The experience of international nursing students studying for a PhD in the U.K: A qualitative study

Currently, UK nursing doctorates consist of two main programme routes - the professional doctorate and the 'traditional' PhD. The former is offered in many universities and, although there are some local variations, it usually includes an initial structured programme of cohort-based taught courses followed by a period of autonomous research leading to a dissertation. The professional doctorate is aimed primarily at practitioners who wish to apply a more evidence based approach to their work. Hence, it is orientated towards applied clinically relevant research and its taught elements usually include research training, clinical leadership and practice development. The practice-based doctorate that is gaining popularity in the USA as the entry level for advanced nursing practice is not yet offered in the UK, but one such programme has recently started in Ireland [11].

Students undertaking a PhD are usually also required to undertake formal research training in the form of taught courses, however, the training programme can be more flexible as the PhD has traditionally been envisaged as a more individualised programme of self-directed study relating to the planning and completion of a piece of original research. The majority of UK doctoral programmes also include substantial provision of transferable skills training to enhance graduate employability [12, 13]. These are primarily delivered through inter-disciplinary 'Graduate Schools' and cover the following areas: research skills and techniques, research environment, research management, personal effectiveness, communication skills, team-working and networking skills, and career management [14].

In the UK, both the PhD and the professional doctorate take approximately 3-4 years full-time or 6-8 years part-time. In most UK universities, students are supervised by a team of 2 supervisors who meet with their student to discuss progress at least once a month.

According to the UK Higher Education Statistics Agency (HESA), in 2007/08, approximately 15% of UK doctoral nursing students were international (124 EU/non-EU students, 692 UK resident students) [15]. The majority of UK-resident doctoral nursing candidates are on part-time programmes however, so international students constitute the majority of full time doctoral students in many nursing departments [15].

A recent literature review carried out by the authors synthesised a wide body of evidence relating to overseas doctoral students [6]. The review highlighted the transitional nature of the international doctoral student experience, suggesting that students face a range of cultural, pedagogic, linguistic and social adjustments [16, 17].

A particular issue that many studies identified was the challenge of adapting to student-centred, self-directed learning practices common to western countries (as opposed to more didactic approaches that are often found in other parts of the world) [18, 19]. The review also points out that the nature of the student experience is strongly influenced by their disciplinary affiliations and traditions and that this is turn is related to the kind of supervisory relationships that can develop [20, 21]. In faculties of science for example, doctorates tend to be undertaken as part of a team of researchers whereby students have opportunities to gain support from peers and supervisors on a regular basis [22]. In social science doctorates however, the study context may be much more isolated making the process of adjustment more difficult [23]. Very little is known about how the particular disciplinary context of nursing affects the international doctoral student learning experience.

To our knowledge there have only been 3 nursing-related studies published on the international doctoral student experience One (published in 1995) was a retrospective phenomenological interview study conducted amongst 23 Taiwanese nursing graduates of US educational programmes, 4 of whom had completed doctorates [24]. Although they were now proud of their academic success, the respondents described their study abroad period as one of enormous stress, hard work and loneliness, characterized by little interaction with US nursing students. Another study (published in 2007) from one institution in the UK presented data based on a survey completed by 5 international doctoral students and 11 research supervisors [25]. Both staff and students saw great value in international education. However both groups identified the need for greater support to facilitate adjustment in a number of areas, including: understanding the PhD process, studying in a second language, working within a different academic culture, managing the supervision relationship, and finding a sense of community. Recommendations included staff training and the development of additional in-puts to support students. A larger scale study published in 2002 in the USA reported on a national survey exploring the international student experience completed by 24 different Schools of Nursing [26]. Challenges for students identified by the faculty included language and communication, development of critical thinking skills, inadequate financial support, loneliness and isolation. The faculty reported enjoying working with this student group but felt unable to give sufficient time to meet their needs, suggesting that more help from the wider university systems was required. This survey was followed up with one focus group with 5 international doctoral students at one US university. The students identified a range of similar challenges: lack of familiarity with US health care system; lack of familiarity with US teaching practices; lack of opportunity to participate in faculty research; communication problems and stress from trying to cope with a heavy workload. Although rather small scale, all three studies indicate that studying overseas can be stressful, although more in-depth data on the nature of specific challenges or ways in which students might be supported through these was rather limited. These studies are now rather out of date. Doctoral programmes and infrastructure are changing rapidly, particularly in response to enhanced global student mobility. More in-depth and contemporary research is required to build up a picture of the current situation.

The study aimed to explore the international doctoral student journey; specifically, to investigate the learning experiences of international doctoral nursing students at different points in their PhD journey and to identify best practice in supporting effective learning in this student group.

