixed-methods study, including questionnaires (n=8) and interviews (faculty, n=3; INS, n=2), disparity existed between students being aware of library usage expectations and meeting them. Faculty identified a lack of broader reading among students and, in some cases, the inability to source articles using online databases. This study implied that INS needs increased library time and library skills training, and faculty need to make their library usage expectations clearer. 37 Another study explored how lecturers at an Australian university draw on several strategies to respond to international students' need to complete written assignments for their courses (Arkoudis & Tran, n.d.). Academic staff (n=4) and IS (n=7) were interviewed, and analyzed results showed that lecturers thought they provided sufficient assessment criteria for writing assignments, but students found criteria lacking assignment specifics. The academic staff also reported a lack of a common approach in supporting students in developing their academic writing within the department. Grading was incongruent among instructors, which confused students. It was recommended that a whole institutional approach to address academic language development should be considered. The fourth study was a mixed-methods study to compare CALD minority nursing students’ (n=13) perspectives with nursing educators (n=22) on teaching and learning challenges (B. L. Fuller & Mott-Smith, 2017). Among the challenges mentioned, respondents had different perspectives. Educators believed they provided students with various teaching approaches to integrate concepts, whereas students complained that few educators provided visual aids or methods to help integrate and apply concepts. Students also reported that tests were culturally biased, and one-third of educators reported that tests were evaluated for such bias. Educators thought language barriers were the primary challenge to learning, but students reported relationships to faculty and classmates as the biggest challenge. Both groups of respondents agreed there was too much workload placed on the students. 2.4 Summary Overall, the literature included in the review has provided relevancy and value to the knowledge of INS and nurse educators of INS. To provide specific knowledge in the Canadian context, empirical evidence is still needed to improve the teaching and learning environment for 38 both INS and nurse educators of INS. It would be beneficial to conduct research where the challenges and barriers are perceived and experienced. To make appropriate proposals for program changes and support services for colleges in Canada that have implemented INS academic nursing programs, further research into this topic must be done. 39 Chapter 3: Methods 3.1 Overview There is a developing body of literature about the realities nurse educators have experienced while teaching INS, but little from the Canadian rural context. The rurality context may provide different findings than similar studies done in urban settings. Rural settings may have fewer amenities (e.g., housing, transportation, religious groups, food variety) and a less diverse population. Understanding the challenges and benefits while facilitating Canadian nursing education of INS may provide the knowledge needed to better support educators, inform stakeholders, and improve curriculum and student learning. This study was designed to fill gaps of missing evidence that can contribute to the answers to questions that higher education institutions, nurse educators, and the nursing discipline encounter as more international nurses are being further educated in Canada. The purpose of this chapter is to explain the methodology used to guide this study, which is aimed to explore the experiences of nurse educators of international nursing students in both the classroom and clinical context. This chapter will present the methodology of Interpretive Description and the reasoning for this chosen methodological approach. It will then describe the study design, including study setting, sampling methods, and sample size. Third, it will explain data collection and analysis strategies. It will conclude with the measures taken to ensure the credibility of the evidence grown in this study. 3.2 Study Design: Interpretive Description Interpretive Description first originated in the nursing discipline but later moved to other applied disciplines with their own foundation of disciplinary knowledge. It is a methodological approach to qualitative research developed to recognize the credibility of a discipline’s 40 philosophical and theoretical foundations. It recognizes that each discipline will have an epistemological orientation that will require unique inquiry methods to ensure that the knowledge generated is usable within the discipline (S. Thorne et al., 1997). It is a research method uniquely designed for applied and practice disciplines that need to be grounded in their epistemological frameworks to be applicable in their practice contexts. In other words, the knowledge generated from the research needs to be applied so that frontline workers, administrators, and stakeholders may transfer this knowledge to influence their way of doing directly. Interpretive Description provides the disciplinary logic that informs the underlying epistemological approach and methodological decisions to ensure that the study findings apply to nursing practice. This qualitative research approach was chosen because other methods, designed to produce social theory, may not adequately address the epistemological approach necessary for an applied discipline such as nursing. Thorne says an epistemological approach “allows for a defensible line of reasoning from the assumptions made about the nature of knowledge through to the methodological rules by which decisions about the research process are explained” (S. E. Thorne, 2016, p. 233). Nurse educators are established in the foundations of professional nursing standards and competencies and are obligated to facilitate students according to these. These professional nursing standards and competencies mean that the evidence that nurses produce should ultimately inform nursing practice. A design that captures nursing's disciplinary knowledge is paramount to be practical and valuable. For example, if a scholar in education were to conduct the same research question, they would not understand the epistemological and ontological knowledge that the nursing instructor has learned from their own educational and clinical experiences. A nursing instructor may consider whether or not the student can provide 41 safe care, therapeutic communication, a team-based approach, person-centered health, assessment, writing, and documentation. These concepts, among many others, are essential to the nursing regulatory body and must be adhered to meet nursing competencies. Interpretive Description is a methodology that considers contextual aspects of a discipline that other methodologies do not. It is essential to be grounded in disciplinary knowledge to examine nursing instructors’ experiences while teaching international nursing students. Therefore, the methodological approach of Interpretive Description was chosen for this study. It allows the findings to construct interesting theories and be used for direct application to practice. 3.2.1 Study Setting This thesis study was conducted in a small rural college in British Columbia, Canada. The province of British Columbia was chosen for this study for its immigrant and international student population and my knowledge development to improve nurse programming at the institution where I work. Statistics Canada reports that 1,212,075 new immigrants have permanently settled in Canada between 2011 and 2016 (Government of Canada, 2017). The percentage of immigrants to British Columbia was 28.3% in the 2016 Census. In a 2018 publication by the Canadian Bureau of International Education (2018), Canada was ranked 4th by Project Atlas is the top study destination for international students worldwide, with 370,975 students in 2017. Twenty-four percent of these students were studying in BC. These numbers demonstrate the relevance of international students studying and working in British Columbia. With the dramatic increase of international students in British Columbia, both colleges and universities have started post-graduate or post-degree nursing programs. Nurse bridging programs were developed explicitly for international nurses to gain skills and knowledge to 42 obtain their nursing licensure in British Columbia and other provinces or to provide advanced nursing knowledge international nurses may bring back to their home country. The program under study is a post-graduate diploma program that began in 2014, admitting students every two years during the pilot phase of establishing the new program. The program is not recognized as a bridging program by the Canadian Association Schools of Nursing (CASN). However, it focuses on providing IENs with a nurse specialty and preparation for nursing registration. The 2019-2020 school year was the first entry of students in consecutive academic years, with 24 students in each cohort. The program serves primarily international students from India and the Philippines. It is a full-time program delivered in-person and has classroom, lab, and clinical instruction. To meet the academic admission requirements for this program, students must possess a Bachelor of Science in Nursing Degree or a Graduate Nurse/Midwifery Diploma from a recognized nursing school with English as a primary language of instruction, be registered with a national/provincial/state nursing association in their home country, and obtain an English language Proficiency overall score of 6.5 on the International English Testing System (IELTS) with no band score (average) lower than 6.0 or equivalent. IELTS is scored on a 1-9 scale, and most universities require a 6 or 7 overall band score. 3.2.2 Situating the Researcher My interest in the research topic stemmed from being a nurse educator and the coordinator of the [Nurse Specialty] Post-Graduate Diploma for international nurses at [name of college]. As the coordinator, I encountered many issues from both international nursing students and their nurse educators. To find solutions to issues that were not well researched, I decided to collect and analyze data that may improve the international nursing program to which I belong and similar programs at other institutions. The proposed study's findings contribute to the body 43 of knowledge for nurse educators, student and faculty services, nursing bodies, and academic administrators. Some ethical considerations should be clarified so transparency of the relationship to the participants is made known. I do work as a colleague with the participants. However, as the program coordinator, I hold no ‘power’ over potential participants in their careers. I hold equal status as a nurse instructor. The department Chair evaluates them, and all ‘power’ would be held by the department's Chair and Dean. 3.2.3 Sample For this study, participants included nursing faculty who teach international nursing students in the public rural Canadian college described above. Several factors were considered when thinking about the representativeness of this sample and the transferability of the data obtained. This study's sample was not designed to represent all INS nurse educators but rather obtain evidence and knowledge specific to this population and the context under study. The outcome of Interpretive Description in applied practice fields differs from the goals of research in many of the social sciences because it attempts to capture reflective description and interpretation of the experiences of participants, rather than the researcher attempting to highly theorize the data obtained (Thorne, 2016, p. 97). Through the lens of Interpretive Description, Thorne (2016) says, “I think we do much better if we understand that representation serves us best as one of those broad social ideals (like dignity or integrity) that is worth keeping in mind, but is not a thing one can actually achieve. This stance forces us to assume that whatever sample we come up with will not in any meaningful way “be representative,” but rather will reflect a certain kind of perspective 44 built from an auditable set of angles of vision whose nature and boundaries we can explicitly acknowledge and address” (p.98). However, Thorne writes that it is essential to use transparent sampling logic and then report our understanding of what the sample reflects. Therefore, to remain logical and transparent in the studies sampling strategy, Robinson’s (2014) four-point qualitative sampling approach was used in this study. The four points include: defining a sample universe, deciding a sample size, devising a sample strategy, and sourcing the sample. 3.2.3.1 Sample Universe, Size, and Strategy. Clearly defining the sample universe or study population defines the totality of persons from which cases may legitimately be sampled in an interview study (Robinson, 2014). Exclusion and inclusion criteria must be determined to create a sample universe (Patton, 2015). Both variability and homogeneity are desirable in this study. Homogeneity within the sample universe is strengthened with the amount of inclusion and exclusion criteria established (Robinson, 2014). In this study, the inclusion criteria were that participants had instructed international nursing students for at least one school year semester in the classroom, lab, or clinical setting. All participants must have also taught at the public college included in the study. The study excluded all other academic institutions, non-nurse educators of international nurses, and educators with less than one semester of teaching experience with INS. This study's variability was established by including participants with different: years of teaching experience, cultural development education, cultural backgrounds, ages, and genders. Convenience sampling was used to recruit the participants of this study. It is the most common type of non-probability sampling chosen because it is convenient and accessible to the researcher (Elliot et al., 2016). Thorne (2016) shares that a sample created entirely by convenience may be an excellent source of insight in that the group of people who are closest at 45 hand may well be an excellent source of insight for applied qualitative researchers about a phenomenon, especially in the early stages of describing aspects of shared experiences. The school chosen to recruit from was selected because it is where the researcher is located and has a program for international nurses. Therefore, a convenience sample for this study has the potential to yield excellent insights about the experiences of educating INS. At the institution under study, 15 educators met the criteria for this study, and 11 of the 15 nurse educators participated. This sample size (n=11) allows for intense analysis of each interview and makes cross-case generalities without getting too overwhelmed with a prolific amount of data (Cleary et al., 2014). It also provides participants to have a locatable and defined identity, rather than being a small piece of data in the larger whole (Robinson & Smith, 2010). 3.2.3.2 Sourcing the Sample. Recruitment for this study occurred via email (Appendix A) to the chosen institution's nursing department faculty. The sample was sourced from the higher education institution where I was a faculty member of the nursing department. I, therefore, had access to the email server to reach all potential participants that met the inclusion criteria. Since I was also the program coordinator, I knew who would meet the inclusion criteria. I also recruited those that had taught in the program in the past. Only one potential participant fit this description, and this potential participant had retired from the institution. This potential participant was contacted via email. A research information sheet describing the study (Appendix B) was included in the email. Interested individuals were asked to contact the researcher for further information on the study and evaluated for eligibility. If the interested individual met the inclusion criteria, a consent form was emailed. The participant was asked to read, sign and email the consent form (Appendix C) back to the researcher. All interviews were 46 conducted by distance via telephone to adhere to current physical distancing health regulations with Covid-19. All signed consent forms are stored in a secured drawer in the researcher’s office. 3.2.4 Data Collection Strategies In Interpretive Description, the goal for data collection is “figuring out an appropriate and defensible means by which to get as close to that subjective experience as you reasonably can so that you have a high probability of being able to access the kind of material that will allow you to answer your research question” (Thorne, 2016, p.135). To answer the research question in this study, it was logical to use individual semi-structured telephone interviews as the primary source of data collection since the aim was to discover nurse educators' experiences during a time of physical distancing related to the COVID epidemic. Semi-structured interviews allow for exploring the participants’ lived experiences concerning theoretical variables of interest (Galetta & Cross, 2013). The interview process was guided by the interview protocol established by Galetta and Cross (2013), with each interview question connected to the research purpose. The questions were strategically placed to reflect the researcher’s deliberate progression toward an in-depth exploration of the phenomenon under study (Galetta & Cross, 2013, p.45), beginning with open-ended questions focused on concrete experiences to more specific questions. A more explicit description of this is provided below under data collection. The interview guide (Appendix E) was developed through a review of existing literature and identifying gaps of information that had not already been addressed or an identified need for a deeper understanding of a question that had been previously explored. Three experienced qualitative researchers reviewed the interview guide before data collection. I conducted 11 interviews with 11 participants over four weeks (May-June 2020). All interviews were conducted via phone due to physical distancing policies related to the COVID-47 19 pandemic. In totality, 319 minutes of interview data were collected, with the average interview lasting 29 minutes. 3.2.4.1 Demographic profile of study participants. Demographic information was collected from each participant using a demographic questionnaire (Appendix D). The questions in the demographic questionnaire were formed to gather participant characteristics that may influence the data. The literature informed the questions chosen. The demographic information collected is reported in the Findings section of this thesis. 3.2.4.2 Interview process. Semi-structured interviews were conducted via telephone to adhere to COVID-19 physical distancing requirements. Before the interview commencement, I addressed any unanswered questions or concerns the participant had and reviewed and acquired the signed consent form sent electronically. An explanation for the audiotape recording was given, and an assurance of confidentiality. The interviewee also sent the demographic questionnaire (Appendix D) electronically to the interviewer. After receiving both the consent form and the demographic questionnaire and answering any interviewee questions, the audiotape was turned on, and the semi-structured interview commenced. The interview guide (Appendix E) was used to maintain organization and provided open-ended questions that prompted the participant's experiences and thoughts. There are three main segments in Galetta and Clark’s interview protocol; the opening segment to create space for a narrative grounded in the participant’s experience; the middle segment for questions of greater specificity; and the concluding segment to revisit the opening narrative for meaningful theoretical connections and to move toward closure. Table 2 demonstrates how I have included questions to fit the main segments in Galetta and Clark’s (2013) interview protocol. 