From Arabic high school graduate to Western qualified nurse: the challenge of transition (a discussion paper)

Studies in Higher Education ISSN: 0307-5079 (Print) 1470-174X (Online) Journal homepage: https://www.tandfonline.com/loi/cshe20 From Arabic high school graduate to Western qualified nurse: the challenge of transition (a discussion paper) E. Tawash, E. Anand, C. E. Holden, J. Hughes & W. Maddison To cite this article: E. Tawash, E. Anand, C. E. Holden, J. Hughes & W. Maddison (2019): From Arabic high school graduate to Western qualified nurse: the challenge of transition (a discussion paper), Studies in Higher Education, DOI: 10.1080/03075079.2019.1623774 To link to this article: https://doi.org/10.1080/03075079.2019.1623774 Published online: 11 Jun 2019. Submit your article to this journal Article views: 30 View Crossmark data Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=cshe20 STUDIES IN HIGHER EDUCATION https://doi.org/10.1080/03075079.2019.1623774 From Arabic high school graduate to Western qualified nurse: the challenge of transition (a discussion paper) E. Tawasha, E. Anandb, C. E. Holdenc, J. Hughesd and W. Maddisone a School of Nursing & Midwifery, RCSI Bahrain, Muharraq, Kingdom of Bahrain; bStudent Academic Regulatory Affairs, RCSI Bahrain, Muharraq, Kingdom of Bahrain; cLanguage and Culture Unit, RCSI Bahrain, Muharraq, Kingdom of Bahrain; dStudent Academic Regulatory Affairs, RCSI Bahrain, Muharraq, Kingdom of Bahrain; eDepartment of Health and Wellbeing, RCSI Bahrain, Muharraq, Kingdom of Bahrain ABSTRACT KEYWORDS This paper focuses on the challenges of transition experienced by local high school graduates of the Arabic school system in the Kingdom of Bahrain, in the Middle East, as they are shaped into the person of a professional nurse through a Western model of nursing education. It investigates the elements that comprise a Bahraini student’s first-year nursing experience in transnational education, and considers how this experience is navigated by the student. Drawing on best international practice, it concludes with recommendations of how to better support Bahraini nursing students’ first-year experience of transnational education, which may be usefully applied to other international contexts providing transnational nursing education. Transnational education; nursing; Middle East; Bahrain; transition Introduction One of the major challenges confronting health care services worldwide is the dramatic shortage of qualified nurses. An estimated shortfall of 12.9 million healthcare workers globally by 2035 was reported by the World Health Organization (2014). It is essential for health care services to sustain a sufficient nursing workforce in order to maintain quality patient care (Tawash and Cowman 2015). To meet the global demand for nursing education and training, some countries have invited well reputed international universities to provide undergraduate nursing education for local students in their own home countries. This arrangement, referred to as transnational education, is popular in the Muslim countries of the Middle East (OBHE 2005); one of the reasons for this being the cultural restrictions often placed on females for traveling abroad to access higher education and professional training. Transnational education is defined as all types of higher education study programs, or sets of courses of study, or educational services (including those of distance education) in which the learners are located in a country different from the one where the awarding institution is based. (UNESCO 2009) In the context of globalization, transnational education has become an opportunity for the promotion of intercultural competencies (Alam et al. 2013). The establishment of international branch campuses can facilitate an increase in mutual understanding between different cultures, empowering students to develop personally and professionally as global citizens. Transnational education can be appealing to local students and their parents or sponsoring bodies in the Middle East as international CONTACT E. Tawash eahmed@rcsi-mub.com School of Nursing & Midwifery, Royal College of Surgeons in Ireland-Bahrain, Building 2441, Road 2835, Busaiteen 228, Muharraq, Kingdom of Bahrain © 2019 Society for Research into Higher Education 2 E. TAWASH ET AL. educational experience is delivered ‘at home;’ there are less financial burden and lower stress associated with traveling to another country to study away from family and traditional cultural norms (Bennington and Xu 2000). However, there have also been concerns expressed over local students’ experiences of transnational education as local cultures are confronted by a ‘westernization’ of their values, which challenge embedded traditions and heritage (Mok 2009). Education ‘hubs’ providing an increasing number of transnational education programs (Alam et al. 2013), mostly delivered by leading Western universities, have been established in the more affluent Gulf Cooperation countries such as Dubai in the United Arab Emirates, Qatar, Kuwait, Saudi Arabia, Oman and Bahrain. In the Middle