Introduction

International education became a global phenomenon when countries such as the United Kingdom (UK), United States of America (USA), Canada, and Australia began to offer opportunities for international students to migrate to study abroad.1 The host countries developed various visas and migration programs to attract international students to study overseas and to fill their labor market shortages.2-4 However, it has been reported that many international students face challenges when transitioning from university to the workforce, including failure to secure employment.2 Difficulty to secure employment may be related to several factors reported by international students in the literature, including lack of knowledge about the employer-sponsorship and job application process, poor language and communication skills, lack of employment-related preparation during their studies, lack of local networks, lack of relevant work experience, and the perceived impact of temporary visa status on employability.2,5-7

In an Australian technical report, interviews with Australian employers and recruiters in the engineering, health, and accounting sectors acknowledged that international students are hard workers and had a strong knowledge base.2 However, Australian employers confirm some issues reported by international students, such as lack of language and communication skills, limited work experience, lack of local networks, and temporary visa status,2,5-7 along with additional factors including limited soft skills (eg, teamwork, interpersonal communication, motivation, and problem-solving), lack of assertiveness, and reluctance to ask questions when in doubt.2 In addition to the extensive paperwork and cost involved in sponsoring international students in the United States, employers are reluctant to hire these students due to their lack of transferable skills, such as leadership, ability to adapt and be a good team player, good written and spoken communication skills, and problem-solving skills.8 Limited integration of culture and confidence in language, lack of information about acquiring local work experiences, and visa rules restricting working hours also affected employability.9

Extensive research has been undertaken about the transition of new graduates from the university to the nursing workforce.10-17 Yet, few studies have focused on domestically trained international nursing students and new graduates' experiences of transition. These few studies have highlighted several factors such as lack of English language and communication skills, limited clinical experience, visa restrictions, and lack of understanding about the health care system as potential barriers to transition.18-21 Because there is little research directly related to the transitional preparation and experiences of domestically trained international nursing students and new graduates, this scoping review will focus on identifying studies that examine factors encountered during a nursing program that can directly or indirectly affect the students' experiences of transition to the workforce. These specific factors include, but are not limited to, socialization, communication and language issues, clinical experiences and clinical role expectations, knowledge about the host country's health care system, financial issues related to the visa process and nursing licensure, prejudice surrounding international nursing students, and campus support services.

Adults are reported to experience transition continuously and react to transition depending on the type, perceptions, context in which it happens, and how much it impacts their lives.22 Transition is explained as a process that includes assimilation phases and constant evaluation as each person moves in, through, and out of transition.22 Four major factors have been identified that influence a person's ability to cope with the transition: situation, self, support, and strategies - known as the 4S system of Schlossberg's transition theory.22 Domestically trained international nursing students and new graduates experience transition as they move into the host country, move through education, and move from the university into the workforce. The focus of this scoping review is on their experiences of transition from the university into the workforce. The evidence from the literature will be organized based on the 4S system of Schlossberg's transition theory.22

For this scoping review, a domestically trained international nursing student is defined as an undergraduate student from overseas on a temporary student visa who is studying an undergraduate/baccalaureate nursing program in any international university/college/school (outside their country of origin). A new graduate is defined as a nursing graduate who has completed a three- or four-year undergraduate/baccalaureate nursing program from any international university/college/school (outside their country of origin) on a temporary student visa. In this review, domestic refers to the host country that provides the undergraduate/baccalaureate program.

A scoping review is an appropriate method to identify the existing literature and provide a rigorous and transparent overview of the potentially disparate evidence on this topic.23 A preliminary search in MEDLINE (Ovid) and the JBI Database of Systematic Reviews and Implementation Reports failed to locate any systematic reviews or scoping reviews on the experiences of transition of domestically trained international nursing students and new graduates. To the authors' knowledge, there are no current or in-progress scoping reviews on this topic. This scoping review will examine and map the available evidence on this topic and inform the development of an interview and survey tool to investigate the education-workforce transition preparedness, and experiences of domestically trained international nursing students and new graduates.