The study adopted a descriptive qualitative approach. A descriptive approach is considered appropriate when the features of particular phenomenon are not yet well understood. The study employed semi-structured interviews to give primacy to students' own perspectives and to the uniqueness of their individual experience [27, 28]. A cross-sectional design was adopted whereby each participant was interviewed once at a particular point in their doctoral journey. The research adopted a constructivist methodological approach [29], recognising that students' accounts of their learning experiences were socially constructed, reflecting their own unique lives and backgrounds and reinterpreted for a researcher during the interview process.

Data was collected in 2008/09. Information letters were sent to all Schools of Nursing in the UK that were identified as running a doctoral programme (n = 44). The letters requested permission to access their doctoral student groups. Of the initial 44 Schools, only 21 reported having any international doctoral students. Of these, 3 declined to participate and 5 did not respond to repeated follow ups. The Heads/Deans of the remaining 13 Schools were then requested to forward one initial and one follow up research information email to their doctoral students and to put up research recruitment posters in student offices. Seventeen students from 6 different universities across the UK volunteered to be interviewed. It is not clear why students from only 6 universities responded - we did not attempt to ascertain whether all 13 participating Schools had indeed followed through with the requests to advertise the study. The interviews were arranged and conducted by a research assistant at a location of the students' choice and lasted between 1-3 hours. The research assistant was an international doctoral graduate (although not a nurse), whereas the other researchers were UK academic staff who led doctoral programmes. The latter were not directly involved in interviewing since it was felt that students would feel more able to open up freely about their experiences to a researcher who was not a UK academic member of staff. In order to enhance reliability or dependability [30], all the interviews were listened to by the principal investigator and a de-briefing meeting was held after each one to monitor quality, to discuss any issues that arose and to ensure consistency within the interviewing process [31].

Ethical approval for the study was granted by the University of Nottingham Faculty of Medicine and Health Sciences Ethics Committee. All students who agreed to participate signed a consent form and were provided with a book voucher as a token of appreciation after completing the interview.

All the interviews were digitally recorded, transcribed and checked for accuracy. Field notes were taken immediately following each interview to provide context and individual case summaries were developed to facilitate analysis of each individual's doctoral experience.

The interview guide asked students to explain why they had chosen the UK and their particular university and type of doctoral programme. They were then asked to talk freely about their experiences in the UK and with the doctorate so far.

Analysis was an on-going iterative process. Trustworthiness of the study was enhanced by a variety of analytical strategies, as suggested by Lincoln & Guba [30]. To maximise credibility, the data was initially analysed jointly by the research team with the aid of NVIVO. Each researcher read the transcripts a number of times and assigned a code to significant units of the text. There was significant inter-coder agreement, but inevitably, the researchers' different experiences and standpoints influenced the coding process to some extent. We engaged in numerous reflexive exercises to clarify our own positions and preconceptions [32]. Any variations in coding were extensively discussed and the transcripts repeatedly revisited until a jointly agreed coding framework was developed which continued to be revised and refined over time. The codes were then clustered into a range of emerging themes and sub-themes which were then grouped into 3 major categories - see table 1[33, 34]. Careful attention was paid to atypical cases and specific examples of these are noted in the findings [35].

The 17 participants represented approximately 14% of the possible international doctoral nursing student population (n = 124) [15]. Table 2 summarises the broad socio-demographic characteristics of the research participants. Some details have been kept deliberately non-specific (e.g. nationality) in order to protect the anonymity of the participants. The number of students interviewed per university ranged from 1 to 5. The students came from 9 different countries. The majority of students were mid-career, both in terms of age and position. Many students (n = 9) were already working in higher education (e.g. as clinical instructors or junior lecturers) and needed a PhD in order to progress further. The majority of these were involved in pre-registration nurse training (rather than specialist post-registration or MSc level education). Likewise, some participants (n = 7) felt that they had reached the end of their clinical career ladders and that their only way forward was a lateral move into higher education which necessitated a PhD. Three of these were senior nursing administrators in hospitals, one was a palliative care specialist, one was a diabetes specialist and two had backgrounds in critical care nursing. Most participants (n = 15) saw their future careers in higher education. The majority (n = 13) were supported via government scholarships and all of those who were married had been able to bring their families. Six participants were male. Four of these were in the UK with their families. The other two were unmarried. Out of the eleven female participants, six were in the UK with their husbands/children; five were unmarried and had come alone. All of the participants were undertaking traditional 3 year PhD programmes involving the student carrying out a piece of original empirical research, presented in a thesis written in English and examined by viva conducted in English.

For many of the study participants, undertaking a PhD in the UK involved a number of significant transitions requiring a process of adaptation, learning and adjustment.