48 Table 2: Interview Segments Main Segment Description of segment questions Developed Interview Questions Opening establish a level of comfort and ensure understanding of participant rights move into broad questions that create openings for a participant to begin to speak from her or his experience when necessary probe for clarification mentally note meaningful junctures in participant’s story to which you will return later in the interview for greater exploration and depth support the flow of the narrative with probes that guide its direction as it relates to your research topic (Galetta & Clark, 2013, p. 47) To begin, I’d like to thank you for taking this time to answer my questions. I also want to make sure you understand the consent form you signed and emailed to me. Do you understand your ethical rights? Do you understand your rights around confidentiality? Do you have any questions about the consent form before you begin? Could you tell me about your overall experience with educating international nursing students? Middle attend to nuances in the narrative thus far shift into questions that are more specific as they relate to your research question loopback, when appropriate, to participant’s narrative material as it connects with specific questions explore further participant’s responses noted as meaningful in the opening narrative extend your probes beyond clarification to meaning-making on the part of the participant toward the research topic (Galetta & Clark, 2013, p. 50) Did you receive preparation for this role? - If so, what was that preparation? - How well did you feel it prepared you? Have you experienced any particular challenges? - If so, what have those been? - What institutional supports, if any, were available to you for these challenges? Can you describe a situation that caused your concern? - Why do you think this situation caused you concern? - How do you think this could be prevented? What aspects of the role do you enjoy or find fulfilling, if any? 49 Table 2: Interview Segments Closing pose questions that may reflect theoretical considerations offer participant the opportunity to explore opening narrative to theory-driven questions where possible return to those stories and metaphors in need of further exploration look for opportunities to explore contradictions work toward a sense of wrapping up and indicating to the participant the interview is nearing completion ask the participant for additional thoughts or final points thank participant and emphasize his or her contribution to the research (Galetta & Clark, 2013, p.52) What wisdom might you have for faculty new to educating international nursing students? What recommendations might you have for preparing instructors in this role? Are there further comments that you would like to make regarding your experience in teaching international nursing students? In my research, the opening segment broadly explored the overall experience of teaching international nursing students. The middle segment focused on issues relevant to faculty preparedness, institutional supports, and the challenges and benefits of teaching INS. The closing segment provided the participants with the opportunity to share their advice, recommendations, and general comments regarding their experiences teaching INS. Being an insider in this study brought enthusiasm and experiential practice knowledge, which is a desirable attribute. However, making the transition from insider to researcher also created challenges. It was vital for me to stay reflexive and transparent through the data collection and data analysis process to keep the data’s credibility. Thorne says, “documenting 50 something of what is happening to you subjectively and conceptually within the research engagement becomes a core element informing your inductive analytic process” (Thorne, 2016, p.119). Thorne suggests keeping a field notebook or research journal to record your own opinions, interpretations, and knowledge will become an essential part of your research document. To stay attentive to my own opinions and knowledge, I kept a research journal. Thorne says that it “does become a very critical part of what you will rely on to understand the implications of your role in data collection and construction” (p. 119). This practice of keeping a research journal helped ensure that I did not forget informative content and ensured that I had access to that material for further reference and elaborations as the research unfolded. As a novice researcher, I wrote detailed field notes following the interview in a template (Appendix F) developed by the researchers from Phillipi & Lauderdale’s (2018) literature review and introductory set of field note criteria guide. It was specifically designed to assist new researchers in collecting accurate contextualized data to ensure the credibility of the data and aid in my inductive analysis. The field notes also helped keep me mindful of the disciplinary background influence that I could have on the participants’ revelations that Thorne (2016, p.120) addressed. It would also remind me of the importance of keeping to the interviewee’s story and not adding my own opinions or knowledge (Thorne, 2016, p. 123). A written summary of the key themes from the interviews was given to each participant after the data analysis had been performed. This interview summary provided the participants with the value they had contributed to the study's greater purpose (Thorne, 2016, p.126). It also allowed participants to review the summary to ensure the data's credibility. I also asked the participant if they had any further questions about the study and asked for permission to contact them if further clarification was needed. 51 3.2.5 Data Analysis Procedure The data analysis procedure was strategic to ensure quality research that is credible by following several qualitative analysis strategies suggested by Thorne (2016) in an Interpretive Description approach. The data analysis strategies used were a blend of coding and analytical critical reflection that provided a novice researcher with a process of intersubjectivity, reflexivity, and feasibility while maintaining a responsible level of methodological rigour (Maltured, 2012). Thorne (2016) explains that the researcher has to build a coherent and solid line of inductive reasoning through ideas that may be complex and contradictory and make defensible arguments as to the directional choices that have been taken along the path (p.155). To build a coherent and solid line of inductive reasoning, I engaged in Morse’s (1994) Cognitive Processing, which includes: comprehending, synthesizing, theorizing, and recontextualization. I have described these steps of cognitive processing in Appendix G. The interview data were de-identified, and all participants were assigned a coded participant number that the primary investigator will securely hold. The data was transcribed using NVivo transcription software. It was then reviewed for accuracy and uploaded into the qualitative research software program NVivo for analysis. To immerse myself in the data, I reviewed and edited all the interviews myself and wrote any pertinent thoughts in my reflective journal during this process. Throughout the data analysis process, I used Srivastava and Hopwood’s (2009) simple framework, that Thorne (2016) suggested, consisting of three iterative questions: “What are the data telling me? What is it I want to know? What is the dialectical relationship between what the data are telling me and what I want to know” (Srivastava & Hopwood, 2009, p.79). One other question I added to these three questions was suggested by Thorne (2016, p 179), “What might I 52 not be seeing?”. This question is formed to include the influence of my disciplinary orientation on the analysis, which may influence how the findings are framed. This question was explored by re-reading the data intentionally reviewing it through the nursing discipline lens. I also consulted and discussed with my supervisor to gain feedback on what I may be missing. After immersing myself in the data with these questions in mind, I wrote down thoughts and concepts in my reflective journal and analytic memos on the transcripts. Through this process, codes and themes started to form. Following this strategy, I engaged in dialogue with my thesis supervisor, who had also read and coded several of the interview transcriptions to enhance the credibility of the data analysis. We analyzed an interview and compared our themes, codes, and pertinent points. After negotiating themes and codes collaboratively with my supervisor, I inputted my codes and interviewed excerpts into the NVivo software for organizing the data. 3.3 Methods to Ensure Credibility in Interpretive Description Interpretive Description follows the same general principles that have been recognized and accepted as evaluative criteria for credibility across the qualitative spectrum. In the following sections, I explain the measures that I took to adhere to these principles. 3.3.1 Epistemological Integrity Epistemological integrity should provide the reader with a sense that there is “a defensible line of reasoning from the assumptions made about the nature of knowledge through to the methodological rules by which decisions about the research process are explained” (Thorne, 2016, p.234). Thorne also states, “for the findings to be credible, the research process must reveal a research question that is consistent with the stated epistemological standpoint and an interpretation of data sources and interpretive strategies that follows logically from that 53 question” (p.233). Throughout this methods chapter, I have presented how my research question and interpretive strategies align with the methodological approach of Interpretive Description. Throughout this thesis process, I discussed and received guidance from an experienced qualitative researcher to ensure my thinking and reasoning aligned well with this approach, from forming the research question to choosing interpretive strategies that flow logically. Additionally, as a nurse educator in the program under study, I am grounded in the disciplinary knowledge foundational in Interpretive Description. This groundedness in the applied discipline of nursing education enhances epistemological integrity by acknowledging the integral role that such positioning plays in the conduct and application of my research. 3.3.2 Representative Credibility According to Thorne (2018), qualitative studies should show representative credibility by the congruency between the theoretical claims being made or the research question asked to the environment that the phenomenon under study was sampled. It is anticipated that these participants will have various experiences and perspectives to inform my question credibly. However, to maintain representative credibility, claims cannot be made from the experiences recorded under one study. It will be important for me as the researcher to align my findings with other related literature. It is also important to note that the participants will be from the same rural college in British Columbia. Therefore, there may be a dominant cultural group that may be reflected in these findings. These limitations of a smaller sample size and a single setting should signal to the reader that caution should be used when transferring the study results to other environments and populations. Understanding these limitations was particularly important when I sought to create recommendations at this study's conclusion. 54 3.3.3 Analytic Knowledge It is expected that “reports of all qualitative studies to reflect an analytic logic that makes explicit the reasoning of the researcher from the inevitable forestructure through to the interpretations and knowledge claims made on the basis of what was learned in the research” (Miles & Huberman,1994) cited in Thorne (2016, p.324). To do this, Thorne (2016) recommends that evidence of logic be made sufficiently visible throughout the research since it is not sufficient for a researcher just to assure the reader that an inductive reasoning process occurred. Through the evidence of logic presented in the research, the reader should be able to confirm or reject its credibility. To make the decision-making process used throughout the study's conduct accessible to the research consumer, several strategies were employed so that the reader can assess its adequacy. An audit trail utilizing analytic memos, field notes, and reflective journal entries was utilized to keep a paper trail of the inductive reasoning process. These strategies helped describe the important context for the study and provided an audit trail of how analysis progressed (e.g., discussions of changing coding structures). I also used verbatim quotes to ground findings in actual data. This occurred by negotiating the data with my thesis supervisor to create a congruent codebook with the data collected. 3.3.4 Interpretive Authority In interpretive authority, qualitative research critics and readers “…. need to be confident as to which claims represent individual subjective truth claims and those which might be more shared or common in nature….. we must be able to grasp the researcher’s intentions in revealing knowledge about the particular” (Thorne, 2016, p.235). As a nurse educator and coordinator for an international nursing program, conscious awareness of my preconceived ideas and biases were recorded in a reflective journal. Altheide and Johnson (1994), cited in Thorne (2016), posits 55 that the aim is toward convincing our audience of our version of the truth through “validity-as-reflexive-accounting”. To be accountable and transparent about my research interpretations, several strategies were employed and included when collecting and analyzing data: recording field notes, writing in my reflective journal, writing analytic memos throughout the data analysis process, and seeking feedback from my thesis supervisor before and after the interviewing process and throughout data analysis. 3.4 Knowledge Translation The results of this study will be made available to the public and study participants on the University of British Columbia-Okanagan’s open-access digital repository. It will also be shared with the international department and the school of nursing at the institution under study. To inform the study setting's appropriate stakeholders, I intend to hold a meeting with an open dialogue about the findings and implications. Additionally, disseminating the results will occur through abstract proposals and presentation proposal submissions to relevant nursing and international education conferences. Furthermore, I intend to submit a proposal for publication to one or more of the following peer-reviewed journals: International Journal of Nursing Education Scholarship, Nursing Education Today, and Journal of Nursing Education. 3.5 Research Ethics Board and Approval Ethics approval for this research study was obtained through the University of British Columbia-Okanagan Behavioural Research Ethics Review Board – Certificate Number: H19-03079 and the college under study Research Ethics Board – REB 2020-002. Throughout this research process, I implemented the Tri-Council Policy Statement's core principles: Ethical Conduct for Research Involving Humans Course on Research Ethics (TCPS 2: CORE), which I took on September 28, 2019. 56 The participants’ identifiers were removed and were replaced with a code to maintain confidentiality. The institution's name was also removed and identified as a rural college in Canada. However, participants were aware that risk remains that they could be identified due to a smaller number of participants. Upon completing this research study, data will be stored electronically on a password-protected, encrypted device for a minimum of 5 years following UBC’s research ethics policies. All hard copies of data will be confidentially destroyed. 57 Chapter 4: Findings 4.1 Introduction to Findings Chapter three described the Interpretive Descriptive methodology used to explore the experiences of nurse educators of INS. Through a literature review on the topic, it was found that scant research has been conducted within the Canadian context to better understand the instructor perspective that is needed to support nurse educators of INS. This new knowledge could help improve the curriculum, support educators, and identify resources that will build success in programs educating international nursing students in the Canadian context. This chapter describes the findings from eleven semi-structured interviews of INS nurse educators to capture their stories and experiences. Using Morse’s (1994) sequential cognitive processes and Srivastava and Hopwood’s (2009) framework that Thorne (2016) recommended for data analysis, four thematic statements were constructed from these interviews: learning the learner, experiencing moral uncertainty in my role, inviting reciprocal relationships, and finding our way. I have chosen to organize the analysis of educators’ experiences by structuring thematic statements. Sandelowski and Leeman (2012) recommend using these statements to “cue readers quickly and efficiently to the conversations you are in, rather than forcing them to try to extract those meanings from the data presentation narrative alone” (Thorne, 2016, p. 201). Furthermore, the findings are presented as a thematic summary “revealing an ordered representation based on data groupings and patterns that have been inductively derived as a result of the analytic process, and therefore constitute an aspect of the findings” (Thorne, 2016, p. 182). The themes are not presented in a hierarchical or chronological order since thematic accounts were laced throughout the interviews. 58 In the first theme of learning the learner, I have explained the instructors’ experiences of teaching an unknown learner and the consequential learning and teaching challenges encountered from not knowing their INS. The second theme, feeling moral unrest in my role, spoke to the situations and emotions experienced that caused ethical uncertainties in the instructor’s teaching role and responsibilities. In the third theme, reciprocal relationships, I have presented the unique relationships developed between the nurse educator and the INS. Lastly, under the theme, finding our way, I have described the unchartered journey instructors went on together to discover their new role of educating INS. These themes were all framed with an overall assumption that the instructors were all pursuing ways to improve their andragogy while amidst new learning experiences themselves. It was evident among participants that it was important for them to do meaningful and virtuous work. The data revealed that they were all striving to adapt their thinking and teaching to achieve success in INS learning. In Table 3, I have presented the finding’s themes and sub-themes that have been described through written narrative and verbatim quotes. 59 Table 3 Thematic statements of themes and subthemes Themes Subthemes 4.2 Learning the Learner 4.2.1 A new classroom, a new realization 4.2.2 Cultural differences and assumptions 4.3 Experiencing Moral Uncertainty in My Role 4.3.1 Ethical issues in INS integration 4.3.2 Professional boundaries: in the grey 4.3.3 Advocating for student well-being 4.4 Inviting Reciprocal Relationships 4.4.1 Collaborative relationships: learning from each other 4.4.2 Becoming a better global citizen 4.5 Finding Our Way 4.5.1 Shifting “on the fly”: unpreparedness 4.5.2 Recommendations for faculty support 4.1.1 Sample Description There were 11 participants included in this study. All participants were recruited through a recruitment bulletin via email through the college nursing faculty email server list on May 13, 2020. The response rate from those currently working for the college was 83%. Additionally, one retired participant volunteered for the study, totaling 11 participants. All participants were nursing educators of INS. The mean length of interviews was 29 minutes, with a range of 20 minutes to 54 minutes. Among these participants, the experience of teaching INS at the college under study ranged from 1 semester to 10 semesters. Four educators also taught INS at other institutions for durations of 3,4,10, and 55 semesters respectively. There were ten self-identified females and one self-identified male. The average age of participants was 45 years, with a range of 38-52 years of age and one outlier of 72 years of age. The ethnic/cultural background that 60 participants identified themselves included: Canadian/European descent, 10; Canadian/Metis, 1. All participants were born in Canada. Among the participants, the mean number of years of nursing experience was 15.9 years, ranging from 7-30 years and one outlier of 50 years. Furthermore, the participants' mean number of years as a nurse educator was 8.45 years, with a range of 1-22 years. The two outliers were eliminated from the mean calculation and ranges to eliminate skewing of the demographic data. All participants were registered nurses with their Bachelor of Science in Nursing degree, and five of the participants also had their Master’s degree in nursing or health-related fields. The demographic questionnaire (Appendix D) also included a question on specific training or education in cultural safety, cultural awareness, or power and privilege. Five participants reported having minimal cultural education and responded that most of their education was received in their BSN programs as nursing students and short modules required with previous nurse employers. The other six participants reported taking specific cultural safety courses or workshops, and/or taking relative courses in their Master’s programs, and/or attending intercultural conferences. Another question relative to this study included in the demographic questionnaire asked which countries the students they had taught were from. All educators had taught students from India, seven educators had taught students from the Philippines, and three instructors also taught students from Suriname, South America, China, and/or Africa. 