East, there is a growing demand for education in health sciences programs (Wilson 2002) in particular as the region faces demographic challenges of a rising young population and the associated pressures on the current level of provision of health care services (Roudi 2001). Wilson (2002) argues that to ensure the quality of educational programs delivered overseas by international branch campuses, certain measures need to be put into place, defined by Hacket and Nowak (1999) as including a credible collaborating partner; appropriately qualified staff; adequate student academic and administrative support; adequate infrastructure; and ensuring that curriculum content is relevant to context. However, despite claims made that international branch campuses, to a large extent, may successfully replicate the situated learning experience of the home campus, there is evidence in the literature that this may not be the case (Altbach 2010). There are also other challenges associated with transnational education, in particular, the transition process required of first-year local students who must adapt to a very new and very different learning environment. Extensive research has taken place over the last 10–15 years across many Western institutes of higher education under the theme of the ‘First-Year Experience,’ with the aim of investigating and developing strategies to ease students’ transition into higher education. This area of research has focused mainly on identifying risk factors which may predict failure, developing approaches to mitigate against such failure and designing early warning predictors and student performance tracking mechanisms (Wilson 2002). Within the field of transnational education, this issue becomes even more complex when taking into account the very different prior educational experiences, culture, language and socio-economic contexts of students (Greenholtz 2000). Background In 2004, The Royal College of Surgeons in Ireland (RCSI) established an international branch campus in the Kingdom of Bahrain: RCSI Bahrain. RCSI Bahrain’s mission is to shape global healthcare leaders through the delivery of quality healthcare education. Unlike the local Arabic public school system which teaches in Arabic and is segregated based on gender, classes in the university are mixed gender, and all teaching, learning and assessment are delivered in English. A large proportion of faculty is Western expatriates who do not speak Arabic. The majority of students in the School of Nursing and Midwifery are Bahraini females who have attended traditional Arabic public schools in Bahrain, speak Arabic as their first language, and most will work in the Bahraini health care context after graduation. RCSI Bahrain is therefore contextualized within the educational history of Bahrain which has the ‘oldest public education system in the Arabian Peninsula’ (Ministry of Education 2016). The literacy rate of Bahrain has been reported at 94.6% (Central Informatics Organisation 2010), which is considered high for the region. Local pedagogical practice typically encourages obedience rather than debate, compliance rather than challenge, and memorization and recall rather than critical analysis (United Nations Report 2007). There is discussion in the literature (Hayes 2017) which suggests that the traditional Bahraini government secondary school curriculum does not sufficiently equip students with the independent learning strategies, critical and reflective thinking, intercultural communications and cross-cultural STUDIES IN HIGHER EDUCATION 3 psychology. These skills are necessary transnational competencies for future healthcare professionals operating in a global arena (Koehn and Swick 2006). Nursing students, therefore, have to be equipped and professionally shaped through their tertiary education to move comfortably between culturally and ethnically diverse societies (Crisp and Chen 2014; Gibbs and McLean 2011). RCSI Bahrain, as a provider of transnational medical and nursing education, is therefore required to address these issues. Nursing in Bahrain Bahrain, like the rest of the world, is facing the challenge of a nursing shortage. At present, there are 4 nurses in Bahrain per 1000 population, compared to a global average of 8.7 nurses per 1000 population (OECD 2010). Many Middle Eastern countries address this issue by recruiting nurses from overseas. Nevertheless, as RCSI Bahrain has now created a local talent pool of internationally qualified Bahraini nurses, there is less dependency on overseas recruitment of nurses – which also opens up local employment opportunities. Context There is little information in the literature relating to students’ experience of transnational nursing education, in particular in the Middle East (Alam et al. 2013). The small body of research currently emerging from RCSI Bahrain regarding first-year nursing and medical experience in transnational education indicates that there are certain ‘gaps’ that require bridging when local students enter into their first-year of tertiary level study. The transition from an Arabic government