Abstract
This study investigated outcomes of the provision, by one Australian and two U.K. universities, of bridging programs that allow registered Malaysian nurses to upgrade their diploma qualifications to degree level. The study was informed by current literature on Transnational Higher Education (TNHE) programs. Not sufficiently explored in the literature are nurses’ lived experiences of such programs and how far they apply TNHE theory in clinical practice. Using hermeneutic phenomenology, interviews were conducted with 18 Malaysian nurses who completed these TNHE programs. The data were analyzed using thematic analysis. The findings were that personal and professional development did occur but it cannot be attributed entirely to the quality of the TNHE provision, which all nurses found to be problematic. Intrinsic and extrinsic factors mediated how far nurses applied the taught theory in their clinical practice. Longitudinal research is needed to identify the long-term impacts of TNHE programs on clinical practice.
Keywords
Introduction
Globalization is affecting higher education (HE). Both developed and developing countries are reconsidering how they fit into and relate to the larger world, and this has led to internationalization of HE. To reflect internationalization, some British and Australian universities’ schools of nursing have attempted to capitalize on their positive reputations, the prestige of nurse education, their pioneering professional practice and development, and HE for working adults (lifelong learning). Their aim, according to Ziguras (2008), is to increase their influence, profiles, market expansion, and income-generating contracts through collaborative links with Malaysia.
Some of these initiatives are to deliver Transnational Higher Education (TNHE) post-registration top-up nursing degree programs. TNHE in relation to this study is defined as the provision of education for learners located in a country different from the one where the awarding institution is based (United Nations Educational, Scientific, and Cultural Organization [UNESCO] & Council of Europe, 2000). Post-registration top-up nursing degree programs are bridging programs that do not change nurses’ registration to practice as a nurse but allow registered nurses to upgrade their diploma qualifications to a degree level without affecting their registration to practice as a nurse.
There is an international trend in nurse education to upgrade from diploma to degree level to foster a more highly educated nursing workforce (Allen & Ogilvie, 2004). In Malaysia, there is a lack of domestic part-time programs to achieve this. Western universities have seized the opportunity to fill this gap; Western degrees are considered prestigious in Malaysia. In addition, there are cost benefits to the Malaysian government of sending reduced numbers of nurses abroad to upgrade their qualifications. Ismail (2006) identifies the Malaysian government’s intention to develop nurses’ familiarity with Western expertise and innovation. These are seen as benchmarks of international standards in the provision of patient care.
With the emphasis on internationalization, the provision of TNHE programs in Malaysia continues to grow and more trained nurses are pursuing these TNHE degrees. Hence, it is essential to identify the impact of TNHE nursing theory on Malaysian clinical practice. To address this, four inter-related subthemes—personal development, professional transformation of nurses, acceptance of nurse-led changes, and implementation—were formulated.
Purpose
The theory–practice relationship in nursing is important to enable nurses to use their knowledge and understanding to assess, plan, implement, and evaluate directly or indirectly the provision of patient care. Overall, the outcomes of post-registration top-up nursing degree programs to nurses, employers, and patients in U.K. and Australian clinical practice remain unclear. Available research shows no profession-wide improvement link (Hardwick & Jordan, 2002; Gijbels, O’Connell, Dalton-O’Connor, & O’Donovan, 2010; Griscti & Jacono, 2006; Leonard, Pelletier & Morley, 2003).
As TNHE programs are a new phenomenon in Malaysia, there is limited literature available on the theory–practice relationship. In identifying this gap in the literature and recognizing the significance for nursing led to the research on Malaysian nurses perspectives of Transnational Higher Education. This paper on the impact of U.K. and Australian TNHE nursing theory on Malaysian clinical practice has been developed from the completed education doctoral thesis (Arunasalam, 2013).
