Impact of U.K. and Australian Transnational Higher Education in Malaysia

Research Design

A hermeneutic phenomenological perspective informed by the work of van Manen (1990) was utilized to explore and grasp an understanding of nurses’ experiences to bring into focus both everyday issues and that which is unseen, unheard, and unknown. It was then informed by the ethnographic principle (Geertz, 1973) of cultural interpretation of the phenomena to facilitate explicitly an emic (insider’s view of their reality) and etic (outsider’s understanding of the phenomena) perspective (Pike, 1967).

Method

A qualitative approach was chosen to allow the researcher to probe participants’ answers to illustrate, clarify, and further develop an insight of nurses’ views. To complement the qualitative nature of the investigation and the small number of interviewees, a one-page demographic quantitative questionnaire was used to provide a snapshot of collective details (n = 18). It was also used to reveal the representativeness of participants’ multi-faceted views and to add value to the interview data.

Sample Group

Six participants were recruited initially from a U.K. university via convenience sampling (Polit & Beck, 2010). When the six participants were interviewed, interest was shown by five nurses in the same clinical setting who had studied at other universities. These nurese were asked to further suggest or introduce others who had been in similar programs. This method of locating information-rich participants is known as snowball sampling (Merriam, 2009). The nurses recruited via snowball sampling were from two additional providers of TNHE post-registration nursing degree programs in Malaysia, that is, a second U.K. provider and one Australian. A total of 18 nurses were recruited, all of whom had completed their TNHE program of study. The sample group for this research was from the universities shown in Table 1.

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Table 1.

Different TNHE Post-Registration Nursing Degree Programs in This Study.

Universities	Number of modules	Type of delivery	Qualification	MQA approval
University A	4	Face to face	Honors degree	No
University B	4	Face to face and distance learning	Degree	No
University C	4 + research project	Face to face and distance learning	Honors degree	Yes

Note. TNHE = Transnational Higher Education; MQA = Malaysian Quality Agency.

Instrument

Semi-structured in-depth interviews were conducted with the 18 Malaysian nurses, six from each university to ensure data saturation. An interview guide that focused on their reasons, expectations, assumptions, experiences, and perspectives was developed. Interviews were undertaken in both Bahasa Malaysia (Malaysian language) and English to facilitate communicative ease for the respondents so that they could more fully define, describe, and evaluate their TNHE experiences.

Analysis

Data analysis of transcripts was done in the language of the interview (Bahasa Malaysia and English) to ensure openness in the research (Twinn, 1998). It was developed from Benner’s (1994) hermeneutic analysis that identified three key steps of (a) isolating paradigm cases, (b) identifying repetitious themes from within and between cases, and, finally, (c) selecting quotes to illustrate themes. The approach was selected to enable a continuous process of in-depth interpretation to explicate meanings that participants articulated or did not articulate in respect of the outcomes of their TNHE experience.

Personal Change

All interviewed nurses acknowledged a personal difference in themselves on completion of the post-registration nursing degree programs. Academic writing and the use of information technology skills for researching, producing their assignments, and online correspondence with academics were identified as benefits by 11 nurses. Most commonly, the nurses felt a sense of achievement, especially because the degree was from a U.K. or Australian university. Twelve nurses described feeling a higher level of pride as their degree had an added title of honors degree. Interviewee 006 said, “When I passed, I felt relieved, happy and proud. My son said, ‘Wah! Mother you also have a degree.’ I said yes, not just degree but UK Honours degree.” The six nurses from the Australian TNHE program still valued their achievement: “ . . . proud I have degree, even if only degree” (Interviewee 016).

Intellectual outcomes noticed were improved knowledge, improved English language proficiency, and keenness to read. There was also increased understanding of how to access and gather information, and improved academic writing skills. Attaining the degree was considered by 15 nurses to be an indicator of their intellectual ability, which boosted their self-confidence: “I changed a lot . . . read more and more, more knowledgeable.” As to effects of their TNHE experience on clinical practice, seven nurses identified changes in their thinking, increased inclination to gather information and to question, more confidence in their communication skills, and a willingness to try new approaches to their daily work.