school to an Irish medical university within the Bahraini context highlights the complexities of the differences involved when local students move from an Arabic, gender segregated government school learning environment, to a very different English language, western learning environment (Lindley, McCall, and Abu-Arab 2013). This process involves the negotiation of social, academic and personal challenges or ‘gaps’ which require addressing early in their academic career (Trotter and Roberts 2006). The basis for this paper is located in prior research, both internally at RCSI Bahrain (Holden 2015; Holden-Rachiotis and Otoom 2015; Maddison 2015; Tawash and Cowman 2015) and externally in the Kingdom of Bahrain (Malcolm 2009; Malcolm 2012). It also takes into account wider international literature on the transition of students into tertiary level learning, with a specific focus on the Middle Eastern transnational context (Cirillo 2015; Koch 2014). The paper addresses the issues of transitional elements that comprise Bahraini students’ first-year experience in a transnational program of nursing education, and suggests how transnational institutions can better support first-year learning in a local context. For the purpose of this paper, ‘transition’ is defined as the educational experiences of students moving from an Arabic curriculum secondary school to a transnational model of nursing and medical education, delivered through the medium of English. Discussion Literature confirms that during a transition from secondary school to university, many students initially encounter differences and difficulties which require them to change or adapt to in order to succeed (Dutton, Broad, and Hunter 2010). However, in a transnational learning environment, there are added complexities. Bahraini nursing students confront challenges which include adjustment to a very differing teaching style and pedagogy from that of the Arabic school system, such as learning in English rather than their native Arabic language; managing the expectation to work independently rather than by rote learning; integrating into larger class sizes of mixed gender; reduced or absent feedback; and minimal tutor/lecturer contact (Brinkworth et al. 2009). Poor adaptation and resulting low performance in the first-year of tertiary education can result in higher levels of failure and ultimately withdrawal from a program of study (Wilson 2002). Key transitional elements 4 E. TAWASH ET AL. comprising Bahraini students’ first-year experience as a transnationally educated nurse were identified at RCSI Bahrain as the impact of learning in English as a second language; adapting to new ways of learning and knowing; cultural adaptation; redefining relationships; and the challenge of moving into new spaces. These elements are outlined below. Learning in English as a second language Challenges in language affect the transition of non-native speakers of English into higher education (Wu and Hammond 2011). Students with lower levels of English language skills generally perform worse academically than those with higher language proficiency (Zhou and Todman 2009). Hayes and Farnill (1993) demonstrated that English language ability is a strong predictor of success, and this finding is supported through previous research undertaken at RCSI Bahrain (Holden 2015). Becoming familiar with new terminology in English is reported to be an added burden for many students in the first few months, but studies have shown that this challenge is navigated whilst students gain new insights and understandings during the transition period of the first year, in particular, the first semester (Marginson 2014). RCSI Bahrain students also cited the pace of delivery and accent of lecturers, the use of colloquialisms and engaging with professional nursing language as being major barriers to their understanding of academic content. The move from a secondary school curriculum delivered through Arabic, to a tertiary level health sciences curriculum delivered and assessed through English presents Bahraini nursing students with considerable challenges. Adjustment to learning in a foreign language is not an inconsequential event. Many students initially utilize a strategy of direct translation to aid their move from learning in their first language to learning in a second language (Holden 2015; Lindley, McCall, and AbuArab 2013). Adapting to new ways of learning and knowing The degree of ‘fit’ between the pedagogical-didactical approach followed in secondary schools, and that used in undergraduate programs also influences first-year achievement (Torenbeek, Jansen, and Hofman 2011). ‘Fit’ and its effect on integration and performance is a highly relevant issue to RCSI Bahrain, where a large number of nursing students enter from rote learning, local Arabic secondary school background. Research by Leksandar-Hayes (2013) considers the scientific knowledge fit between Arabic secondary schools in Bahrain and RCSI Bahrain to be appropriate. However, language transition, understanding the new learning environment, managing expectations and new