4.2 Learning the Learner Participants quickly realized that they were facing many unknowns as they took on the nurse educator role of international students. They found themselves standing in front of a classroom with students who had newly arrived in Canada or lived in Canada for less than two years. Their students were from different countries, cultures, languages, and education systems 61 unfamiliar to the instructors. The participants included new and seasoned nurse educators, but all described that they were trying to understand who their learner was and how they should effectively instruct them. Two subthemes emerged under the overarching theme of learning the learner, including a new classroom, a new realization, and cultural differences and assumptions. 4.2.1 A New Classroom, a New Realization In this subtheme, I have presented the surprising and sometimes shocking differences that the participants realized in their new classrooms of INS compared to teaching a classroom of Canadian-born nursing students. These included differences in language skills, teaching and learning strategies, cultural perspectives, and curriculum design. From their first day of class, the nurse educators recall experiences that demonstrated they had little knowledge about their international nursing students. One participant used the following analogy describing their experience of teaching INS, “It was very much like kind of swimming through cotton candy…I didn’t know where I was going or how to do it, so I was kind of feeling my way as I went” (P2). The educators realized that their past teaching approaches did not have the same effectiveness for their new learners. Overall, many participants discovered the first step was figuring out who their learner was and recounted reflections they had in the process. For one interviewee, this was exemplified in this reflective statement: ….hard work has come into really understanding, you know, the learner. And it is taking, making assumptions and taking for granted how you traditionally teach has been the wrong thing to do. And there are assumptions that in the beginning anyway, for me and I can only speak for myself, but that I thought, you know, I thought I knew my learner and very quickly learned that I did not. (P4) 62 For this veteran educator, it was a surprise that the teaching tools and approaches used in their past teaching experiences were not easily applied to their new learner. Assumptions about the learner were made by other participants, which required educators to unlearn what they thought they knew and start trying to get to know the learner. A couple of participants recommended to “be patient with yourself (P4)” and “get to know the students individually and as a group (P6)”. Another assumption three of the participants (P3, P7, P8) made was that all the students would be proficient in English in written and verbal language. The educators knew that the program's admission requirement was that the students’ nursing education had to have been delivered in English, so they were surprised that they had difficulty understanding the students’ verbal and written English. As one participant commented, …so, you know, understanding, just understanding, you know, like language, right, like the use of English language, ensuring kind of a common understanding and that we're coming from the same place. So that was a big learning curve for me verbally, but really a challenge in writing and understanding what, you know, what was being said. (P3) For some, there were moments of self-consciousness as they struggled to understand the students’ verbal English due to strong accents and different English dialects. The need to ask students to repeat themselves and the inability to remember foreign names and faces made one educator feel inadequate and led to this participant (P8) questioning whether they thought they were uninterested in a genuine student-teacher relationship impersonal approach. Educators were also unsure how much the students understood their speech while giving lectures and instructions on assignments. This lack of understanding was demonstrated when a couple of participants (P1, P8) worried that students did not understand their English after receiving assignments that did 63 not align with the instructions given in class and receiving responses to questions in class discussions that did not pertain to the question asked. Learning to rephrase questions, clarifying, and paraphrasing became a regular practice, which one participant (P11) said was a barrier to time management in the classroom. Understanding their role as nurse educators of INS was further complicated for many as they tried to balance teaching both the English language and nursing. One participant recalls having to differentiate the role of being an English language educator and a nurse educator and felt they were moving too far away from the subject they were hired to teach, as reflected in this statement: There was other challenges that I think just working with students where English as a second language and letting go of I'm not teaching English, I'm still teaching nursing. Just letting go of that because I'm a bit of a...I don't know, my pet peeve is poor grammar and you know, I had to let go of a lot of that mentality because it's not helpful really to the students or myself. …. It's just like the writing skills and language barrier, you can spend a lot of trying time as an instructor to help with it them and you lose focus on the nursing and it shifts to something else. (P10) Challenges were also encountered from developing a program without knowing the learner. Two of the participants (P4, P7) involved in the planning phase recounted the experiences of developing a program for ‘unknown learners’. One of the interviewees explained they had experiences developing a similar program for Canadian students and helped develop a nursing program in a different country. However, these experiences still did not equate to the 64 knowledge needed for a program specific to a group of unknown learners. The participant reflected: I've been educated in the Canadian system at so many levels and I see things through my Canadian lens so I had to learn to see things through their lens and be able to understand where they were coming from and be able to assess what their learning needs were or what their education level was before I could even begin to share very much in terms of my knowledge about [nursing subject] that I wanted them to learn and so I think the key challenges for me were learning to assess where they were at and what they needed to know and wanted to know. And then being able to self-reflect on what I needed to know to be able to communicate properly with them. (P7) This participant recognized that the knowledge initially thought to create a successful nursing program for INS was inadequate. Through this, both participants who were developers of the program recalled the numerous changes required to be made on the program’s teaching philosophy, teaching strategies, curriculum, and assessments. One of the participants (P4) mentioned that these changes would happen in the future in a program refresh. These required changes were consequently felt by educators who were new to teaching in the program. They expressed concerns about the curriculum not being well suited to the learner, making it difficult for the educator to teach. There were two primary concerns about the development of the curriculum. The first one was the leveling of the curriculum. A few of the participants (P5, P9, P11) believed that the courses they taught were leveled too low, which affected the engagement in the classroom. One participant said, “my expectations did not really meet my reality. I was quite shocked with how highly educated the students were” (P5). These 65 educators found the students already knew the concepts that were being taught in their courses, as one participant said in regards to the curriculum: But even a very basic level of an RN coming in, I still found have that knowledge already, and it needed to be upped a bit…… it just felt like they lived this for so long with their own nursing education previously or their own work as a nurse that I was asking them to do things that they weren’t really gaining any new knowledge on…….I guess that goes to speak a little bit about being well prepared for the students coming in…and not knowing exactly who it is that I’m going to be teaching and where they’re coming from. I mean, that’s tricky in that there’s a wide array, even just with the Indian students where they’re coming from, the type of education that they had but then you throw students who had their education from the Philippines in there. And it's again, a whole other level. (P11) The second concern regarding designing a curriculum without knowing the learner was the time and skill required to change the curriculum to suit the learner better. Since most of the educators were new to teaching, they did not feel they had the time and skills to make these changes, so most often, the courses were left unchanged, making classes challenging to teach. This feeling of incompetency that new educators experienced supported one participant’s (P9) firm belief that new instructors should not teach in this program because of the skills required to adapt or re-design curriculum to the learner. This understanding that many revisions needed to be made to the program did not go unnoticed and was the impetus for allocated funding for a program refresh. However, the time between program start and the time of the program refresh had created some tensions and 66 negative outlooks on the program, resulting in one participant (P9) deciding not to teach in the program until changes were made. This participant voiced their concerns about the problems created from developing a program that did not have well-established research, curriculum blueprints, or evaluation strategies to successfully develop a program without sufficient knowledge of the learner. For others, the program refresh provided hope for fixing the program's problems and remove barriers so educators could find fulfillment and enjoyment in teaching INS. In summary, all participants quickly realized that the teaching approaches used in their previous nursing courses of Canadian-born students were not going to be pedagogically appropriate for their new classroom of INS. Participants recalled experiences that explained how the realization of the INS’s lower English language proficiency affected the classroom environment, assignments, and time. Some participants also recognized that the program itself required major revisions after realizing that the program philosophy, content, and assessment strategies were not well-suited to the learner. Lastly, many participants remarked on how the curriculum was not leveled appropriately to their learner and also commented on the complications of revising the curriculum in a program taught with many new instructors. 4.2.2 Cultural Differences and Assumptions There was a common teaching philosophy among educators valuing the importance of collaborating with the students to make their education meaningful. However, educators found they needed cultural awareness, competence, and safety to succeed in these interactions. In this subtheme, I have presented the cultural differences recognized and assumptions that participants felt influenced their teaching and learning interactions with INS. The cultural differences and assumptions that the participants experienced included classroom culture, diversity among students from the same country, academic integrity, and cultural customs. 67 Some participants spoke about how the INS's influence being raised in a culture with different classroom customs and perspectives on how education is delivered took time and new knowledge to understand. One of the participants commented how they approached these differences in classroom culture and education systems: It is just adapting to.. to ... collaboratively meeting in the middle, you know, coming from a style of education that I'm used to and them coming from what I see as a much more formal style of education, you know, and meeting in the middle somewhere where everybody's comfortable. You know, it took a while for me to adapt to the student who's been called on to respond in class standing up. (P2) This is an example of how the participant needed more nuanced practices and cultural knowledge to understand different classroom customs that the INS were accustomed. Where many times the instructors saw these differences as novel, some differences were challenging. Other cultural differences or perspectives related to being raised in different education systems included the lack of computer skills students had coming into the program and many assignments rather than one final exam for course evaluation. After witnessing how the students struggled with their computer skills and how the number of assignments quickly overwhelmed the students, many of the participants questioned whether they were approaching their assessment strategies correctly and if the expectations extended to INS were reasonable. Some educators felt that their lack of cultural competence led to the inability to collaborate with students effectively. Since educators were still trying to understand their learners, some assumptions or cultural misconceptions created learning and teaching barriers. One such misconception was that since the students were all coming from mostly one country, 68 their culture and education level would be similar. However, participants realized that cultural differences between students from the same country were vastly different and their level of education. When speaking about this issue, an interviewee said: I made the assumption that everybody would have the same level of education, which was totally untrue. India is a huge country and the North, the West, and the South might as well be three different countries, um, because they don't speak the same languages, they don't eat the same foods, and depending on where they took their training, whether it was rural or urban….. so my mistake was assuming that because they were all from the same country, they would all come from the same standard of education, which we pretty well can assume in Canada. But we cannot assume that when people come from other countries, especially depending on the difference between the urban and the rural in a more developing kind of country. (P7) This educator found they were unaware of their learners’ culture and the broad assumptions made about the group. Two educators (P3, P7) were surprised about the many cultural, educational, and language differences among students within the same country. Another area identified among the educators was the difference of interpretation around academic integrity. Higher education institutions in Canada have strict academic integrity policies, where it may be different in other countries. About academic integrity, participants grappled with discerning what amounted to cultural differences that deserve more time of instruction for the students and what should be penalized. This was a struggle amongst many instructors, and most of them voiced that a plan should be in place that delivers the education on academic integrity to international students and a “unified approach” should be developed that 69 all instructors adhere to for evaluation of INS work, so there is consistency in grading. However, educators seemed to still conflict with what needed to be done in these situations; as one participant remarked, A situation that caused me concern? (longer pause) um...I think something that, you know, I even struggle with to this moment. And, you know, I'm not sure how to address it or where we're going with this in the program. Just the really big differences around academic integrity and it continues to be. I think it's a concern because I know that these are students that come from an educational system that has different expectations and different standards around academic integrity. And then there's kind of our policies. Just where does it all align?.....It's like my expectation is different between the international students and the domestic students that I teach, you know, so it concerns me and it gives me you know, makes me go….(P8) Several educators (P2, P3, P10) questioned how to best support academic integrity to a group of learners with different interpretations due to cultural differences in education systems. There were some concerns around plagiarism. Participants struggled with the current institutional academic policies and questioned if the consequences were appropriate for a learner who was just starting to understand the institution’s academic integrity expectations. Therefore, some of the participants found that grading papers took some ethical decision-making. As one participant said, One of the big times that I can think of was when there was a student who blatantly plagiarized something, you know, by North American standards that, you know, is enough grounds for failure. You know, potentially even expulsion 70 in a drastic case, you know, sort of tempering that....with a blend a little bit with the fact that this is their cultural considerations at work here. (P2) Overall, the participants knew some changes needed to be made around academic policy that supported both the instructor and INS. One participant commented that a whole class could be taught on academic integrity, and something was needed to bring fairness to the students and hold up academic standards. Clinical practice was another environment where participants realized that a better understanding of their learners’ cultural background and ways of knowing would have been beneficial. Two of the participants (P1, P10) did not know what to do when trying to be a supportive instructor for INS in clinical practice without fully understanding the students themselves. One of these participants (P1) recalled an experience in clinical practice where they assumed students would voice their opinions if they disagreed with them but later discovered that it was disrespectful for them to question the instructor in the students' culture. Educators had both cultural and ethical issues, and there was uncertainty on how to collaborate with students over these differences. For one participant, they questioned how to support a student with strong religious or cultural beliefs in clinical practice: As an instructor, I'm already working on the assumption that they're just going to get it the Canadian way and then we're in clinical practice and things sort of come up, and you kind of have to stop and go, oh, wait a second, wow, I didn't even know that would be an issue for you, or I'm just thinking back to one of my students who wore a headdress, just like a scarf over her hair for religious purposes. What is the impact of that when you're working in an isolation, or a high acuity isolation type situation? Or a student, let's say that wears full arm 71 length shirts and who isn't allowed culturally to show skin above the wrist, but for whatever isolation reasons or for infection control reasons, you have to be able to pull that up. What is the impact on that person, on that student? Or that future nurse and their religious beliefs? You know, just lots of things like how patients might respond and what are the differences in religious beliefs that can impact how we interact and how we perceive our clients and how we perceive our students and vice versa. (P1) On a larger scale, some of the participants felt it was themselves that needed cultural competence to adapt their way of thinking to a different learner and at the education and health systems level. A couple of the participants believed that a new cultural mindset needed to be adopted across all institution levels for progress to occur. This was demonstrated in this comment, I mean, all learners learn differently. But now there are these extra layers of cultural competence and awareness and helping, not only helping students......I'm going to use the word conform, but it's not, I don't really mean truly conform, but helping students integrate into our educational system and then help our system shift to understand and respect and take in the way that these particular students may learn based on their prior experience, both in their profession and in their education. So it's not just about us helping the students adjust, it's about somehow trying to help our system adjust and to have a broader perspective on how to teach, and that's probably where the hardest work is trying to shift systems and not, it's just not easy. (P4) 72 In response to the cultural shift in the academic institution, it was noted by several of the participants that they knew of resources and workshops that were available to help build their cultural competence but did not have the time to take them. They also felt these were not visible resources and not a concept the whole institution was adopting together. To summarize this subtheme of cultural differences and assumptions, participants experienced teaching challenges that arose from the assumptions made about students related to cultural differences. These challenges included the differences in classroom culture that the INS and nurse educators had, such as standing up when speaking, different assessment strategies, and lack of computer skills. Another issue that caused challenges was the difference in interpretation on academic integrity, which left participants unsure of how to evaluate assignments properly. Lastly, participants recognized a cultural shift in the academic institution needed to support INS and INS educators to overcome cultural assumptions and collaborate on new ways of meeting both teaching and learning needs. 