A sense of personal achievement and recognition from others was evident in all these nurses. Interviewee 011 stated, “everyone respects you more because of degree.” Similarly, Interviewee 006 said, “So I am more confident. Before, I went to work and came back, like a robot.” The other three nurses (of the total 18) felt they had always been self-confident, for example, “No change, I always confident.”

Although nurses reported they had found accessing support and online resources, and learning online, extremely difficult and frustrating on the TNHE programs, the positive outcomes emerged later in clinical settings as evidenced by Interviewee 011’s point:

Interest to find out, certain terms I don’t understand, I will go and search in the internet. Before, I just ignore or not my job or ok if I don’t know that, as long as I can understand what I need to understand.

Critical thinking was reported by three nurses to have become a part of their daily lives, following their exposure to the questioning required for analytical thinking processes in meeting the criteria for their assignments. Interviewee 017 explained, “Even choosing my indoor plants for my new house, I question, gather all the evidences, I looked for the right plants not just simply buy any plants.”

Professional Transformation in Nurses

An immediate outcome nurses noticed following completion of their degree programs was that others—including health professionals, patients, and their relatives—appeared to respect them more. Thus, in clinical practice, other health professionals were apparently listening more carefully to their views. This may be because there is a tendency in Malaysian culture for academic qualification to be synonymous with status: “I was a senior but was not recognised by management. When I finished my degree, only then I recognised” (Interviewee 008). This recognition for Interviewee 007 also draws attention to her previous self-perception in contrast to her newer self-image: “[In the past, I] accept I am a nurse, just a nurse, not a professional.”

Recognition of change with regard to the doctor–nurse relationship was noted: “We are timid, like a mouse, with doctors, I think we should emulate Western outspoken kind of attitude, little bit into our society and health care settings. Sometimes we need to tell off the doctors for the patient’s sake” (Interviewee 004). A changed attitude led toward professional accountability: “Before, I instantly follow doctors’ orders. Now, I ask, reason and give view to doctors” (Interviewee 007).

Questioning, reasoning, and their newly learnt knowledge enabled some nurses to engage with nursing care decisions: “Now, I feel more complete the way I nurse the patient, not just do and go. I take the initiative to spend time with the patient . . . find out their views or their needs” (Interviewee 011).

Similarly, Interviewee 014 noted, “Before when I work, I follow what I learnt at my School of Nursing. That is what I follow, no name, just do. After doing degree, only then I know, name and why doing.” This personal and professional shift was further emphasized by Interviewee 005: “Before I didn’t think, no critical thinking, just do and do only, now I think.” And again by Interviewee 009 who said,

When management collect data, last time questionnaire, we so busy, we just tick, didn’t even go through it! Now we learn, we understood, collect data to improve work, not give extra work, so we take time, read and do properly.

It can be seen so far that personal development was linking directly into enhancement of their professional interpersonal skills:

More sure of myself in problem solving . . . how to give orders, I’m more confident with my communication, diplomatic way. When I handle students and staff, I use sandwich technique, hopefully they learn something, lah. In the past and now the same but the thing is now I polish up my way. (Interviewee 004)

Certain nurses developed the ability and confidence to test out new interests in their daily working life. Several developed positive professional attitudes toward their capabilities: “Initially I don’t like management post, don’t like me be in charge, not on management. After course . . . why not try, give a try. Now I manage unit” (Interviewee 002).