The first of these was the need for some students to adjust their expectations of the PhD programme structure and content to the reality that they encountered. Many participants had expected a highly structured academic programme with a strong emphasis on course work as well as research (more akin to the professional doctorate). They expressed great surprise that they were expected to develop their own programme of work according to their own learning needs:

Likewise, many students (n = 13) noted that they had expected a greater focus on professional nursing issues within their programme and were surprised at the almost exclusive emphasis on research. Some students had expected to undertake clinically-oriented specialist courses alongside clinical practice, as was their experience from their own countries:

Others were not specifically seeking further specialist courses but had expected the PhD programme to include more input on understanding the UK nursing situation. Only two mentioned having spent time visiting clinical settings during their time in the UK. A number of students commented that this lack of engagement with UK nursing had hindered their ability to reflect critically upon nursing in their own countries or to act as agents of change upon their return:

When asked why they had chosen the PhD rather than the professional doctorate, the majority of participants said that they had never heard of the professional doctorate programme and did not know anything about it. Those that had heard of it thought it required a compulsory clinical practice component (which is not the case in the UK model of the professional doctorate) and therefore excluded themselves on the grounds of not having UK nurse registration. In addition, most participants felt that it would not be recognised in their own countries.

A second transition for students was the need to adapt to the self-directed autonomous nature of learning at doctoral level. Many participants found this extremely difficult, especially in the first year, when they were trying to find a focus and identify their research questions. Some students described how the need to define and take the lead on their own projects had created deep anxiety and a desire for more guidance:

Others however noted that, although deeply challenging, independent learning had been a liberating and exciting endeavour:

A third transition was the need to understand and adjust to the expectation of originality and criticality in doctoral level work. Many students noted that their educational backgrounds had trained them to describe and replicate knowledge rather than to create it. They commented that their doctoral work had initially reflected this descriptive approach and that developing criticality was a long and slow process. Students frequently associated personal development in this area with particular supervisory practices (see below) such giving detailed feedback and discussing specific texts with students. Several students noted that, although challenging, they had come to enjoy 'finding their own voice', noting that their growing ability to articulate their own ideas and to contribute to academic debates was empowering:

A fourth transition that affected 16 of the sample was the need to learn and write in a second language. These students strongly emphasised the enormous challenge of studying in English. For them, social interaction and academic study initially demanded a huge effort which created stress and anxiety because of the extra time and energy that every task required. In addition to learning to study in a different language, students also commented that they needed to adapt to different expectations of academic writing, particularly conventions of how to structure longer pieces of work and how to develop a critical academic argument. For many, this had also been a significant challenge:

Most of the participants felt that English classes provided by their universities were not very helpful in meeting their language needs. These were considered too basic and too generic. Rather, one to one feedback or discipline-specific language training would have been preferred.

For many students, the transitions described above were most pronounced at the beginning of their doctoral programme study (the first year was often mentioned as a particularly difficult time). In spite of the challenges of adjusting to doctoral study, several students described how their sense of academic capability had grown over time:

Given the range of adjustments that needed to be made to UK doctoral study, many students described a strong need for support during their doctoral journey. This need for support was identified in the context of three sets of relationships: through supervisors, through interactions with the department/institution and through relationships with other students and wider social networks.

The supervision relationship revealed itself as by far the most significant element of the students' learning experiences. Expectations of the supervision relationship were strongly influenced by the participants' past educational experiences. For example, many participants described their previous student-teacher relationships as having been rather hierarchical whereby students were expected to demonstrate extreme respect and where students were not encouraged to ask questions or to voice their own opinions. This had an impact on the way in which participants engaged with their UK supervisors with many students describing an initial uncertainty in how to approach the supervisory relationship:

Likewise, many participants noted that in their own countries, supervisors would be expected to actively lead a project by telling students what to do. For these students, the British expectation of student-led project management was a real challenge:

In other cases however, the participants favourably contrasted UK supervisors with their home experience and appreciated the time and attention given as well as the more egalitarian and collegiate ethos:

In discussing supervision experiences, participants were very clear about what constituted good or poor quality supervision practice - as summarised in table 3. Interestingly, although students clearly valued particular supervisory characteristics such as being knowledgeable or accessible, the most highly valued supervisory attribute was the demonstration of a personalised student-centred approach. This was seen as foundational to the development of trust in the supervisor:

The personalised approach was contrasted unfavourably with supervisors who adopted a task-oriented 'professional' approach or with supervisors who were inconsistent in the way they dealt with students. There was a strong sense that students wanted their supervisors to understand them as people as well as to care about their projects:

One EU student had a different point of view, expressing satisfaction with purely project focused 'professional' interactions. This student was already highly skilled in project management however and was a senior figure in his field. Unlike many other international students, he was perhaps less reliant on his supervisors to maintain his confidence and to reduce anxiety.