4.3 Experiencing Moral Uncertainty in My Role This overarching thematic statement, experiencing moral uncertainty in my role, was constructed fromparticipants' experiences and remarks that expressed uncertainties over ethical issues they faced while educating INS. These feelings of moral uncertainty were most often developed from the personal ethical conflicts participants had with INS's integration process into the school, community, and Canadian health care system. In trying to assist students with integration, participants also shared experiences that challenged their views on professional boundaries. This theme is broken into sub-categories that delve into some of these ethical issues that educators grappled with as they educated INS. The three subthemes include ethical issues in INS integration, professional boundaries: in the grey, and advocating for student well-being. 73 4.3.1 Ethical Issues in INS Integration Overall, participants viewed integrating IENs in the Canadian healthcare system positively and recognized that the IENs were filling nurse shortages and improving culturally appropriate care to clients from diverse ethnic groups. One interviewee (P10) thought that the IENs also brought compassion, intercultural connection, and a hard work ethic to the clinical area. However, even though it was viewed positively to integrate IENs into the Canadian nurse workforce, participants had ethical concerns about how this was being done within their nursing program and institution. The sub-theme, ethical issues in INS integration, was constructed from participants’ uncertainty over the ethical dilemmas associated with whether the program helped integrate INS into the school, community, and Canadian healthcare system in a successful way. This sub-theme presents those ethical issues that participants grappled with in understanding their role in INS integration into Canadian society that participants experienced, including the responsibility of a) meeting basic needs, b) ensuring a supportive community environment, c) supporting personal autonomy, and d) providing a valuable program. Several participants recognized that some of the moral uncertainty they experienced came from their sense of responsibility to ensure students’ needs both inside and outside the institution were being met. Since most INS do not have strong social support, students would often come to instructors for educational and personal support. Because of this phenomenon, instructors understood the many challenges students faced in their personal lives, even meeting basic needs. This awareness of student needs brought ethical dilemmas to the instructor. One instructor realized these basic needs in this comment: I think what it was, was about the time that [name] came into my class one day and brought a comforter for one of the students, and then I thought, wow, this 74 is bigger than just busses and housing. They don't even have like blankets, you know, so then I started to do a, What else don't they have? You know, do they have food? And so for me, that was bigger, that was pretty much the biggest thing that I lost sleep over with. (P5) For several participants, feelings of privilege were felt when comparing their quality of life to the INS. Some educators commented about feeling guilty that they were going home every day to food, transportation, and a supportive environment. Yet, they were very aware that was not the case for their students. Educators began questioning what they should be doing to meet basic needs and help create supportive and inclusive environments for students to become successful learners. These thoughts led to suggestions toward the academic institution to ensure systems were in place to help meet students’ basic needs, such as a carpooling system, a clothing and household item bank, and alternative housing options. Along with the uncertainty of unmet student basic needs and learning needs at the academic institution level, educators also felt issues with how students were being integrated into the community. One interviewee used the following analogy to describe what they thought was needed to assist INS in integration into the community: There's this critical component missing, this big piece of the puzzle missing. It's like they're under water and they're treading water and you just keep saying, keep holding your breath eventually you'll get to the surface, but what they really need is to have that buoy that they're holding on to at the surface, which is that community engagement piece and that community welcoming piece, because that's what we're trying to build, community. We're trying to build a workforce that is going to nurture Canadians and their families and our 75 families. And yet... Are we really prepared as a community to welcome them…. We have to have something in place in the community, that is welcoming them with housing, transportation, employment, you know, addressing racism and bigotry and all of that sort of stuff at a community level. (P1) Like this participant, several other educators spoke about the importance of community engagement for successful integration but commented that this necessary component of integration was not being met. Some participants questioned whether the community was prepared to welcome many international students. One participant (P4) spoke about how difficult it is for international students to come into a community shifting from a very homogenous community to one with racial, cultural, and ethnic diversity. This same participant recalled speaking to various institution members about the importance of working more closely with the community during this cultural transition. The interviewee commented, There are issues everywhere but we've taken a pretty white society and shifted it on its head and that it's been that, you know, in all fairness, it's hard. It's been hard for our community, so we need to work that much harder. If we are bringing these people into our community, and I don't think these people like othering them, but these poor individuals. But we're bringing them into a not very accepting environment. That to me seems unethical. (P4) In response to a comment the interviewer made about the college changing the cultural diversity in the community, this participant said, “..like hands down we did…so therefore with that to me comes a great responsibility.” (P4) 76 Another issue that several of the participants (P1, P2, P6) spoke about was the moral uncertainty that came along with the knowledge that some of the students did not choose to come to study in Canada, but rather families enforced this responsibility on the student in hopes for permanent immigration and the opportunity this could mean for the family as a whole. Instructors felt empathy and concern about the psychosocial impact of leaving spouses and children. This concept was complicated for educators to understand when coming from a culture filled with individual choice and autonomy. For some participants, moral uncertainty came when questioning whether the program's purpose was meeting the students' expectations and needs. These participants realized that INS enrolled in the program with the expectation of immigration for themselves and family members, nurse registration, and increased quality of life. Therefore, most participants recommended that the program's purpose be clarified and reflective of both the student and workforce desires and needs. One of the participants grappled with students being in the program for immigration purposes, which seemed incongruent with the program's purpose. These questions that the educators were asking themselves to make sense of what they were doing needed to be clarified to come to terms with their motivation. One of the participants thought that moral unrest could be reduced if instructors knew the program was “ensuring that we’re giving good value to these students for the hardships and challenges they are facing” (P8). There was an under-riding feeling that instructors wanted to encourage and tell students that all of this will be worth it in the end. However, if the program was not providing students with what they needed or desired, this could not bring moral rest to the educators. One instructor (P9) specifically recalled being very concerned about the program's purpose and delivery and asked what the program's purpose was to administration but felt they were provided unclear 77 answers. This participant felt their concerns were being dismissed and questioned the lucrative business model of academic institutions recruiting international students, which went against their ethical principles. Another participant made a comment demonstrating this misalignment between student and program expectations and outcomes: ….I felt like the program was telling me, 'no, you're teaching them this, this, and this but the students didn't want that...they wanted this, this, and this because they wanted to be....to write their NCLEX or you know it was... I was confused about the focus on [nursing specialty] or is it a bridging program? (P10) Furthermore, participants experienced some uncertainties with the integration of INS into the Canadian health care system. The two main concerns were that the program was not equipping them to obtain their nurse licensure and that nurse licensure had many barriers for IENs in the province where they were being educated. The variability amongst nursing regulatory bodies frustrated some of the participants. It made them wonder if something more themselves or the program could do so INS could register in the same province they were being educated, as many of the students wanted to remain local. One educator thought there was a misalignment between the education system and the nurse registration system if these students have to move to a province that is easier to gain registration, as this participant shared: They have huge amounts of experience and knowledge that they could be bringing to our own Canadian nurse profession. And then you see them struggle and have to work as care aides and LPNs and finally eventually have to move away to work as RNs and not work here locally. And that that's very frustrating cause I see just how amazing they are as nurses. (P11) 78 Another participant commented: ….we're not taking them to that place where they are working RNs in Canada. Right, it's like a stepping stone for them to then carry on with that somewhat onerous process….and I don't know that we have a good process in place right on how to really support internationally trained nurses and coming to Canada and being successful. (P1) These comments and concerns regarding whether the INS are competent with their communication skills to practice safely brought along one more element to contribute to the moral uncertainty experienced by participants. To summarize this subtheme, ethical issues in INS integration, participants experienced ethical issues in integrating INS into Canadian society. These issues included the difficulty educators had in knowing their students were having difficulty meeting their basic needs, living in unsupportive and unwelcome community environments, not having autonomy in their decision to come to Canada, and not gaining the expected value of the program. 4.3.2 Professional Boundaries in the Grey This subtheme will present the educator experiences related to the ethical struggles related to the unclear professional boundaries in their nurse educator role. For many, moral uncertainty was experienced when educators were put in positions that made them question their professional boundaries. One participant (P6) described it as unprecedented, whereby they never experienced the personal favours and requests that were asked of them by students. Another participant (P2) was challenged by feeling more involved in the student’s personal challenges, “ranging from economic to housing to family…all of the things that are challenging when somebody comes to a different country and has to learn different customs and language” (P2). 79 Educators were confronted with many personal issues of INS that would have easily been viewed outside of their professional boundaries in a program with domestic students. This often brought confusing and conflicting ideas around professional boundaries. However, many of the instructors recognized that their students had minimal social supports and felt obligated to help. One participant expressed the uncertainty they felt in the following comment: So a lot of things came up that kind of shocked me, I think, in the beginning. I mean, I don't know, just asked to go above and beyond what I was used to with the BSN students, like the boundaries were not nearly as clear, and the students were coming to me with problems that I felt like, ohh, it's sort of out of my scope to solve this for you, so I think a lot of the time you feel a bit stressed kind of because you don't feel like you're doing your job because your students aren’t well takin' care of, but what can I do about the bus schedule? I end up giving them a ride home or a ride to practice. (P10) Educators made decisions to not ‘step out’ of their professional boundaries, but the uncertainty was also experienced in these situations. One participant remarked how these situations left them feeling “helpless” and “not feeling very good” (P2). However, two participants (P4, P11) that had more experience teaching in the program stressed the importance of setting firm boundaries, as one participant recommended: I just would caution instructors with their boundaries and this is any instructor, but especially when we're dealing with students who have exceptional barriers, as we've noted international students do, or exceptional needs. We still as instructors have to have our boundaries. I think that's really important for our well-being because if we're feeling really stretched and overworked and I have 80 been there and I'm not placing judgment on anybody or any situation. I'm speaking from personal experience. I've been there. I've been on New Year's Eve moving students from [city name] to [city name], packing them, and unpacking them. I feel that we so easily, especially us as nurses, because we care so much, how easily we can get, our boundaries can get very grey. (P4) Another recommendation made by a different participant (P11) was to prepare educators for the number of personal requests made by students and education around what is within and outside the instructors' professional boundaries. To summarize this subtheme, professional boundaries: in the grey, participants shared experiences and comments about the moral uncertainty they felt when challenged with setting professional boundaries with the INS. The ethical issues surrounding professional boundaries were different from those they had encountered with Canadian-born nursing students. Overall, the INS had relatively more personal requests and concerns than their domestic students and educators felt responsible to help; however, some of these issues were questionably outside of their professional boundaries or scope of practice, contributing to the moral uncertainty within their role. 4.3.3 Advocating for Student Well-being Many of the professional boundary issues ‘in the grey’ that caused moral uncertainty also caused educators to advocate for student well-being considerably more than what they were used to doing for their domestic students. Not only did they feel they needed to advocate more, but for issues they did not fully understand themselves. This sub-theme explores these experiences of advocating for student well-being around racism and discrimination, student learning needs, and defining instructor responsibilities around advocation. 81 Participants (P1, P4, P6, P9, P10) made references that indicated racism and discrimination were observed or heard within the academic institution, community, and practice environments. Often these behaviours left the participant feeling like “something needs to be done” (P4). One participant (P10) explained how they did not feel prepared to handle racism and discrimination situations in clinical practice and suggested the need for specific training on how to communicate appropriately while advocating and protecting INS. They went on to say that it was very difficult to maintain the balance of keeping strong relationships with practice partners while also properly advocating for INS. At one point, when advocating for a student when a staff member was racist, they thought, “oh my gosh, I made this worse by bringing this up because (student) got a talking to…I just felt like with whatever way I spin this, it’s gonna be harder on the students potentially” (P10). Two participants (P4, P9) spoke about their experiences of instructors and administration's attitudes that indicated racism and discrimination towards international students within the academic institution. Below is one of the remarks a participant made regarding institutional racism and the need for advocacy in the institution: Whether it be, you know, straight-out prejudice or racism. Really there is no other way to coin it, you know, making assumptions that, you know, they're all cheaters. Very serious, typical kind of comments, so that causes me great concern. It does not sit well with me at all. And so, you know, helping instructors shift that perspective and take perspective and do perspective-taking is so vital, the groundwork that needs to happen before anything else. (P4) Another participant (P6) recalls attending a meeting that the program coordinator arranged where the team of instructors met with the chair and international manager to discuss the program's 82 concerns. Two participants commented that this meeting was necessary to advocate for both students and faculty over barriers to student learning, such as curriculum redesign, student services, and faculty supports. Overall, most participants wanted to know which advocating roles were their responsibility as one participant said, You know, do we have a role in engaging with [province name] transit to facilitate better transportation? Do we need to look at support for housing, you know, things like that, just to make it so that the students can focus more on school and less about just trying, trying to live. (P2) In summary of this sub-theme, advocating student well-being, participants were challenged with the moral unrest of being put in a position of advocating for student well-being on issues that they were unfamiliar with. Participants recalled experiences where they felt unprepared to advocate for issues of racism and discrimination, program design, and institutional supports. Participants felt they were also put in the position to advocate to the institution for student services that would help meet the INS's learning and well-being needs. These acts of advocating left participants wondering how much of it they should be taking on themselves and how much is the responsibility of the academic institution. 