Contextual Framework
Studies undertaken with regard to TNHE provision have sought to investigate and address the four aspects that Knight (2004) asserts need to be considered, namely, language, culture, geography, and history. In relation to these four areas, research in literature has focused on different types of delivery, auditing courses, partnership reviews, internationalizing the curriculum, educational preparation of academic staff, and the learning preferences of students (Brown & Holloway, 2008; Dunn & Wallace, 2008; Knight, 2004; Leask, 2005; Mc Burnie & Ziguras, 2007; McNicoll, Clohessy, & Luff, 2006; Naidoo, 2007).
In Malaysia, there are two types of part-time TNHE post-registration nursing degree collaborative programs: (a) private hospitals that promote them as part of their in-service training either as complete degree programs or as four stand-alone modules (Malaysian Nursing Board, 2008; Ministry of Higher Education, 2003). As in-service programs, Malaysian Quality Agency (MQA) approval is not required; (b) TNHE universities collaborate with Malaysian public universities to market the degree programs, which are MQA-accredited (MQA, 2009).
All these programs enable registered nurses to upgrade their diploma qualifications to degree level. They are from Western countries, part-time over 2 years, and delivered by “flying faculty” academics. In each semester, nursing theory is taught through two 15-credit modules (each taught over 1 week) or one 30-credit module (taught over 2 weeks), either face-to-face or by distance learning. The content is 100% theory and lacks a practice component. There is therefore no automatic right of registration to practice in the United Kingdom or Australia.
Pre-registration nurse training and education programs in the United Kingdom, Australia, and Malaysia have similarities in practices and outcomes. However, there are also notable dissimilarities between these countries. All three countries emphasize the equal importance of theoretical knowledge and practical knowledge and learning in practice settings. In the United Kingdom, there is no national examination for pre-registration courses, but student nurses must pass both the theoretical and practice learning outcomes set by their individual Higher Education Institutions to register with the Nursing and Midwifery Council (NMC; 2004). Similarly, in Australia where the diploma pre-registration nurse education program has been replaced by degree programs, there is no national licensing examination. Registration is via the Australian Health Professionals Regulation Agency (AHPRA), which oversees the national Australian Nursing and Midwifery Board and other health care professions. Student nurses in Malaysia are required to take the national Lembaga Jururawat Malaysia or Malaysian Nursing Board’s (MNB) 100 multiple choice questions examination, which is assessed at diploma level on completion of their program.
Nursing professional bodies worldwide require continuous professional development (CPD) to maintain credentials, standards, and competencies and to avoid obsolete practices in the delivery of patient care. Professional development requirements for nurses in the United Kingdom, Australia, and Malaysia vary according to environmentally determined social and cultural differences. In the United Kingdom, Australia, and Malaysia, nurses with diplomas are not expected to meet the new degree standard but are given the option to upgrade their qualifications as part of their professional development. Upgrading their diploma to degree level in the United Kingdom and Australia offers no financial incentive, automatic salary increase, or increased chances of promotion. However, in Malaysia, the Ministry of Health (MoH) offers a monthly graduate allowance of RM$400 as an incentive to upgrade, and there are increased chances of promotion.
In nursing, a practice-based profession, theory is taught or acquired within academic settings to enable understanding of what is, or should be, practiced and why (von Glaserfeld, 1989). Practical or process knowledge is learnt within clinical settings (T. P. Phillips, Schostak & Tyler, 2000). Theoretical knowledge gained on nurse education programs is intended to develop from, and underpin, clinical practice. Only then will the individual nurse be able to internalize and contextualize the theory taught within the national and/or cultural context (Chiu, 2006; Leininger, 1978). Results from previous studies on the impact of post-registration nursing degree programs in the United Kingdom and Australia in clinical practice remain unclear. There is no research that shows a profession-wide improvement (Gijbels et al., 2010; Glass, 1998; Griscti & Jacono, 2006; Hardwick & Jordan, 2002; Leonard, Pelletier & Morley, 2003). In contrast, three studies undertaken in Malaysia appear to offer clearer results (Birks, 2005; Chiu, 2005; Chong, Sellick, Francis, & Abdullah, 2011). They indicate application of theory in practice that resulted in improved patient care delivery.