Review questions

What evidence is available regarding domestically trained international nursing students' and new graduates' experiences of transition to the nursing workforce?

The review sub-question is: What evidence is available regarding factors encountered by domestically trained international nursing students and new graduates during their nursing program that can directly or indirectly affect their experiences of transition?

Inclusion criteria

Participants

This review will consider studies that include domestically trained international nursing students enrolled in an undergraduate/baccalaureate nursing program (outside their country of origin) and new graduates within their first year of completing an undergraduate/baccalaureate nursing program (outside their country of origin). Participants may be either employed or not employed in the host country's nursing workforce. Studies that include participants from any other nursing programs, such as a diploma in nursing, postgraduate certificate courses, master's or associate degree in nursing, doctorate in nursing, and nurse practitioner courses, will be excluded. Studies that focused on international nurses who qualified in their own country or students and new graduates of other health disciplines will also be excluded.

Concept

The concept of interest is the transition from nursing education to workforce. This refers to the movement of domestically trained international nursing students from the context of study within a university environment to the workforce, including, but not limited to, aged care, acute care, specialized care, primary care, or disability care. Because little is known about the transition experiences of domestically trained international nursing students and new graduates to the workforce, this scoping review will focus on identifying studies that examine factors encountered during their nursing program that can directly or indirectly affect their transition. The factors include, but are not limited to, socialization, communication and language issues, clinical experiences and role expectations, knowledge about the host country's health care system, financial issues related to the visa process and nursing licensure, prejudice against international nursing students, and campus support services. These factors will be grouped into four categories based on the 4S system of Schlossberg's transition theory (Table 1): situation, self, support, and strategies.22

Table 1 Factors that directly or indirectly affect workforce transition based on 4S system of Schlossberg's transition theory

Context

The review will include all studies, irrespective of geographic location, in the context of domestically trained international nursing students and new graduates transitioning from any university/college/school to the nursing workforce in the host country at a graduate level.

Types of studies

This review will consider all research methodologies: qualitative, quantitative, and mixed methods. Additionally, any new literature reviews, scoping reviews, or systematic reviews that meet the inclusion criteria will be considered. Primary studies included in those reviews will be considered for inclusion. If text and opinion papers are published in peer-reviewed journals and meet the review objectives, they will be included. Theses and dissertations will be eligible for inclusion.

Methods

This scoping review will follow JBI methodology and will utilize the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) reporting guideline and checklist.24-26

Search strategy

The review will include both published and unpublished literature. The first step is an initial limited search in Ovid MEDLINE, followed by an analysis of text words contained in the title and abstract of retrieved papers, and index terms used to describe the article. These will be used to develop the full search strategy (see the full search strategy for Ovid MEDLINE in Appendix I). A second search using all identified keywords and terms will be undertaken across other included databases, such as Scopus, Emcare, ERIC, PsycINFO, ProQuest Central, ProQuest Dissertations and Theses Global, JBI Evidence-based Practice Database, and ScienceDirect, as these databases contain the most extensive collections of nursing research. Thirdly, the reference lists of all included studies will be examined for any additional relevant studies. Gray literature will be sought using Google, Google Scholar, Research Outputs Repository, and Trove. Targeted hand-searching (eg, examination of sources that have cited included studies) will also be used to identify additional potentially relevant sources of evidence.

Research available from 2000 to as close as possible to the writing of this review will be considered for inclusion. Based on a preliminary search, the authors expect that most of the studies found will be within this time frame, as overseas higher education attracted international students in the mid-1990s and early 2000s.27 This time frame is also based on a systematic review that explored the experiences of undergraduate nursing students who chose to study at an English-speaking university outside their home country.28 In this systematic review, the researchers searched for studies from January 1990, but there were no relevant studies identified that related to this cohort until early 2000.

Studies that are published in the English language from any geographic context (studies published in English but from non-English-speaking countries) will be eligible for inclusion.