4.4 Inviting Reciprocal Relationships Experiencing and learning a different culture and international perspective was a great source of fulfillment for almost all the participants. Many sentiments were made with an appreciative tone similar to this participant’s comment, “but I learned more from them than I think that they learned from me” (P5). Several educators talked about how it was refreshing to engage with new learners from a different culture and that it was so different from teaching in a nursing program with all Canadian-born students. It was commented that it was 83 “challenging…..but also refreshing” (P2). The theme of inviting reciprocal relationships was constructed from statements about the unique relationships built between nurse educators and INS. This theme is divided into two subthemes. The first, collaborative relationships: learning from each other, presents the many benefits educators identified in their relationship with INS. The second theme, becoming a better global citizen, illustrates the impact of their reciprocal relationship with students for themselves, clinical staff, patients, and for the students becoming better global citizens. 4.4.1 Collaborative Relationships: Learning from Each Other For many participants, a unique reciprocal relationship was built with their INS. This relationship was built from multicultural perspectives to develop new ways of approaching nursing, education, and life. This subtheme shares the participants’ experiences in these beneficial relationships. It explores how the approach to ‘learn from each other’ brought a naturally collaborative approach to teaching and learning. Specifically, this sub-theme will present the benefits that new educators received in their relationships with INS, the amount of knowledge shared between educator and student, and the appreciation and gratitude demonstrated between both teacher and learner. All the participants (P2, P3, P65, P6, P8, P10. P11) who were new nurse educators shared the common view that the INS received them with exceptional kindness and acceptance. Many participants shared experiences that demonstrated they were taken aback by the students' genuineness to build a relationship with them. This student attitude was illustrated in this participant’s comment, “they’re affectionate, and they just seemed honest about it, and just really no fakeness about it” (P8). Another participant’s view of student acceptance to new instructors was, “the students were very receptive to me being new, and they were forgiving, and 84 we had an open relationship that we were both learning how to navigate this” (P2). Other new educators shared experiences where they would collaboratively work together with the students to; better construct the classroom environment, adjust the curriculum to make it more meaningful, understand different perspectives, and decipher the verbal and written language. Participants also shared sentiments that showed they valued the nursing knowledge and different cultural views that the INS brought to the classroom and clinical practice. Some participants recognized that many of the INS were highly educated and experienced nurses, and the knowledge they contributed to the classroom and clinical was highly beneficial. More veteran instructors also reported that they felt they were learning with the students because they came into the program as nurse professionals. One interviewee felt “they were on a level playing field, that there was not a power difference” (P10). By learning different cultural views of nursing from INS, three participants also talked about their learning that occurred through class discussions with INS over differences in perspective on caring for the aging adult, palliative care, and chronic disease treatment between cultures. Several participants also expressed how they learned by observing the natural and gentle approach to care that the INS could provide their clients. They related this natural and gentle approach to the INS’s culture of caring for their older family members. Two participants (P1, P2) viewed their relationship with INS as their future colleagues and future carers in teaching the INS. Therefore, they thought it was essential to train them and impart values that are “universally beautiful ways to be” (P1). Another frequent benefit that the participants (P3, P6, P10) felt they received from their INS was their gratification from teaching INS. Not just oral gratification from students but also the self-gratification they received by seeing the student grow and develop throughout the program. As one participant commented, 85 I feel like you sort of.... you're doing a little bit more caring and looking out for your students, but you also get a lot more back because they're a little more dependent on you at first and then just seeing the difference by the time they graduate. That pride you feel as an instructor is pretty neat. (P10) The benefits of establishing a reciprocal relationship with INS encouraged several participants to continue developing the program and working hard to remove learning barriers for the students. The participants were rewarded with frequent appreciative comments from students and lasting relationships in response. One participant summed up what they learned from their INS in this statement: I have to be honest, I feel like I've learned so much from them as well through the process, just about cultural competency, cultural perspective, cultural safety and, you know, just getting to know some of them as people and really as colleagues because they are nurses. (P2) To summarize this subtheme, collaborative relationships: learning from each other, participants shared many benefits from their reciprocal relationship with the INS. The nurse educators who were new to teaching remarked how well the INS received them and how the newness of teaching and learning for educators and students created a collaborative relationship. Participants also shared their views on the equality of the relationship with students and how students were also viewed as colleagues since they were experienced nurses. Lastly, participants shared the value they received in learning from the INS cultural perspectives and their self-gratification in watching the students grow in a new culture. 86 4.4.2 Becoming a Better Global Citizen Building a relationship with the INS helped educators become better global citizens by learning new cultures, gaining perspective on different ways of viewing nursing and life, and advocating by promoting cultural diversity in the school, community, and workplace. One participant recognized that through all the challenges they experienced and the benefits they received while educating the INS, it also taught them to be global citizens right in their workplace. As one participant makes the following remark: I think the most rewarding is very selfishly understanding, being a better global citizen and then just having a better understanding of people outside of my little box. That feels really good to me and I think it makes me feel like I'm a better citizen because of it. It helps me be more compassionate and understanding and empathetic and it broadens my views and perspective and I think that's so important in life. (P4) This participant also commented that the exposure of students from a different culture in their own home country is a great privilege, especially for someone who does not travel the world, like themselves. Several interviewees commented that building a reciprocal relationship with the INS taught them about the resiliency that people from other countries have when coming to another country. One participant said, “I think that’s one of the biggest benefits I had, was just being a part of their world as they moved to Canada to come to a school like this. (P11)” For many participants, admiration for the INS grew as they witnessed the student’s resiliency. One participant expressed: 87 I really enjoyed actually seeing the way they were able to grow into a different culture. I think about the resiliency of the students as well and it's just amazing and what they do for their families and for themselves to better their lives is just incomprehensible for me, so I think it’s very inspirational to see that. (P8) Witnessing this resiliency level and having the cultural exposure that the educators experienced were appreciated by almost all the participants. For one participant (P1), multiculturalism, cultural integration, and cultural diversity were incredibly important to them personally. Being part of an international education program made them appreciate the opportunity to participate in their global citizenship. Other participants recognized that the INS could expose cultural diversity to the staff and clients in their practice placements. As one participant said, “this may be the only time that some people interact with a differing culture” (P10). Two participants (P6, P7) saw the benefits a multicultural lens from the INS brings to the health care system. Specifically, one of these participants believed the INS brings a different perspective focusing on holistic and family care to the Canadian system and views this as very valuable and also went on to say, “so I think that integration of the two different world views behind education systems and ways of thinking brings the best when we put them together” (P7). This participant also remarked on the hope for INS to share the Canadian perspective back to their home countries. These participant experiences support how participants were increasing their global citizenship. By becoming more culturally competent through their relationships with INS, educators improved upon their cultural safety when interacting with diverse cultures. They also gained an admiration for the INS in their resiliency in coming to a new country. Participants recognized that the INS also brought more exposure to other cultures to healthcare professionals 88 and patients. These interactions were viewed positively by participants hoping that both the INS and Canadians could learn from one another and increase their global citizenship through these reciprocal relationships. 4.5 Finding Our Way There was a strong response from the educators that they were not adequately prepared to teach INS. However, there was also a sense of determination among the interviewees that they were striving to ‘find their way’ as they responded to new challenges. It is worth noting that many of the educators were new to teaching, so they were also undergoing a significant transition in their careers. The theme finding our way is divided into two subthemes. The first, shifting on the fly: unpreparedness, captures the participants' unpreparedness of dealing with the constant change within the program as the program was developing with its learner. The second subtheme, recommendations for faculty support, provides participants’ advice and recommendations to build a more robust program to support faculty. 4.5.1 Shifting “on the fly”: Unpreparedness Some educators quickly responded with a strong ‘no’ that they did not receive any formal preparation to teach INS. While other participants said they did not receive any formal preparation, but they did find they could draw from cultural knowledge they learned from previous educational experiences. This sub-theme was constructed from several instructors using the metaphor of adapting or responding “on the fly” when teaching INS. Educators reported a constant change within the program as issues were brought to awareness and often left educators scrambling to make changes. This sub-theme will also present differentiating views that participants had on new educators teaching in a complex program that was still undergoing many changes. 89 One participant felt they needed to “change my approach on the fly” (P11) when teaching certain concepts after realizing their students already had the knowledge they planned to teach and saw the students were looking unchallenged in class. Another participant made this remark when experiencing their first class, “I walked into that classroom and realized I had to completely on the fly in that moment, redesign that entire course” (P9). These two participants both used the term “on the fly” to illustrate the pace of the need to adapt their teaching strategies to their learners. Some participants felt this “on the fly” teaching approach was difficult. Many participants commented that they thought better preparation would have made teaching easier or eliminated some of the problems. One participant commented in response to the interview question as to whether they were prepared to teach INS: So I would say, you know, a very short answer is no; I was not prepared. I thought I was, that's the silly thing of it all. I thought I was. And as I described, you know, for one of your other questions, I very soon learned that I wasn't prepared. And, you know, we were changing things on the fly and we learned things. And yet, really, what you know, in hindsight 20/20, what really should have happened was a pause and a revision. But, you know, really, I don't think we even knew enough a couple of years back on exactly what we should revise. (P4) Not only were educators challenged with re-designing curriculum and assessments “on the fly”, but they were also challenged to quickly change more logistical problems. For example, two participants (P6, P9) explained how they changed their class time to accommodate the bus schedule so students would not have to come hours before class began or wait hours after class to take a bus home. One participant (P6) also mentioned shifting the course schedule to a later time 90 also helped students who would work night shifts to be more attentive in their classes. These changes occurred once the semester began, so instructors were rushed to make appropriate connections to make a system change. One participant (P4) commented on how the whole school was learning to shift “on the fly” as the number of international students rapidly increased. This participant went on to say that the college recognized major gaps in both instructor knowledge and student learning and began implementing more resources for support. However, instructors were frustrated because the institution was working in a response mode rather than developing a proactive plan. This participant also took a new role with a teaching and learning institute and made this remark: And the crazy thing is, I was still just learning. We were still just learning, we were learning together. It was, so I kind of look back and I laugh a little bit and I think, oh, my gosh, I'm so sorry, everybody. I didn't really, I was trying to figure it out as I was going to. (P4) Another issue that came up frequently throughout the interviews regarding unpreparedness was that many educators in the program were new to teaching. Two of the participants (P3, P8) discussed how it was not easy to respond to these quick adjustments that needed to be made according to INS’s learning needs. They talked about needing time to prepare and not having the skills to adapt lessons “on the fly” as one interviewee said: So it's hard when your first living it as a new instructor, you're trying to figure out your own style and your own philosophies and your own theories and all that stuff. But then to put that on top of it (teaching INS), it's a little challenging. (P8) 91 This interviewee also spoke on the confidence needed to teach well and that confidence was difficult to develop when they were a new instructor teaching new learners. There were differences in views on whether new educators should be teaching INS. One participant (P9) was shocked that new instructors were work-loaded to teach INS and thought it was a poor pedagogical decision. This same participant suggested that it “would have looked very different, and 80 percent of all of the concerns would have been mitigated in the first year if experienced instructors would have been put in there first” (P9). They went on to say that, “if we start identifying what’s required of an instructor in this program, you’re going to see that it’s at a higher level of complexity than a brand new instructor”. However, the interviewees that were new educators had mixed responses. While they thought it was challenging, they also described it as a great experience. One participant even said they were more comfortable teaching INS than BSN domestic students because they were accepting of their newness. Still, other participants saw the benefits of educators evolving with the learner and recognized the complexity of teaching in an international student program. To summarize, the “on the fly” approach that participants experienced was challenging and frustrating to many of the participants. Educators found they had to make many last-minute changes to lesson plans, teaching strategies, and scheduling as they responded to INS's learning needs. New instructors were challenged with the teaching skills required to adapt to the learner at an in-the-moment pace. There were differentiating views on whether new educators should teach in such a complex international student nursing program. 