Research on overseas or offshore students is extensive. However, the strand researched, that is, the extent to which TNHE post-registration nursing degree theoretical knowledge has been applied in clinical practice, appeared to be “hidden from public view” (Seale, 2004, p. 72). As these programs continue to grow in Malaysia due to the promotion of education provision required for the needs of health care practitioners (Wilkie & Burns, 2003), it was pertinent to explore their overall impact in clinical practice.
Research Framework
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.
Different TNHE Post-Registration Nursing Degree Programs in This Study.
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.
Findings
Impacts of the U.K. and Australian TNHE nursing theory in Malaysian clinical practice are addressed under the following areas: personal change, professional transformation in nurses, implementation of theoretical knowledge in clinical practice, and acceptance of nurse-led changes. In relation to all four areas, all of the nurses viewed themselves differently on completion of the program of study, and most appeared to have acquired increased agency in their clinical settings. In this sense, data under one area overlapped into another area. This was because sometimes, changes in one area seemed to be mediating changes in others. At the same time, the positive changes raised questions. They were at odds with the negative evaluations by nurse interviewees of some aspects of the TNHE programs. Thus, the positive changes cannot be entirely attributed to exposure to the TNHE programs but rather to what this represented in nurses’ minds in terms of enhanced status and confidence (see “Discussion” section).
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.
Discussion
Overall, the difficulties between the Western academics and the Malaysian nurses—the nurses’ lack of subject knowledge, poor response from academics, and lack of understanding of their accent, language, and questions—led to a belief among the nurses that there was a failure on the part of the academics to support their learning needs. Chiu (2005) and Birks (2006) indicate that participants have to bridge from their existing learning mode to a new educational paradigm when studying with international universities. Without this, Knight (2008) argues that the lack of a common vocabulary leads to challenges including when attempting to evaluate the effectiveness of TNHE programs. On the very short courses investigated, it appears that TNHE academics were unable to adapt in time (without adequate preparation) to the assumptions, expectations, outlook in classroom, and professional ways of working in practice that they met when they began teaching.
Alongside the above findings, there were contradictory views with regard to the implementation of changes in nurses’ clinical practice. The general consensus among the 18 nurses was that the culturally constructed status and role of nursing, hierarchy, financial resources, and time implications in Malaysia failed to offer the opportunity or support for applying TNHE theoretical knowledge in their clinical settings. Despite the lack of a practice component, it appeared TNHE academics assumed the nurses would easily translate and demonstrate the practical application of Western theory and professional values into local clinical settings. It seemed insufficient consideration had been given to the personal, professional, and cultural shifts that nurses would have to make to ensure provision of care was consistent with the culturally different contexts in which that care had to be delivered. Post course, participants believed that when facilitating change with the new perspectives, if a practice component were part of TNHE programs, then the flying faculty academics’ guidance and support would be on hand and could be called on during their clinical experience. This would have enabled them to access different strategies to overcome challenges they may have faced. However, it must be highlighted that the issue of the theory–practice gap in nursing is prevalent worldwide and is not solely related to TNHE programs in Malaysia (Hardwick & Jordan, 2002).
Certain nurses used their acquired knowledge and their agency in practice, but there were no clear indications about what enabled them to internalize what they had learnt, nor were there particular indications of their ability or motivation to implement some of their learning in practice settings. Neither was there any clear indication about how far a positive impact of the TNHE knowledge in practice settings would require nurses to make adaptations over the long term and not just in the short term.
In a theoretical study, Volet and Jones (2012) addressed the issue of the transferability of study approaches from one learning context to another. It concluded that some aspects of student learning can transfer well across cultures, whereas others reflect ambivalent, difficult, or inappropriate transfer. This is confirmed by this study, as certain nurses borrowed Anglo-centrically from their association with TNHE programs. The changes in attitudes, perceptions, and decision-making skills evident from their acquired knowledge increased some nurses’ status and power in their practice settings, and were acknowledged including among doctors. This is worth noting because interviewees did outline a conflict between Western and Malaysian pedagogic and professional values and clinical practices. Associate Professor Dr. Hamidah Hassan, Chairman of the Nursing Education Task Force of the Ministry of Higher Education Malaysia (2010), confirms that in clinical settings in Malaysia, nurses remain submissive to doctors’ orders. Previously, this has been confirmed by studies by Chiu (2005) and Birks (2006).