ways of knowing are also essential components of a successful ‘fit’ (Holden 2015). At an early stage in the transition period of the first year, students begin to develop an awareness of their own changing subjectivity and start to re-contextualize their previous assumptions into their new environment (Maddison 2015; Marginson 2014). During the first semester, in particular, Bahraini nursing students require tools and mechanisms within the specific cultural and gendered transnational learning environment to develop aspects of self-determination and resilience, leading to an empowering and successful transformative learning experience (Maddison 2015). Other studies into first-year learning experiences indicate that self-determination is also an important factor in terms of student success (Beachboard et al. 2011). Self-determination as a theory of motivation posits that in order for students to succeed, certain needs have to be met. These are autonomy, competence and relatedness (Milyavskaya and Koestner 2011). Implications for institutes of transnational education are that such needs have to be understood and met in a local cultural context in order to avoid ‘academic shock’ (Foster 2008). Further development of students’ skills and competencies such as critical reflection and self-awareness (Hanson, Harms, and Plamondon 2011) can also lead to a deeper understanding of motivations, power relationships, ethical issues and impact (BaxterMagolda 1992) in a local context that support students’ personal and academic achievements, and ultimately cascade into their professional practice. STUDIES IN HIGHER EDUCATION 5 The process of cultural adaptation Carroll and Ryan (2005) discuss the challenges of ‘culture shock’ when entering unknown social and cultural environments. Adaptation from the norms and beliefs of an individual’s own culture to that of a new culture can be a long and difficult process. The process of personal change experienced as a result of sustained contact with individuals from a different cultural origin is commonly known as ‘acculturalisation’ (Redfield, Linton, and Herskovits 1936). Bennet (1993) discusses that a fundamental shift is required for an individual to learn and adapt to a new cultural context, whilst Bochner (1986) conceptualizes culture as a process that can be learned. Mismatches in the ‘cultural capital’ (Bourdieu 1991, 230) of the transnational institution and local students can result in feelings of alienation, helplessness and disempowerment (Holden 2015). It is frequently assumed that a student will be culturally assimilated into a transnational institution and little thought is given to this process, rather the institution constructing ‘the home identities and languages as problems that have to be fixed’ (Badenhorst and Kapp 2013, 466). Changing relationships During the transition period, students reassess and redefine three groups of relationships in particular; that of family, faculty and friends (Maddison 2015). Bahraini society is grounded in a collectivist culture; families are close, and students often reported guilt issues when they distance themselves from their families to study. Becoming shaped locally as a global healthcare professional offers up new hybrid potential, comprising aspects of both continuities grounded in Arab Islamic culture yet with a changing sense of self (Enns 2010) as a transnational nursing student. Both Arab and western faculty are reported to be important role models in students’ educational experiences (Dornan et al. 2015; Maddison 2015). Students confided that they were able to build relationships with their lecturers in RCSI Bahrain which would not have been possible if they had been attending a local university (Maddison 2015). They valued being treated as independent, mature and responsible individuals by faculty, a change from being previously directed and dependent learners in Arabic secondary school. Friends are critical in this journey through the first-year transition. Thomas (2012, 48) states that ‘students who found it harder to make friends had a more negative student experience’ and this negative experience can result in academic failure. RCSI Bahrain students echoed this sentiment (Holden 2015) and confirmed that they feel well supported and part of a transnational family. Supported by a wide range of academic, pastoral and social activities, effective social integration can develop cohort identity and an overall sense of institutional belonging. Transnational spaces The tensions of differing cultural contexts are invisible components of a hidden curriculum of transnational nursing education which shape student personal, academic and professional socialization and achievement from the first year of engagement. The first-year Bahraini nursing students established a necessary ‘network of peers’ (Tinto and Goodsell-Love 1993, 18) and formed a very specific community within their new transnational space. The space created by this new community of transitioning students propelled them forward and provide them with opportunities for the development of self-determination (Brooks and Young 2011). Transnational learning space can have a positive and creative influence on those who learn within it and from it; practitioners in transnational education, therefore, have to develop a culturally appropriate, responsive and transformational pedagogy (Kim and Slapac 2015), with epistemological and ontological gaps and challenges identified in context as soon as possible. This will enable students who are struggling with the transition to be guided to firmer ground (Kim and Duff 2012), in particular as Bahraini schooling typically does not teach skills such as 6 E. TAWASH ET AL. critical and reflective thinking, intercultural communications and cross-cultural psychology, which are necessary transnational competencies for future global healthcare professionals (Koehn and Swick 2006). Summary This paper has discussed key elements of transition which require navigation by Bahraini nursing students as they embark on a path of Western transnational nursing education in their home country. This transitional learning journey comprises many gaps which have to be bridged, including pedagogical differences, learning through English, and engaging with new cultural, social and learning contexts. This represents a paradigm shift in the student experience. Recommendations It is important for educators in the transnational education field to acknowledge that letting go of previous mind-sets and taken-for-granted assumptions can be uncomfortable for students, but tapping into their previous educational experience and supporting their situated knowledge through the creation of a robust and culturally appropriate framework can enhance their learning (Gay 2010) and sustain a transformative educational encounter (King 2004). This points to the importance of facilitating students’ skills in critical reflection (Hanson, Harms, and Plamondon 2011; Marlowe et al. 2015; Stutz et al. 2015), during their transition period so that they gain a deeper insight and understanding of their transformative learning experiences as key stakeholders in the transnational education process (Patel and Lynch 2013). The movement from ethnocentric, where one’s own culture is central to reality and is used to measure cultural differences, towards ethnorelative where one’s own culture is recognized as an equal representative of many other valid viewpoints, is an essential component of successful cultural sensitivity (Greenholtz 2000) and is a concept which Bahraini nursing students are frequently exposed to during their journey in transnational healthcare education. It is therefore recommended that institutions providing transnational education embed autonomy, critical thinking, self-awareness and independent learning into the curriculum, as a fit for purpose transnational educational model in a local context. It is also recommended that language support is provided on a tri-part model; as part of the credited curriculum, as additional voluntary support and in the form of the institutional mind-set. It is key that students are provided with frontloaded formal English language tuition which is dovetailed with the core curriculum content to address academic and lexical requirements. This early provision of English language support within the curriculum that clearly relates to core content enables students to identify the language relevancy and directly apply new knowledge. External to the formal curriculum and meeting the needs of the students developing self-awareness is the provision of targeted voluntary sessions to support students with specific skills and sub skills sets. For students who require more individual support one to one language sessions, which are aimed at analysing problem areas and direction towards self-access resources can aid students to develop more independent learning strategies. In addition to the formal curriculum, it is advised that the English language forms the backbone of the hidden curriculum with students being encouraged and motivated to communicate at all levels through English. This core underlying requirement forms an important aspect of the institutional mind-set. The elements identified in this paper create an argument for early, culturally adaptive interventions where RCSI Bahrain nursing students, as well as other students in different contexts who are on their own particular transnational learning journey, are provided with an appropriate range of support mechanisms in order to successfully travel through this multi-faceted and complex transition. STUDIES IN HIGHER EDUCATION 7 Geolocation information The Kingdom of Bahrain is a small island country with a population of just over a million inhabitants in the Arabian Gulf, situated between Qatar and the north eastern coast of Saudi Arabia. Acknowledgements We would like to thank RCSI Bahrain for supporting this work. We also appreciate the contributions made by RCSI staff and students. Disclosure statement No potential conflict of interest was reported by the authors. References Alam, F., Q. Alam, H. Chowdhury, and T. 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