Implementation of Theoretical Knowledge in Clinical Practice

There were inconsistencies in viewpoints, throughout individual interviews, with regard to whether nurses had made changes in practice settings. For example, Interviewee 004 together with Interviewee 015 (they had studied with two different U.K. TNHE universities) sought to use their new theory about evidence-based practice:

We did observational studies, we go all around the wards . . . we analyse, tabulate and present during meeting. And the results were circulated to all the unit managers. Having evidence from your place, we able to speak out and make comparison with WHO standards. They were like, “Wow!” (Interviewee 004)

Elsewhere in the data, Interviewee 015 reported she had made no changes in clinical practice: “nothing really can apply in practice.” Yet, this same interviewee talked about using her learning and confidence in strategic ways:

. . . [The TNHE programme] helped me a lot how I talk to doctors in meetings. When I say it is the National Health Service UK evidences actually said . . . , many of us like to use that to present to doctors, because they don’t ask any more questions! Back to culture and this perception that British are best. Because we colonised, their influence is still there and we look up to them. Their very good reputation still remains. Immediately, doctors say is there anything that we can adopt.

Among other interviewees, acknowledgment of professional responsibility also led to reflection on previous practice:

The importance of incident reporting, e.g., infections or diseases. In the past we keep quiet. (Interviewee 009)

Sometimes we know it is important but we don’t do, like maintain documentation. We have to change our own way. (Interviewee 013)

Clinically related modules prompted Interviewee 007 to consider reducing the risk of pressure sore development:

I said, turn patient every hour or two hours, before every three or four hours. I explain why we do, our care must be quality. I tell them record on form when turn patient.

Throughout the program of study, nurses were primarily focused on attending the classes or undertaking online sessions to complete their assessments for achieving the degree. At a personal level, they did not give any serious consideration to the application of TNHE knowledge in clinical practice. On completion of their degree, though, they became aware that the lack of a clinical practice component and guidance and support from the Western academics caused them concern and posed difficulties in the theory–practice link.

It was evident that most nurses did not accept certain aspects of the status quo they found when they returned to work, and that they did have the confidence to make some changes to the management of patient care after exposure to TNHE programs. Areas to which nurses were directing their attention included the clinical environment, handling and managing of other health professionals, student nurses and patients, and reporting of patient information and documentation. However, the extent to which TNHE theoretical knowledge was now being applied in clinical settings remains unclear and cannot be established, due to differing views and the limited number of examples given. This in turn indicates the difficulty of ascertaining where and how theory and practice were linked. In terms of scale, Interviewee 003 suggested, “Implementation of change, on a smaller scale, yes, but in a big scope, no.”

Acceptance of Nurse-Led Changes

It is necessary to review the status of nursing in Malaysia to discuss the acceptance of nurse-led changes. Bryant (2003) stresses that in Malaysia, nursing is still considered a menial job. Interviewee 007 confirms this as she related her relative’s comment:

. . . do you need degree to clean faeces? You don’t know, I really felt it. People look at nurses as the lowest, they only see we look after others, . . . faeces, vomit, . . . Despite degree, peoples’ perception has not changed, still think dirty job, culture lah. They don’t see nurses help them recover, they think its Doctors.

Nurse Interviewee 001 had a different viewpoint: “Status perception has changed, in the sense of education level, even though performance not good. Most Malaysian nurses already done Masters, PhDs!”

With regard to management, four nurses thought they would accept change if it benefitted patients and staff. Others, like Interviewee 016, stated, deference to authority was demanded: “Management don’t like if we develop . . . culture and politics. You talk no use, they don’t listen.”

Attitudes of other health professionals affected their keenness and motivation:

. . . they saying it should be based on evidence but if culture does not support nurses verbalising and thinking out of box then it is not leading to patient safety. Here, there are nursing managers who have done degrees and yet their degree stays at home. The knowledge stays at home, it doesn’t come to the workplace, they are still the same, as how they were. They happily walking about and not implementing anything. My leaders are different from the leaders from the book. (Interviewee 015)

Most nurses had views similar to Interviewee 015 above, as illustrated by Interviewee 002: “Culture in Malaysia, they don’t see change will give them any benefits, they only see reward. If I do this, what is my reward, they don’t see the higher reward like job satisfaction.”