The dichotomy between the program as a theory-based top-up degree and the ability of participants to link the TNHE theoretical knowledge to their everyday clinical practice was evident in the limited experiences they described. There were few examples of how it had directly influenced care. This led to difficulty in ascertaining the extent to which TNHE theory was applied in clinical settings. These findings support Hardwick and Jordan’s (2002) study that showed self and professional perspective transformation, but changes in practice and patient outcomes were inconclusive. This highlights the complexity of assessing these empirically and demonstrates the multi-faceted nature of the issues surrounding the relationship. The interview data presented in this article reflect the voices of the TNHE nurses who have now become part of a new community of practice within the Malaysian post-registration top-up nursing degree program, health care system, and society.
In general, it seems that there was no recognition that the nurses were studying in their own country, within their national context, and a major challenge lay in breaking with tradition to try to change beliefs and old habits that were likely to be resistant to change. After the short TNHE teaching period, the nurses would return to the social environment where other professionals, patients, and communities would still hold those strong cultural values. The nurses also had a responsibility to provide appropriate care for these multicultural, multiracial, and multilingual patients in a culturally sensitive manner. It is emphasized that relevant care for patient needs can only occur when cultural care values are known and serve as the foundation for meaningful care (Leininger, 1978).
Dawson and Conti-Bekkers (2002) and Heffernanan, Morrison, Basu, and Sweeney (2010) argue TNHE programs are intentionally chosen in Malaysia based on the assumption that Western education and nursing tenets are superior. Adaptations may conflict with the MNB’s, employers’, and nurses’ expectations while also compromising academic standards. Hence, only superficial changes are made by TNHE providers to internationalize the curricula suitably for Asian countries’ social, cultural, and educational values (Leask, 2005; Tikly, 2004; Wang, 2000).
Participants in this study thought it inappropriate that they were taught and assessed in exactly the same way as Western students. The reasons given were the short time frame, lack of subject knowledge, and differences in classroom culture, education, and health care systems. These nurses had believed that, as they were in their own country studying for a foreign degree, the curriculum could be changed to make it meaningful to their own clinical contexts, that is, they had hoped to internationalize their existing knowledge and skills but still be able to maintain their national identity and cultural rules to keep them firmly rooted within the Malaysian clinical context.
In this sense, the nurses were aligning with Birks, Chapman, and Francis’s (2009) assertion that attempting to achieve “uniformity of practices” with uncritical imitation and adoption is neither practical nor desirable. This view is further highlighted by Abdullah (2010) that Malaysians who adopted and practiced Western values instead of integrating Western ways of knowing within Malaysian values were considered culturally ruthless, over-trained, and brainwashed.
This highlights the pertinence of developing cross-cultural effectiveness. Van Damme (2014) as keynote speaker at the seminar “Economics and Ethics in International Higher Education” also identified its importance. They stressed it cannot be overlooked in the pursuit of income generation and international positioning by higher education institutions (HEIs) as it is necessary for success in both of these. Although Hunter, Leask, and Rumbley (2014) agree with this, they point out that HEIs face challenges to meet targets, improve teaching, and ensure quality within the short time frames and limited resources provided. Nevertheless, they too note how vital it is to reflect and develop strategies to overcome challenges within TNHE education.
Conclusion
Given that many TNHE universities are building their future around the student experience, it is pertinent to consider the views of the Malaysian nurses. They contribute to an enhanced understanding of the pedagogical challenges that accompany the delivery of TNHE programs. The study indicates the need for educational preparation of academics providing TNHE programs. For example, in the case of the current study, they highlight the need to focus on teaching theoretical knowledge that is relevant to nurses’ clinical practice. Overall, the data are relevant to a broader range of stakeholders engaged in international collaboration and higher education.
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.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