4.5.2 Recommendations for Faculty Support Despite the challenges that instructors faced in teaching INS, there was a sense of commitment and hopefulness that the program could be successful and faculty could feel 92 supported if the right changes were made. Throughout the interviews, most participants made recommendations, gave advice, and imparted wisdom that they believed would help support faculty and build a better program for INS learners. This subtheme will present participant recommendations and advice related to educator attitude, team-building, orientation and mentorship, institutional supports, and perspective building. Much of the wisdom and guidance that educators wanted to impart on others entering the program was to recognize that as an educator, you will be learning much from the INS and approaching the learner with the intent of getting to know them. Many participants emphasized how important that relationship is to understand who your students are. However, just as important was for educators to be open and approachable so students may establish a trusting relationship. One participant cautions educators not to come in with a teacher-centered approach and that “you are the provider” attitude. Instead, this participant explained that you would be learning just as much from them, and it is better to form meaning and understanding collaboratively. Another participant cautioned educators not to make assumptions about the INS and investigate cultural misunderstandings so educators can continue to grow and learn about their learners. One instructor also commented how working with the INS helped them become a better person. One last piece of advice to other nurse educators related to the educator attitude, given by an experienced educator, was: Approach what you’re doing with more curiosity to learn from them as you do the need to give them education, so as if you come at your work with international students with this eagerness to discover who they are and what they know and what they want to become. (P1) 93 When asked in the interview about what helped prepare the participants for this role or what supports were available to them, many participants replied that other faculty on the team was their greatest support. Participants said regular team meetings and an open-door policy from the program coordinator helped solve issues and provided emotional support. One participant (P11) explained that the approach taken to address issues was more of a responsive approach than a proactive one, such as when you have challenges and issues, you seek help from the coordinator or another instructor. However, one participant (P1) commented that this type of approach is not developing permanent solutions and the same problems kept reoccurring. Two participants suggested regular team meetings to create action plans to solve these reoccurring issues and a more formalized process for international faculty to meet regularly to share and debrief. The concept of learning together as both a program and institutional team was recommended among several participants. Continuing to build a strong faculty team by limiting the number of faculty teaching in the program was a suggestion made by a participant. This participant believed this strategy could reduce the challenges and barriers felt by new instructors trying to learn a new program and being divided among teaching in more than one program. Since many of the participants felt most supported in their faculty team, often meeting in hallways and offices to debrief or obtain advice, participants recommended that a limited number of instructors was needed to build a cohesive team. All participants felt that the team was integral to success, as remarked in this participants words of wisdom: “Come into the position with a desire to really grow a team. You can't do this alone. You just can't. The strength is always in your team”(P1). Most participants remarked that a proactive approach to prepare educators of international students should be taken, but also recognized the complexity of the many 94 components involved. To become better prepared themselves in educating international nursing students and build confidence in their teaching, it was recommended that a thorough orientation and mentorship program needed to be developed. Participants highly recommended that an orientation and mentorship program could help alleviate unpreparedness. Numerous participants suggested that orientation needs to include a general understanding of cultural awareness and a more focused orientation on the specific cultural differences explicitly related to the cultural group or groups of students in the program. One participant suggested that the orientation should be leveled over five years so instructors are not overwhelmed with information. Others (P8, P9, P11) suggested a short orientation and an ongoing mentorship program. Another participant (P9) remarked how the research points to the complexity of teaching international students, so a strong mentorship program needs to be in place to “build confidence that would build skill” in the new educator. It is also worth mentioning that interviewees believed that the college had other supports available, but they did not know what those were, either because they were never told or did not have time to seek them out. One participant (P11) also said it would be beneficial to include descriptions of roles of those that belonged to the International Department of the College to use them as a resource. Another participant understood they could go to the International Department for support but said, “But I'm not sure I could even formulate questions at the beginning, to ask what I needed to know, and so it was kind of learning on the go” (P7). There was also mention of conferences and workshops to attend that could have helped, but again there was no time to attend these. All of the interviewees taught in both the BSN program and the International nursing program that the college offered, so time was constrained when working in multiple programs. 95 The last recommendation made by a few participants was to create a culturally safe and inclusive environment for the INS. The participants made suggestions to ensure all institution educators are receiving cultural education and workshops on perspective-taking. One participant believed this was important to cultivate an inclusive culture within the whole institution. Regarding creating culturally safe practice placements, it was also suggested that a practice partner agreement form should be signed between the academic institution and practice placement that states there is zero tolerance for racism and bullying of students. One of the participants also suggested that educators prepare clinical staff by sharing knowledge about the INS before they come into practice. To summarize, participants shared advice and recommendations for future nurse educators of INS and academic administrators on better supporting faculty and making program improvements. These recommendations were to build: trusting teacher-student relationships, a strong faculty team, a comprehensive orientation and mentorship program, and a culturally safe and inclusive environment. 4.6 Summary In this chapter, the study’s findings were described. Semi-structured interviews were conducted with 11 nurse educators of INS in the Canadian college context. Using Morse’s (1994) sequential cognitive processes of comprehending, synthesizing, theorizing, and recontextualizing described in Thorne’s (2016) Interpretive Description approach, four thematic statements were constructed from these interviews. In the first theme, learning the learner, I described participants' experiences as they were trying to understand who their new learner was and how to effectively teach them when confronted with issues related to cultural competency. The second theme, experiencing moral uncertainty in my role, described the uncertainties 96 participants had about integrating INS properly into the school, community, and workplace and issues around unclear professional boundaries. In the third theme, inviting reciprocal relationships, I described the benefits experienced by educators by becoming better global citizens through the cultural knowledge and relationships with their INS. Lastly, in the fourth theme, finding our way, I described the nurse educator’s determination and dedication to the program, students, and themselves through the many challenges teaching a new learner from an unfamiliar culture brings. 97 Chapter 5: Discussions, Recommendations, and Conclusions 5.1 Introduction to Discussion In this chapter, I will discuss the contributions this study has made to understanding the experiences of INS nurse educators in a Canadian college context. With the paucity of research on the nurse educator perspectives of teaching INS, this study aimed to gather nurse educator experiences that may help build knowledge for establishing and improving nurse educator of INS teaching practices, program development, and program improvements of similar programs. Concerning the literature review that was written previous to data collection, the findings derived from this study revealed new knowledge that will help advance the practice, education, and research of INS nurse educators. The evidence presented in the literature review of this study was focused on the specific student challenges that nurse educators of INS encountered, such as language barriers, cultural competency, unpreparedness, and lack of time issues. In comparison, this study's findings revealed that nurse educators of INS were challenged more on the equity and reciprocity issues about teaching INS. Similarly, both the literature review and this study presented faculty experiences of language barriers and unpreparedness. This chapter engages in discussion around the key contributions of the analyzed interviews set within the research literature. It will conclude with the study's limitations and recommendations for education, practice, and research. 5.2 Discussion In this section, I will discuss the primary contributions this study brings to the literature on INS nurse educators. Three key topics were captured in the findings that I will discuss and contextualize within nursing, education, and social science research literature, as well as grey literature related to government and organizational policy. Throughout the discussion, the 98 concept of “internationalization of higher education” will be related to many of the issues under discussion. This concept will be further explained, and the implications of this movement will be threaded throughout the discussion. The discussion chapter will focus on three important insights with the aim to improve nursing education. These issues will be presented under the following headings, unpacking equity issues in teaching INS, faculty preparedness: building strength and capacity to teach INS, and learning to see each other. 5.2.1 Unpacking Equity Issues in Teaching INS Findings from this study indicated that INS nurse educators recognized and questioned the equity issues involved in the recruitment of INS and the lack of provision of physical and social supports for INS well-being. This recognition of inequalities was described in the findings by one participant, that there is “a piece of the puzzle missing” (P1) regarding how INS are integrated into our Canadian systems. This missing piece was the cause of moral uncertainty among nurse educators, making it difficult for many participants to be satisfied in their INS educator roles. There were three prevalent equity issues that participants consistently referred to in their interviews which I have discussed within related literature. These included the equity issues around INS recruitment, nurse migration and integration, and INS well-being. 5.2.1.1 INS Recruitment in Higher Education: Capitalistic vs. Humanistic. In the findings, participants experienced moral uncertainty about the equity issues involved in recruiting INS from lower-income countries into Canadian higher education institutions. Participants in the study remarked on the many advantages that INS brought to Canada but witnessed equity issues that disturbed them and left them questioning Canadian higher education and government recruitment practices and intentions. In the study context, the school and community saw a drastic increase in international students within a less than 10-year timespan. 99 This was largely related to Canada’s International Education Strategy as written about in this study's Background section. Like many other economically advantaged countries, Canada has seen the high economic and labour value of international students, and it has become a competitive market both nationally and globally among academic institutions. In the 2019-2024 International Education Strategy, the Minister of Immigration, Refugees and Citizenship announced there were more than 721,000 international students who studied in Canada in 2018 and wrote how international students are the ‘ideal candidates’ for permanent residency since they are young, possess in-demand labour skills, proficient in one of the official languages, and help build ties for international trade and the global economy (Canada & Global Affairs Canada, 2019). With the statistics showing that International students contributed around 21.6 billion dollars to Canada’s GDP in 2018 alone, one can see how the economic and globalization advantages that international students bring have birthed a competitive market for international students among many colleges and universities in high-income countries. Most higher education institutions have named this concept of recruiting and integrating international students as the internationalization of higher education and have written internationalization directions into their strategic plans and actively pursue increasing international student recruitment and retention and building internationalized campus communities. For the purpose of this discussion, I will be using Knight’s definition of internationalization as “the intentional process of integrating international, intercultural, or global dimension into the purpose, functions and delivery of post-secondary education in order to enhance the quality of education and research for all students and staff, and to make a meaningful contribution to society” (Knight, 2004, p. 11). In this definition, internationalization 100 sounds like a positive concept for faculty, students, and society, but research has shown that it has been fraught with challenges. Knight (2013) now believes that internationalization is losing its way. It has become a catch-all phrase used to describe anything and everything remotely linked to higher education's global, intercultural, or international dimensions. The literature is vast on internationalization in higher education, especially from the UK, USA, Australia, Ireland, and a few other European countries. Many of these countries are about ten years ahead of Canada in “internationalizing” their schools. There are many arguments from scholars that question the ethical and equity issues of internationalization. Khoo (2011) has found that the literature on this internationalization presents two major discourses: market-driven and ethically driven. Market-driven is fostering economic performance and competitiveness, whereas ethically driven is related to the charitable concerns for enhancing the quality of life of disadvantaged students. Through this influx of international students, many educators in higher education institutions have been left struggling with the ethical dilemmas that came with the push to “internationalize” academic institutions. For this study, nurse educators were specifically challenged with the ethics of capitalistic versus humanistic motives of higher education. They wanted clear answers on the institutions’ motives behind INS recruitment, mainly because the program outcomes did not align with the student expectations and the value of education that the students wanted from the program. Nourpanah (2019) called what vocational colleges were doing with designing such nursing programs as a “drive-by” education. After interviewing twenty-nine foreign-born nurses in Canada, this researcher found that foreign-born nurses were entering Canada as international students as an easier way to enter the country, gain work permits, and hopefully secure jobs eligible to apply for permanent residency. In my study, this “drive-by” education caused 101 participants to question the academic institutions’ values of developing a nursing program for increased enrolment of international students and capitalistic motives, rather than educating them to become nurses in Canada or bringing nursing knowledge back to their home countries. In Knight’s (2013) perspective article, it was recommended that internationalization discourse and practice need to be re-oriented to academic and social values. 5.2.1.2 We Are not Seeing Them Become Nurses in Canada. To expand on the equity issues involved in the internationalization of higher education within the context of this study, participants also grappled with INS not becoming nurses upon completion of the program. It makes one question if the programs being developed to ‘internationalize’ the academic institution are genuinely beneficial to the students. In Noupanah’s (2019) research, participants also spoke about how they spent much money on tuition, but their courses did not help them obtain nurse registration. Like Noupanah’s findings, the nurse educators in this study also saw that participants were not achieving their goal of becoming registered Canadian nurses after investing large sums of money for tuition and school fees. The participants also verbalized the frustration of seeing competent nurses de-skilled and working as care aides and practical nurses rather than registered nurses like they were trained to be. This discrepancy in program outcomes made nurse educators question the motivations behind creating a program for international nurses that did not guarantee nurse registration in Canada. The educators in this study desired to provide more educational value to the students. They might have found some moral certainty if they knew students were becoming nurses after all the money invested and hardships they endured. Becoming a nurse in Canada is an expensive and onerous process. Canada has worked to improve upon the streamlining process for internationally educated health professionals, but there is still a disequilibrium between supply 102 and demand and credential recognition by regulatory colleges (Sweetman et al., 2015). While the participants understood the need to ensure safe care to patients through nursing competencies and regulation, they also believed the program could be doing a better job preparing the students for the regulation requirements. In the program under study, the diploma granted upon completion of the program was in a nurse specialty, so it would only be beneficial once the INS became registered nurses. This inability to register as a nurse upon completion of a nurse specialty program points to whether international students are genuinely ‘ideal’ immigrants claimed in the international education strategy (Canada and Global Affairs Canada, 2019). Scott et al. (2015) investigated the relationship between policy makers’ assumption of international students being desirable candidates for permanent residency with international students' actual lived experiences in Canada. The study revealed that international student integration into the Canadian system was not as ‘ideal’ as policymakers assumed, and integration into the Canadian labour market and systems was hindered by language, connectedness to host communities, and perceived employer discrimination. Therefore, Scott et al.’s (2015) study brought forth the same ethical question that the participants in my study faced, “Are international students (or INS in my study) the ‘ideal’ candidates when they are not getting jobs in their fields at the end of their schooling?” In a recent report by the OECD (2019), the statistics show that there are many health care professionals from other countries who are de-skilled once they get to Canada and never regulated in the jobs for which they are trained. The sending country also loses skilled professionals and the public investment in training these individuals. This phenomenon has been coined “brain waste” and reflects the mismatches between health and immigration policies. This report found that workforce growth was the worst in the number of practicing registered nurses 103 than physicians, practical nurses, and other healthcare workers. This study highlighted the contribution that foreign-trained health workers have made to the growth in the number of physicians and nurses (particularly practical nurses) over the last decade. However, it also pointed to ongoing issues regarding the high and increasing percentage of qualified foreign-trained health professionals who are not working in their field of training, particularly for those trained as registered nurses. This leads to the much-debated concepts of “brain drain” and “brain gain”, where high-income countries gain skilled professionals while draining professionals from low and middle-income countries. It is particularly ironic when many of these professionals are likely to be de-skilled once they arrive in Canada. These concepts, paired with the questionable ethics of the internationalization of Canadian higher education institutions, have left nurse educators of INS with complex and confusing equity issues, causing moral uncertainty among my study participants. From my interpretation of the participant interviews, they seemed to want to know if the program was taking skilled professionals from lower-income countries and if this program was developed merely as a lucrative and strategic maneuver to increase the number of international students and income for the college. 