Bryant (2003) asserted that the medical profession in Malaysia has a more favorable regard for nursing than that shown by the public. However, Interviewee 007 points out, “Doctors look at nurses like stupid, you just follow what I say, like nurses no brain lah.” She further voiced her frustrations as she summed up her reality: “Some doctor don’t want this, don’t want that, don’t want this. Here Sister you do like this, you follow my style. Three Doctors three styles so . . . ”

Nurses found that senior nurses, commonly known in Malaysia as “hard core” (Interviewee 004) with their “rigid mindsets” (Interviewee 001), were more “difficult and stubborn” (Interviewee 012) toward accepting proposed changes. Reasons cited were satisfaction with their senior status, their long service, their confidence with routines, and complacency.

Some junior nurses, too, opposed change, as Interviewee 003 said: “They see as extra work or extra paperwork, e.g., this year another new chart, to them is hell. They don’t see importance of compliance. Their attitude, if I don’t do, so what?”

Interviewee 007, noted above as trying to make changes to patient turning to reduce the risk of pressure sore development, found that staff “ . . . didn’t do, or not doing correctly, or do only when see me.”

With regard to patients, all participants concurred that “ . . . patients, whatever you want to do, they will agree” (Interviewee 009). This is an important point as it indicates that patients trust nurses with their care and have a positive approach to change.

Research findings support Hardwick and Jordan’s (2002) study that showed self and professional perspective transformation, but changes in practice and patient outcomes were inconclusive. Resistance to change in clinical areas remained. The data confirm Wenger’s (1998) belief that failure of expected learning in a given situation still results in learning of a different kind. The journeys described are unique to these Malaysian nurses, but many issues they raised have been reflected in previous studies of post-registration nursing degrees.

Negative Nurse Evaluations of the TNHE Programs

Despite the above findings, there were high levels of dissatisfaction among most of the nurses with the quality of the TNHE provision. Nurses faced challenges in the classroom and had to fast track their learning to complete assessments within the short time period allocated to each module in the program. Seventeen out of the 18 nurses felt that they had not been adequately supported by the Western teaching staff. Interviewee 002 stressed the academics’ Western orientation was evident by their lack of insights into Malaysian ways of support and guidance:

They don’t understand our culture. When break, we go to see them, they tell us sorry we having break and when finish class, they gone. Even when they come and teach other groups we cannot go and disturb. They don’t entertain, they say email. What we don’t understand, when we email often, they don’t like it, . . . we become a nuisance. They tell us to wait for response, then email, but sometimes no response for weeks! We felt abandoned.

Not only did the nurses often not get prompt responses to their emails, but also, they stated, their questions were often misunderstood and so the academics’ responses did not reflect their queries. Another complaint was that they had moved on with their assessment, which meant the nurses constantly had questions unanswered.

Regarding TNHE academics’ assumptions, another nurse suggested,

Their perception is, it is distance learning so we have to take all the effort and do. I can’t be asking another third party to come and teach me, because I am doing it with you and I am paying you. So it is your responsibility. (Interviewee 017)

Participants had wanted to be allowed to go and personally ask the academics questions (Interviewee 018). The typical times when these nurses sought support was during a break and when they finished the lesson (Interviewee 002). They wanted to ask their questions in private and on a one-to-one basis after teaching not to lose face. All of these obstacles to communicative ease influenced nurses’ motivation and ability to transfer and apply the TNHE taught theory into practice. Interestingly, these findings are in line with similar findings of the National Union of Students and U.K. Higher Education Academy (2012). These were that students on TNHE programs found the amount and quality of support provided by Western academics varied. Students stated that information with regard to the type and level of support they could expect from academics should be clearly outlined from the beginning. Again, students preferred and expected to speak to academics outside of teaching sessions and to get responses to emails. At the same time, it should be noted that students in U.K. universities in the United Kingdom are often provided with one-to-one or small group tutorials for completion of their assessments or in preparation for their examinations. These were not provided to the Malaysian nurses on their much shorter and more intense courses.