Study selection

Following the search of databases and gray literature, records will be uploaded into EndNote v.X9 (Clarivate Analytics, PA, USA) and duplicates will be removed. The remaining sources will undergo study screening and selection against the predefined inclusion criteria. One reviewer (DJM) will undertake this process with input from other reviewers if required. Using inclusion criteria, sources of evidence that appear to be relevant will be explored further in full-text form. The selection process will be led by one reviewer (DJM) and supported by the second and third reviewers (MP and NC). Additional reviewers (MC and ME) will be consulted if any uncertainty arises. Reasons for excluding any full-text sources will be reported in the scoping review report. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses for scoping reviews (PRISMA-ScR) flow diagram will be used to map the inclusion and exclusion process in the final scoping review.26

Assessment of methodological quality

In scoping reviews, as per PRISMA-ScR, it is not a requirement to include an assessment of the methodological quality of the studies identified through a literature search.26 However, in this proposed scoping review, the authors have decided to include an assessment of the methodological quality. This will provide a structured and thorough way of critically evaluating the characteristics of evidence related to domestically trained international nursing students' and new graduates' transitional experiences to the nursing workforce. Critical appraisals of the methodological quality of all relevant studies will be assessed using JBI's standardized tools pertinent to the study design (eg, the JBI critical appraisal checklist for qualitative research29). The critical appraisal will be presented in the results section of the review with the source's strengths and limitations.

Data extraction

Data extraction and synthesis will focus on identifying and charting data about domestically trained international nursing students and new graduates and their transitional experiences to the nursing workforce. The data extracted will include specific details about the publication: author(s), year, type of source, country of origin, study design, study purpose, participant information and sample size, study findings and conclusions relevant to the review, limitations mentioned by the authors, and reviewers' comments (Appendix II). The relevant key findings from the included studies will be extracted in a separate summary table based on the review's concepts and grouped into four categories: situation, self, support, and strategies (Appendix III). One reviewer (DJM) will carry out the data extraction process independently and will be checked by another reviewer (MP, NC, MC, or ME). Any changes or refinement will be explained in the scoping review report.

Data analysis and presentation

The extracted data will be presented in tabular form accompanied by a narrative summary that aligns with the objective of this scoping review. The extracted results will be organized into four categories based on the review questions: situation, self, support, and strategies. Each article's summary will include the author(s), year of publication, country of origin, study purpose, participant information and sample size, study design, concept of interest, key findings related to the scoping review questions, study outcomes, and limitations identified by the authors. Conclusions will be drawn from the mapped evidence with recommendations for future research in this area.

Acknowledgments

Sarah McQuillen at the University of South Australia Library for her assistance with the development of the search strategy.

Appendix I: Search strategy

MEDLINE (Ovid)

Search conducted on 2020 Apr 24; records retrieved: 384

1. ((international^* or foreign^* or overseas^* or nondomestic^* or non-domestic^* or abroad) adj3 (study^* or student^* or graduate^* or undergrad^* or bachelor^* or baccalaureate^*)).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]

2. nurs^*.mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]

3. 1 and 2

4. Nursing, student/

5. (Nurs^* adj3 (studying or studied or student^* or graduate^* or undergrad^*)).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]

6. 4 or 5

7. (international^* or foreign^* or overseas^* or nondomestic^* or non-domestic^* or abroad).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]

8. 6 and 7

9. 3 or 8

10. Nursing education research/

11. (education^* research and nurs^*).mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]

12. (transition^* or "read^* for practi^*" or "read^* to practi^*" or "practice read^*" or "practise read^*" or "work^* read^*" or "read^* for work^*" or "work force read^*" or "work place read^*" or preparedness or "work^* prepare^*" or "work place prepare^*" or "work force prepare^*" or "employment read^*" or "read^* for employment").mp. [mp=title, abstract, original title, name of substance word, subject heading word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word, unique identifier, synonyms]

13. 10 or 11 or 12

14. 9 and 13

15. limit 14 to (English language and humans and yr="2000 -Current")

Appendix II: Data extraction table

Appendix III: Key findings based on Schlossberg's transition theory

References