5.2.1.3 INS Learning and Personal Needs: Who’s Responsible? In my study, participants shared their experiences of being exposed to the INS's many basic learning and psychosocial needs. They felt a moral responsibility to help the students and questioned why their needs, particularly their psychosocial needs, were not being met through institutional and government services. They believed that the academic institution and government should be ensuring security for the INS. While some administration departments may view that the college is doing a great job providing for international students, the first-line faculty may not see it that 104 way. In my study, nurse educators who were working directly with students heard the student stories about housing, health, transportation, school, and job insecurity and were troubled by the numerous personal and learning needs that the INS were experiencing. As mentioned previously in the debate on INS recruitment being capitalistic or humanistic, administration departments may be looking at the number of students to meet budget lines and leaving instructors to navigate the student’s personal issues. In a large study conducted at a University in Australia, with over 15,000 international students, it was found that international students' security is at great risk (Forbes-Mewett & Nyland, 2008). In this study, international student security is a term used to encompasses physical, social, and economic dimensions that relate to human rights, cultural difference, and relocation. The researchers of this study believed that both the government and the university were responsible for ensuring international students' security. The study's findings found that frontline University staff and faculty were the ones taking responsibility for the security needs of this vulnerable student population because the government and institutional processes had failed to provide this assistance. Regarding who is responsible for meeting learning needs for both international students and faculty, another mixed-methods study evaluated the perceptions of faculty in health care and social sciences and found only 30% of faculty members perceived that it was primarily their responsibility to support the learning needs of international students. At the same time, the majority felt the primary responsibility should be with the host institution. Furthermore, 75% of the participants disagreed that the school supported internationalization in training faculty and staff teaching international students (Mantzourani et al., 2015). In a study in the UK, researchers found an expectation from many cultures that the teacher would attend to the spiritual, moral, and intellectual development of the international 105 students. However, the program directors, immersed in western education traditions, believed that it was the institution's responsibility to promote the development of independent or autonomous learning (Robson & Turner, 2007). This may indicate why the participants in this study had difficulty deciding where the boundary is in assisting students. Perhaps culturally, students expected the teachers to assist them with all their needs, and faculty were unfamiliar or uncomfortable with this expectation. At the college under study in this thesis, one of the directions in their internationalization strategic plan was to support international learners in their acculturation and academic success, specifically through providing effective transition services, such as orientations, workshops, and study groups; developing in-person and virtual social supports for learners; providing relevant and appropriate academic support services; developing leadership opportunities for international students and providing program outcomes that lead to successful graduate employment. This plan's values and directions would provide INS with both social and academic supports. However, the ground realities that the educators of this thesis study experienced were quite different. The participants were either unaware of the school supports they could refer students to, or these institutional supports did not exist. Furthermore, participants witnessed INS not always having their basic needs, such as housing and transportation, being met. These essential supports did not seem to be accounted for in the school’s strategic plan. Despite the ambiguity of roles among faculty, institutional, or students as to who is responsible for students' transitional and well-being needs, research has shown that it is often left to the instructor to meet these needs. However, faculty in my study had questioned whether this responsibility should be theirs and if it lies within their professional boundaries. Again, these are equity issues consequential to the much-debated internationalization process. 106 5.2.2 Faculty Preparedness: Building Strength and Capacity to Teach INS This discussion revolves around the issue identified in the findings that educators did not feel prepared to take on the role as a nurse educator of INS. It was voiced repeatedly that participants received little or no preparation before stepping into a highly complex teaching environment. For nurse educators teaching INS, there is a wide range of new knowledge to learn about the learner: immigration processes, nursing registration for international nurses, new teaching philosophies and pedagogical perspectives, and creating safe learning environments for INS. With this vast amount of new knowledge to learn for the nurse educator, faculty preparation has been recommended throughout the literature to prepare nurse educators for success in their teaching (Boyd & Lawly, 2009; Salminen et al., 2012; & Shanta et al., 2012). In this thesis study, some debate whether new nurse educators should be assigned to teach in highly complex teaching and learning environments, such as this post-graduate international nursing program. New instructors also commented in the interviews that demonstrated that they were overburdened with navigating their new role as nurse educators, so adding another complexity to their new role of teaching INS may be overwhelming. This coincides with research findings that clinical nurses have difficulty transitioning to the nurse educator role, especially without formalized orientation processes (Boyd & Lawly, 2009). The National League of Nursing (NLN) in the United States established nurse educator competencies (NLN, 2012) that a nurse educator should be able to: facilitate learning and learner development and socialization; use assessment and evaluation strategies; participate in curriculum design and evaluation of program outcomes; function as a change agent and leader; pursue continuous quality improvement in the nurse educator role, engage in scholarship, and function within the education environment. However, research has found that organized preparation to become nurse 107 educators has been challenging (Allen & Aldebron, 2008; Anderson, 2009). Therefore, to have the teaching skills to meet the nurse educator competencies, new nurse educators, such as those teaching in the study’s program, need an extremely robust orientation and training process with ongoing professional development and mentorship. This thesis study also found that INS educators desired more cultural knowledge of their students before classes commenced and formal knowledge on tools to teach INS. They believed this preparation would help them create a culturally safe space to learn in both the classroom and clinical settings. Similar to findings outlined in this thesis's literature review, nurse educators in this study felt culturally incompetent when teaching INS (Esterhuizen & Kirkpatrick, 2015; Greenberg, 2013). Studies have shown that after implementing cultural education to nurse educators and health care professionals through computerized learning modules or workshops, post-self-assessments resulted in increased cultural competence scores (Greenburg, 2013; Wilson et al., 2010). This helps demonstrate that a formal program for INS educators would benefit from ensuring a safe learning environment and may also increase faculty feelings of preparedness. Recently, academic institutions have been striving to build Equity, Diversity, and Inclusion (EDI) practices. Experts in this field believe that to thrive or even survive in our increasingly diverse and globalized context; higher education institutions will need to create an environment of belongingness for faculty, staff, and students (Glass et al., 2015; Museus, Yi, & Saelua, 2017; Strayhorn, 2012). Many higher education institutions have adopted professional development education on cultural competence and diversity through online learning for their faculty and staff (Hode, Behm-Morawitz, & Hays, 2018). As stated previously, in studies evaluating cultural competence education among nurse faculty and allied health professionals, post-assessments showed increased knowledge. However, these studies did not look at faculty's 108 transformative practices that this education influences. For example, does the faculty taking professional development on cultural competence change their perspectives and teaching methods, or is it knowledge gained but not utilized? With time constraints on educators, professional development has moved to increased online teaching formats. Hitchens and Hode (2019) used Mezirow’s transformative learning theory to gauge how much transformative learning occurs through online learning environments. In an online course, Diversity 101, for university faculty, the researchers found that transformative learning did occur through online dialogue within the course and outside of the course. Specifically, participants were able to have honest discussions on privilege, unconscious bias, and microaggressions. The researchers’ findings also demonstrated how the course's online format gave participants time to reflect upon and integrate the new ways of understanding themselves and others into the social context where they work and live. Another key finding in this study was that faculty and staff reported having a better understanding of unconscious bias, microaggressions, and privilege and a desire to take action to help ensure a more inclusive environment in their professional and personal spheres of influence. It is also important to note that the educators in my study also grappled with the curriculum design, assessments, and teaching strategies and found that what they were doing before while teaching domestic students in the BSN program was not transferrable to the INS. This points to the importance that INS nurse educators need a stronger foundation in adult learning theory and inclusive teaching pedagogy. In a phenomenological study by Heringer (2019), ten professors at a Canadian university were interviewed and found that professors felt overwhelmed with internationalization and their beliefs and experiences posed challenges to the process of internationalization. One concept often used for good pedagogy for international 109 students is to ‘internationalize the curriculum’. According to Leask (2009, p. 209), internationalization of the curriculum aims to incorporate international, intercultural, and global dimensions into the content of the curriculum as well as the learning outcomes, assessment task, teaching methods, and support services of a program”. Providing professional development for nurse educators of INS on education philosophies and pedagogies that are effective in cultivating inclusive and responsive learning environments is needed. Nurse educators of INS could also become liberated from some of the moral uncertainty caused by ‘internationalization’ if they were provided more knowledge and understanding of the internationalization process. Friesen (2012) shows how faculty members are key agents in the internationalization process but do not clearly understand what internationalization means, involves, and proposes. Utilizing de Wit’s (2002) internationalization rationale framework, Friesen (2012) investigated faculty’s motivations in a Canadian University to evaluate faculty engagement in the institutional internationalization process. It was found that there was a range of faculty member engagement related to the alignment of personal motivations with institutional rationale. It was recommended that ensuring internationalization strategies are relevant and meaningful to faculty will promote engagement in the endeavors to internationalize the higher education institution since faculty are seen as the knowledge mobilizers. In relevance to my study, participants also seemed unengaged in the institutional processes of internationalization when they questioned the meaning behind it. Heringer (2020) also showed that professors felt that they could teach international students adequately, but they vehemently expressed that it stemmed from their own experiences and did not feel that the University provided any specific support in teaching international graduate students. 110 One last prevalent finding was the language barriers identified by participants in this thesis study. Participants were challenged with navigating class discussions, assessing writing assignments, miscommunication about student and assignment expectations, and understanding accents (both educator and students had trouble with each other's accents). As stated in the Findings, nurse educators found that the English proficiency admission requirements did not necessarily prepare them for the Canadian education or healthcare system. Fuller (2013) has provided evidence for instructional strategies that educators may use to develop teaching practices so they are better prepared to teach culturally and linguistically diverse (CALD) nursing students. These strategies include supportive strategies, language development strategies, and teaching strategies listed in Table 4. Table 4 Instructional Strategies to Facilitate CALD Nursing Student Learning (Fuller, 2013, p.120) Supportive Strategies • Offer self and provide guidance to system and learning resources. • Facilitate inclusive caring environment in all settings. Language Development Strategies • Arrange opportunities to practice nursing language. • Encourage bilingual dictionary use in classroom, clinical, and during examinations. • Promote student development of vocabulary list/journal/log of unfamiliar terms. Teaching Strategies • Avoid slang and complex language when teaching. • Make connections with visual aids such as concept maps, graphic organizers, and pictures. • Deliver consistent explicit instruction in all venues. • Allow extra time for processing and responding when interacting and evaluating. • Provide feedback during activities and on assignments. 111 Further exploration of evidence-based teaching practices and assessment strategies in the nursing and educational disciplines would help build successful orientation and professional development programs to support educators of INS. 5.2.3 Learning to See One Another Participants in this thesis study consistently remarked how much they learned from the students about their culture, resiliency, and ways of caring for patients. Some studies have emphasized the challenges INS has brought to the education system and educators (Donnelly et al., 2009a; L. Newton et al., 2016; Wilson et al., 2010), while this study also highlighted the benefits that faculty receive when having INS as students. Participants saw that having INS in our educational institutions and health care systems as an opportunity to exchange knowledge in academic, social, and practice contexts. However, this idea of building collaborative knowledge between international students and teachers is not widely adopted. In one study, Heringer (2020) sought to explore professors’ views of international students as active agents of knowledge circulation and production at a Canadian university and found that none of the professors mentioned cooperative knowledge production between students and teachers as an essential part of internationalization. Most professors saw it as a one-way street where students come to Canada to profit from Canadian education and then immigrate to Canada or become more successful in their home country. This way of seeing the transfer of knowledge as a one-way street may stifle a two-way street's potential in generating new knowledge with multi-cultural perspectives. In relation to my study, this co-production of knowledge also has the potential to create nursing knowledge with a multicultural perspective to both Canada’s education and health care system and the student’s home country’s education and health care systems. 112 Learning to see one another as equals is another possible way to build people with global perspectives in a globalized world. In this thesis study, participants frequently reflected on the new knowledge and experiences they learned from the INS. The following studies are an example of how the potential for respectful and reciprocal relationships between educators and INS could help reconceptualize the way knowledge is generated and circulated. Madge, Raghuram, and Noxolo (2015) wrote a paper on reconceptualizing the international student to bridge the literature on international education. The authors believe that this may help recognize international students as agents of knowledge, as Heringer’s (2020) study mentioned. According to these authors, this reconceptualization could also facilitate consideration of the mobility of students in terms of circulations of knowledge, rather than through a migration lens, and a “means to acknowledge the complex spatialities of international education in which students and educators are emotionally and politically networked together through knowledge contributions” (Madge et al., 2015, p. 681). Both Madge et al. (2015) and Heringer (2020) saw this concept as a way to recognize internationalization not merely as a flow of people but also ‘circulations of knowledge’. It is a constant learning system that brings new perspectives for both Canadians and the INS, which seems ideal for promoting transformative nursing education. Suppose higher education systems can attain a reciprocal relationship between INS and faculty. In that case, there is potential to create an inclusive and equitable learning environment that can help build students and faculty to become critical global citizens. The definition of global citizenship used in this thesis is an “awareness, caring, and embracing cultural diversity while promoting social justice and sustainability, coupled with a sense of responsibility to act” (Reysen & Katzarska‐Miller, 2013, p.858). Critical global citizenship can be promoted among teachers and learners by sharing world perspectives, building relationships with other cultures, 113 and exchanging general and health care knowledge and approaches between cultures. For example, Bovill et al. (2016) critically looked at the co-creation of learning and teaching strategies to ensure inclusivity in student and staff partnerships. This inclusive pedagogy attempts to move away from the student as a consumer model and instead promote a collaborative approach to developing meaningful education. The concept of internationalization also has the potential to help with building critical global citizens among nurse educators and INS. 5.3 Summary of Discussion In summary of this discussion, this thesis study and related literature brought forth considerations that could help alleviate some of the moral uncertainty and unpreparedness issues that participants in this study experienced. The internationalization of colleges and universities among many nations has brought considerable challenges to faculty. In this thesis study, faculty experienced moral uncertainty around equity issues on INS recruitment and integration, program goals ill-aligned to student goals, and the lack of services for INS’s psychosocial needs. This discussion presented literature that could support nurse educators in their professional development in teaching INS, create more inclusive learning environments, and improve faculty engagement in improving the internationalization process. 5.4 Limitations Important contributions from this study were made to the nursing, education, and social science disciplines. However, it is essential to name the limitations inherent in this study. There were two main limitations. Firstly, the participants all came from one college, making the study less transferable. This was a unique context in terms of faculty preparedness, institutional vision, and the nature of INS. Therefore, the application of the findings should be used with caution 114 since the study was distinctly specific to one rural Canadian college. Secondly, participants may have experienced a power differential between the interviewer and themselves. The interviewer was the program's coordinator, so participants may have been hesitant to disclose everything they would have without the power difference. Even though the interviewer held no power to jeopardize the participant’s job status, the coordinator could have still been seen as an authority figure. However, given the transparency of the critique obtained in the finding, this may have added to the quality of data, as participants may have seen their participation as a road to meaningful change. Thus, given the specificity of the context in which the study took place and the power difference that the participants could have experienced, care should be taken when interpreting and transferring the results of this study. 5.5 Recommendations This section will provide recommendations for education, policy, and future research supported by the study’s findings and the literature reviewed. However, it is important to consider these recommendations within the limitations described above. Recommendations in this sense are insights that have the potential to inform education and practice, but this should be done cautiously with attention to the study context and the affiliated supporting evidence. I will begin by providing recommendations for nurse educators and administrators on the areas of education that would help build nurse educator preparedness in teaching INS. Next, I will provide recommendations for the policy related to providing improved professional and program development. I will then conclude with recommendations for future research. 