All the nurses stated that, in Malaysia, TNHE programs with Western academics are considered to be superior in credibility, integrity, and expertise, and are a status symbol compared with programs provided by local universities. However, shortcomings in the TNHE teaching and learning environment and applicability of the taught theory in clinical settings led to participants questioning the validity of these programs. Part of the reason for this was that the 2-week courses were too short for the nurses to adopt new ideas, values, and modes of teaching and learning. It takes time to adjust and adapt. The academics too appeared to the nurses to be unprepared for their encounter with Malaysian (expectations of) ways of teaching and learning.

Limitations

Constraints of time meant the study’s interviews were conducted between mid-August and mid-September, 2010, the only time suitable for me to be present in Malaysia on a continuous basis for 5 weeks without affecting my teaching commitments in the United Kingdom.

Recommendations

The TNHE courses need to be longer; the current 2-week modules are too short for the nurses to adapt in time to U.K. and Australian HE styles of teaching and learning. More time is needed for the hidden values of Western classroom practices to be made explicit. It is suggested that an induction module is needed to provide nurses with a clear outline of the course structure over the 2 years, the requirements, method of teaching delivery, assessment approaches, and an initial essay writing practice to become familiar with new teaching and assessment approaches.

Similarly, it is recommended that the academics teaching on TNHE programs undertake a short period of cultural immersion or engagement with the local community prior to teaching on TNHE programs. This minimal induction period would provide them at least a basic knowledge and understanding of cultural rules, values, and the environment of the host country. Given the accounts of the nurses in this study, it could be helpful in enhancing the effectiveness of the teaching.

The nurses’ perspectives provide insights into refinements that the MNB needs to make to its continuous professional education policy. This should be accompanied by more careful selection on the part of the MNB of the most appropriate TNHE programs for the Malaysian nursing context.

Suggested Further Research

TNHE is currently developing fast in Asian countries, including Malaysia, China, and Singapore; a fact evidenced at the third International Conference of Teaching and Learning (INTI International University and Colleges, 2011) where the interim results of this study were presented (Mc Iver & Arunasalam, 2011). The data suggest possible further research focusing on a longitudinal study looking at the degree of impact of taught knowledge in clinical practice 1 year, 2 years, and 4 years post-TNHE post-registration nursing programs. This would provide valuable information of the long-term impact on nurses and their clinical practice and could usefully inform the Malaysian government and TNHE providers. This suggestion is based on the assumption that all stakeholders and participants wish to move beyond only the award of Western degrees and toward a more effective approach to improving the quality of patient care in Malaysia.

Contribution of This Research

This study addresses the gap in research where the voice of the offshore student “is conspicuously missing from the research literature” (Chapman & Pyvis, 2005, p. 40). The original contribution that my study offers is the unique insights, through nurses’ own voices, into their personal and professional transformation, which led them to succeed (through conflicts, struggles, experiences, adjustment, adaptation, and successes) and become part of a new community of nurses.

My role as a U.K.-based Malaysian nursing academic instigated this study. I attempted to put forward robust emic and etic standpoints, as both reflexive insider and outsider, with respect to interpreting Malaysian nurses’ view, specifically to the extent they have applied TNHE theoretical knowledge in clinical settings. It enabled me to illuminate Western TNHE as delivered in Malaysia, from Malaysian nurses’ perspectives. The findings are not quantifiable, but they enable a new synthesis or a third view to emerge, one that was not previously revealed.

Partnerships and collaboration appear to be ways forward. Addressing the issues that these accounts identify will be beneficial for other Malaysian nurses, TNHE providers, academics, the Malaysian MoH, the MNB, employers who sponsor the programs, and the HE sector.