Several participants who were in years 3-5 noted that the supervisory relationship changed over time commenting that there was a gradual development of greater control of their own progress:

The student experience of finding support from their departments or from social relationships in addition to their supervisors was rather variable. For example, two students felt very isolated because they were the only international students in their departments (and part of a small group of PhD students more generally). Others noted that they had developed good links with other international doctoral students (primarily due to physical proximity when sharing an office) but all commented that it was difficult to get to know UK PhD nursing students. Many commented that UK PhD nursing students are usually part-time and are thus rarely in the department. Others mentioned that they felt shy about approaching UK students and several expressed a feeling that the UK students seemed too busy or not particularly interested in their international peers.

Some Schools organised regular PhD student and/or staff research seminars and students placed great value upon these as useful arenas for relationship building:

The ability of students to develop relationships with other staff in their School was also variable. In some cases students felt that academic staff did not always take the time to get to know them and did not recognise the skills and experience that they brought with them:

Where good relationships developed however, students had sometimes found opportunities to work as research or teaching assistants and felt that they had gained valuable transferable skills, as well as building wider social networks.

A large number of students commented that a whole-School approach to international students was needed, in which all staff, including administrative and cleaning staff displayed a positive approach and where systems were in place to meet student support needs:

Outside the department, some students had been able to develop enjoyable and supportive social links (although these were primarily within their own religious or ethnic communities or with other international students). A number of participants mentioned that social events organised by the university had been an important factor in developing friendships and having an occasional break.

Those students with stronger social networks (particularly those who had come with their families) seemed more positive about their overall PhD experience.

The majority of participants indicated that the PhD felt like a long, emotionally and academically challenging journey - see table 4. The academic transitions and challenges took place in the context of adjustment to leaving home and learning to live in a new country and culture. Thus, many participants described struggling with loneliness, isolation and the cost of living in the UK:

Most participants carried the weight of high expectations from family, colleagues and sponsors on their shoulders which, in some cases, had clearly led to chronic anxiety about whether they would succeed. In some cases, this prevented students from being able to engage in social aspects of life in the UK and prevented them from being able to enjoy their PhD experience:

As noted above, students who had come with their families had wider social networks and some spoke positively of the support they had received from their spouse and children. On the other hand, both male and female married participants commented that their families required precious time, attention and financial resources, noting that it was sometimes very stressful trying to juggle conflicting demands. However, amongst the 7 unmarried participants, the 5 females in particular expressed considerable loneliness. This was especially marked amongst those from the Middle East who were used to living in extended family situations in a context where everyday activities of life were often undertaken collectively and who now found themselves having to manage everything alone:

Almost all the participants were used to being high achievers and, in some cases, had enjoyed social prestige from being in highly respected positions in society (e.g. a lecturer). The interviews showed that, for a significant number of students, this self identity was challenged as they struggled to adjust to UK academic practice but also to the social status of being a student again:

On a more positive note, students at a more advanced stage in their studies talked at length about how much they had developed throughout the course of the PhD. Much of their discussion focused on the personal development that stemmed from adaptation to a new country as well as academic development as a result of their studies. Many noted that their confidence and their ability to manage their life and work independently had grown tremendously. This appeared to be particularly pronounced for the female participants, especially those from the Middle East:

Interestingly, although adjusting to 'independent study' was one of the biggest challenges that students said they faced, many also described tremendous satisfaction at having developed independent research and problem solving skills. Some participants described how their whole outlook had changed as a result of their experiences in the UK, noting a general development in their intellectual maturity:

In sum, for many participants, the PhD was experienced as a stressful but transformative journey.

Overall, the findings suggest that Schools of Nursing need to create an infra-structure and whole-systems approach to 'scaffold' the learning of international students within their doctoral programmes. Such an approach should aim to support the transition to doctoral level study, to create a sense of confidence in their direction of travel, to support the development of productive supervisory relationships and to support engagement with other social and academic/research networks. A range of possible scaffolding inputs is summarised in table 5. A key element of this approach is supervisor training to ensure that supervisors understand the particular needs of this student group and develop effective strategies for providing feedback and guidance.

The most significant limitation of this research is its cross-sectional design which provided only a snap-shot of student views at a particular point in time, and in so doing limited the conceptualization of the PhD as a long term learning process. The fact that the sample included students at different stages of the PhD overcame this limitation to some extent, but a longitudinal design would provide opportunities to gain a more in-depth understanding of how the PhD experience unfolds. It is not clear how representative the sample was. Due to self-selection, it is possible that it included students with particularly strong views.

Respondent checking to enhance trustworthiness (particularly credibility) is a contested concept in qualitative research, and this was not undertaken in a formal manner as many of the participants had graduated and returned home by the time the final study report was completed [54]. Nonetheless, a number of seminars about the research were held with international doctoral students based at one UK University and at one national event on teaching international students. All those present strongly endorsed the analytical framework presented here, commenting that it mirrored their own experiences. In addition, the findings are highly consistent with the existing literature in this area, lending some support to their wider transferability [55].