5.5.1 Education Three recommendations apply to the education of nurse educators of INS. Firstly, to develop educators that can promote equitable and inclusive academic programs, it is 115 recommended that professional development is provided on inclusive pedagogies and philosophies. This professional development should include the consideration of providing education on how nurse educators of INS can provide cultural safety within their classrooms (Arieli et al., 2012). With increased cultural diversity in nursing classrooms, it would be essential to educate nurse educators on providing inclusive and responsive nursing education. Secondly, both this study and the literature emphasized the importance of building culturally safe practices among faculty and staff. Hode and Hutchins (2019) provided helpful research in understanding the types of interactions that can lead to cultural competence development in an online diversity course for university faculty. This is important in advancing the goal and overcoming the resource challenges of professional development that enhance faculty and staff's capacity to foster diverse and inclusive classrooms and work environments. Educating nurse educators on equity and global issues around nurse migration will also be essential in building practices that are not exploiting IENs. Nurses will also need to build their reflexive practices in examining implicit and non-implicit bias, stereotyping, and microaggressions. Thirdly, as the literature demonstrated, informing and engaging faculty and staff in the internationalization process could lead to transformative practices. Since faculty are seen as the knowledge mobilizers, their engagement in internationalizing the curriculum and campus environment is vital to meet strategic goals to create internationalized and equitable, and inclusive education. 5.5.2 Policy Based on this study's findings, there are three recommendations for policy. The first recommendation is to align the program outcomes to meet nurse regulatory requirements, so INS 116 are provided educational value from the program and adequately prepare them to meet licensing requirements. This recommendation would require a review and possible re-write of the program goals, curriculum, assessment, and course learning outcomes. It would also be advantageous for program administration to build relationships with nursing regulatory bodies to collaborate on strategies to streamline the licensing process and ensure nurse competencies are being met. The second policy recommendation is to seek accreditation for quality assurance. In the findings, instructors desired to know that the program provided value to the students, and there was reciprocity to the amount of money, time, and hardships students were undergoing. One way that the quality of education could be objectively reviewed is by gaining accredited program status. In 2018, the Canadian Association of Schools of Nursing (CASN) began an accreditation process for Internationally Educated Nurse (IEN) programs. Currently, there are only four colleges that have gained IEN program accreditation. Accreditation is recognized worldwide and is a step in the right direction in keeping higher education institutions accountable to their students, parents, and taxpayers. It is an objective way to assess the quality of education that the institution is providing. Many of the participants were also part of an established accredited BSN program held accountable to many organizations, CASN, CNA, provincial regulatory body, and the provincial body of nursing schools. Being accountable creates a strong program due to the processes to make sure students are ready to enter the system as competent nurses. However, more significant system issues must also be addressed to ensure ethical recruiting practices between low-income and high-income countries are well developed. The third policy recommendation is that education institutions provide formal programs to prepare nurse educators of INS appropriately. Nurse educators of INS require competent teaching skills and experience to have the ability to provide teaching excellence to a complex 117 teaching and learning environment. Effland, Ortiz, and Blanco (2020) conducted a literature review to identify factors that facilitate or impede nurse educator’s transition into the educational role and found that orientation programs, mentor support, clarity about role expectation, and ongoing feedback performance during the transition phase are essential for academic institutions to retain excellent nursing faculty. 5.5.3 Research Currently, there is scant empirical research on inclusive pedagogy and inclusive learning environments for INS. I found one research article that addressed inclusive education in practice placements (Harrison & Ip, 2013). However, this applied to practicums in the social work context, where it would be advantageous to extend this research into INS nursing education. While this study’s finding points to the importance of nurse educators creating culturally safe and inclusive environments, further research into the formation and application of these environments for INS warrants attention. This study indicated that INS, who are competently educated as nurses, are deskilled when immigrating to Canada. Therefore, research investigating the processes and relationships between bridging programs and provincial nurse regulatory bodies could aid in the number of IENs and INSs becoming regulated nurses in Canada. This research could also investigate nurse regulation policies and processes limiting competent international nurses in being licensed to work in the Canadian healthcare system. On a larger scale, research should also be conducted to examine the political economy of nurse migration and its relationship to internationalization in higher education systems. This would directly affect the previous recommendation of INSs and IENs being in Canada to integrate as nurses into the healthcare system. 118 Extending this study’s questions to other settings and programs across Canada would help build the knowledge of INS nurse educators' needs. Since this study was conducted at a rural Canadian college, it would be interesting to know if other rural colleges with bridging programs and nurse educators are experiencing the same challenges and benefits. It would also be advantageous to compare urban and rural contexts to examine the differences and similarities. All these research recommendations will help build robust knowledge supporting INS educators and a better understanding of nurse migration and its relationship to internationalization in higher education institutions in Canada. 5.6 Conclusion This study indicates that INS nurse educators at a Canadian college experienced both moral uncertainty and gratitude while teaching nursing students from other countries. They shared deep reflections on the equity issues of INS and feelings of unpreparedness to lead a highly complex teaching environment of INS. 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Your institution’s website or the department head has indicated that you are a nursing instructor of international nursing students. Therefore, I would be grateful for your participation in this study. Please see the attached information sheet provided that further explains the research study and how you may be involved. Kindly, Gail Crockford, RN, BSN, B.Ed, MSN (IP) [Name] College, School of Nursing Office: O-123, 250-365-1389 Cell: 250-719-4356 135 Appendix B: Recruitment Script Seeking Instructors to Participate in a Research Study on International Nursing Students Project Title: Experiences of Nurse Educators of International Nursing Students: An Interpretive Descriptive Study Principal Investigator: Barb Pesut, RN, PhD, Professor, School of Nursing, University of British Columbia Master Student: Gail Crockford, RN, BScN, BEd, School of Nursing, University of British Columbia What is this Study About? The purpose of this research study is to examine the experiences of nurse educators of international nursing students. Understanding these experiences will facilitate in developing better support for nursing educators, improve curriculum, and enhance student learning. What would I have to do? If you volunteer to be part of this study, you will be asked to complete a demographic information form and participate in a 30-60 minute telephone interview. The interview will be about your experiences as a nurse educator of international nursing students, looking at both the challenges and benefits. These interviews may be performed by telephone or via virtual media. With your permission, the interview will be recorded. Who is eligible to participate in this study? If you have been a nurse educator of international nursing students for at least one school semester in the classroom, lab, or clinical then you may participate in this study. Thank you for your valued time and consideration of participating in this study. Please contact me if you have any further questions or concerns: Gail Crockford [Name] College (Office O-123) Work: XXX-XXX-XXXX Cell:XXX-XXX-XXXX 136 Appendix C: Informed Consent Fom Informed Consent Form [Name] College, and those conducting this research study, subscribe to the ethical conduct of research and protection of participants. This research is being conducted under permission of the [Name] College Research Ethics Committee and the University of British Columbia-Okanagan Research Ethics Board. The main concern of the Ethics Committee/Board is the health, safety, and psychological well-being of research participants. This consent form, a copy of which has been given to you, is only part of the process of informed consent. It should tell you what the procedure is about, and what your participation will involve. If you would like more detail about something mentioned here, or information not included here, you should feel free to ask the researchers. Furthermore, should you wish to obtain information about your rights as a participant in research, or about the responsibilities of researchers, or if you have any questions, concerns, or complaints about the manner in which you were treated in this study, please contact Paula Vaananen, Chair of the [Name] College Research Ethics Committee at pvaananen@selkirk.ca or 250-365-1430 or UBC Office of Research Ethics toll free at 1-877-822-8598. Your signature on this form will signify that you understand the study information included on this consent form, which describes:  the procedures of the research,  whether there are possible risks and benefits of this research study,  that you have received an adequate opportunity to consider the information describing the study, and  that you voluntarily agree to participate in the study. If necessary, the study information may be contained in a separate Study Information Document, a copy of which has been provided to you. Study Title: Experiences of Nurse Educators of International Nursing Students: An Interpretive Description Study Principal Investigator: Barbara Pesut, PhD, RN; UBC-O Co-Investigator(s) name(s): Gail Crockford, RN, BSN, BEd; Selkirk College Investigator(s) School: University of British Columbia – Okanagan (MSN student) 137 Purpose and goals of this study: Gail Crockford, Co-Investigator, is completing this study as part of the Master of Science in Nursing program at UBC’s Okanagan campus. The purpose of this research study is to examine the experiences of nurse educators of international nursing students. Understanding these experiences will facilitate in developing better support for nursing educators, improve curriculum, and enhance student learning. What the participants will be required to do: If you volunteer to be part of this study, you will be asked to complete a demographic information form and participate in a 30-60 minute interview. The interview will be about your experiences as a nurse educator of international nursing students, looking at both the challenges and benefits. These interviews will be performed via telephone due to the physical distancing restrictions of Covid-19. With your permission, the interview will be audio recorded. Risk to the participant or third parties: Speaking about your educator experiences may bring back pleasant and frustrating emotions. You will be asked to reflect on these experiences and may feel some emotional discomfort. If you experience discomfort during the interview you may refuse to answer any questions and I can turn off the recording device at any time. A telephone number of a counseling service will be given to you in case you require further support. There is no obligation to participate in this study and you may choose to withdraw at any time. If you choose to withdraw from this study all physical copies of personal and research data will be deleted. In addition, you can call the [College Name] Protocol Officer for [Name] College or the Research Participant Complaint Line in the UBC Office of Research Ethics toll free at 1-877-822-8598 or the UBC Okanagan Research Services Office at 250-807-8832 to talk about the interview. To protect your identity in published work, all identifiers will be removed and replaced with a code. The name of the institution will not be named, but rather identified as a rural college in Canada. However, even with the de-identification of data, a risk remains that you could be identified due to a smaller number of participants. Benefits of the study to the development of (new) knowledge: There are no assured benefits in volunteering for this study. However, your personal experiences may benefit other nurse educators in similar situations and contribute to the knowledge needed to improve educator supports, curriculum development, and student learning. Statement of Confidentiality: All four members of the study team listed on page 1 will have access to study data. During the study period, electronic data files will be stored on a password-protected computer and a password-protected encrypted USB stick. Hard copies of data will be stored in a locked filing cabinet. After the interviews have been transcribed and verified, the audio-recordings will be deleted. After the completion of the study, all documents will be sent to the institution of the Principal investigator where it will be securely stored. The data will be held for 5 years and then will be confidentially disposed of by the Principal investigator. Inclusion of names of participants in reports of the study: Your name or personal information will not be shared in this study. Coded identifiers will be assigned to all participants and will be used when publishing the research findings. 138 Contact of participants at a future time or use of the data in other studies: • The data will be used for the researcher’s thesis project with the possibility of future publications. • There is not any apparent or potential conflict of interest on the part of the researchers, their institution or sponsors. Plan for dissemination of data: The results of this study will be reported in Gail Crockford’s graduate thesis, which will be made publicly available on cIRcle, UBC’s open-access digital repository (www.circle.ubc.ca). The findings may also be published in journal articles or books, and presented in presentations. I understand that I may withdraw at any time without penalty, and that I will be given continuing and meaningful opportunities for deciding whether or not to continue in the study. I also understand that I may register any complaint with the Chair of the Research Ethics Committee, Paula Vaananen: pvaananen@selkirk.ca, 250-365-1430. Having been invited to participate in the research study named above, I certify that I have read the study procedures which are described in this document. I understand the procedures to be used in this study and the personal risks to me in taking part in the study as described above. I understand the risks and contributions of my participation in this study and agree to participate: PARTICIPANT Name (Print) Signature Date WITNESS Name (Print) Signature Date A copy of this consent form will be given to you. Please keep it in your records for future reference. 139 Appendix D: Demographic Questionnaire Demographic Questionnaire Project Title: Experiences of Nurse Educators of International Nursing Students: An Interpretive Description Study Please complete the following questionnaire. These questions are intended to provide background information about you for the research study. All information will be kept confidential. Date:___________________________ ID Number: _____________________________ 1. In what year were you born? _________________ 2. Gender: ______________________ Prefer not to respond 3. How would you describe your ethnic or cultural identity? ___________________________ 4. Have you had specific training or education in cultural safety, cultural awareness, or power/privilege? If so, please describe____________________________________________________________________ _____________________________________________________________________________________ 5. Were you born in Canada?_________________6. How many years have you been a nurse? _____ 6. How many years have you been a nurse educator? _____7. What are your credentials? ___________ 8. How many semesters have you taught international nursing students at [Name] College or other institutions? [Name] College _______ Other higher education institutions_______ 9. How many semesters have you taught Canadian nursing students? ____________ 10. What countries do most of the international nursing students you have taught come from?_______________________________________________________________________ 140 Appendix E: Semi-Structured Interview Guide Semi-Structured Interview Guide Project Title: Experience of Nursing Educators of International Nursing Students: An Interpretive Descriptive Study Date: ________________________ ID Number: _____________________ Interview Questions: Opening Segment Question: 1. To begin, I’d like to thank you for taking this time to answer my questions. I also want to make sure you understand the consent form you signed and emailed to me. Do you understand your ethical rights? Do you understand your rights around confidentiality? Do you have any questions about the consent form before you begin? 2. Could you tell me about your overall experience with educating international nursing students? Middle Segment Questions: 3. Did you receive preparation for this role? • If so, what was that preparation? • How well did you feel it prepared you? 4. Have you experienced any particular challenges? • If so, what have those been? • What institutional supports, if any, were available to you for these challenges? 5. Can you describe a situation that caused you concern? • Why do you think this situation in particular caused you concern? • Do you think this could have been prevented? If so, how? 6. What aspects of the role do you enjoy or find fulfilling, if any? Closing Segment Questions: 7. What wisdom might you have for faculty new to educating international nursing students? 8. What recommendations might you have for preparing instructors in this role? Are there further comments that you would like to make regarding your experience in teaching international nursing students? 141 Appendix F: Field Notes Study Title: EXPERIENCES OF NURSE EDUCATORS OF INTERNATIONAL NURSING STUDENTS: AN INTERPRETIVE DESCRIPTION STUDY Investigator: Date of Interview: Time of Interview: Setting: Participant No., Interview: • overall response to interview • response to each individual question • changes to interview questions Critical reflection: • reflection on the interview as a whole • reflection on your performance as an interviewer • biases • feelings 142 Appendix G: Summary of Cognitive Processing Morse, J. M. (1994a). “Emerging from the data”: The cognitive process of analysis in qualitative inquiry. In J. M. Morse (Ed.), Critical issues in qualitative research methods (pp. 23–43). Thousand Oaks, CA: Sage. 1. Comprehending: Learn everything one can about the setting or the experiences of the study participants. 2. Synthesizing: Merge various instances or events to describe typical or composite patterns withing data, decontextualizing. 3. Theorizing: Develop “best guesses” about explanations. 4. Recontextualization: Articulate what has been synthesized into a form that is applicable to other settings and contexts.
Thesis/Dissertation
eng
Nursing
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Pesut, Barbara
Experiences of nurse educators of international nursing students : an interpretive description study
Text