Culturally and linguistically diverse nursing students' experiences of integration into the working environment: A qualitative study

Background Understanding how culturally and linguistically diverse students experience clinical practice and their competence development is important to retaining registered nurses. This study aimed to describe culturally and linguistically diverse students’ experiences of clinical practice, perceptions of their career path, and intentions to stay in the nursing profession. Methods A descriptive qualitative study was conducted. The participants were culturally and linguistically diverse nursing students (n=22) from six Finnish higher education institutions. Nine focus-group interviews, with up to six students per group, were conducted during the spring and summer of 2021. Data were analysed using inductive content analysis. Results The factors which affected culturally and linguistically diverse students’ intentions to stay in nursing profession in Finland consisted of support during university studies and clinical practice, perceived equality, nursing competence development, successful integration into the workplace and social life, and clinical practice experiences. Conclusions The results support the development of a model for culturally and linguistically diverse nurses’ integration into the Finnish health care settings by identifying the key factors for an effective transition to the profession.

Culturally and linguistically diverse nursing students' experiences of integration into the working environment: a qualitative study

Background
Understanding how culturally and linguistically diverse students experience clinical practice and their competence development is important to retaining registered nurses. This study aimed to describe culturally and linguistically diverse students' experiences of clinical practice, perceptions of their career path, and intentions to stay in the nursing profession.

Methods
A descriptive qualitative study was conducted. The participants were culturally and linguistically diverse nursing students (n=22) from six Finnish higher education institutions. Nine focus-group interviews, with up to six students per group, were conducted during the spring and summer of 2021. Data were analysed using inductive content analysis.

Results
The factors which affected culturally and linguistically diverse students' intentions to stay in nursing profession in Finland consisted of support during university studies and clinical practice, perceived equality, nursing competence development, successful integration into the workplace and social life, and clinical practice experiences.
Career, clinical practice, culturally and linguistically diverse nursing student, health care, integration, nurse competence

•
Organisational support is key for integration, especially for improving linguistic skills.
• Peer support is a relevant strategy for integration.
• Equality and equity about career opportunities are important factors in improving integration.
• Linguistic and communication skills are core areas to focus on for improving students' integration, well-being and self-confidence.

INTRODUCTION
There is a global shortage of nurses. Due to the aging nursing population 17 % of the world's nurses are expected to retire within the next 10 years (WHO 2020). It is expected that 10.6 million nurses are needed by 2030 (ICN 2021) because of population growth and the shortage of professionals (WHO 2020). The Finnish health care system lacks 8 000 nurses (Keva 2021). The lack of professionals will become more pronounced in the future. Culturally diverse nurses are required to provide care to the multicultural population (Aalto et al. Ensuring a successful education and integration into the workforce are crucial factors to provide culturally sensible care and an adequate nursing workforce. Moreover, proper support at the educational and organizational levels is key to improving academic success and organizational outcomes, such as retention. This is crucial to support healthcare systems in an international context of healthcare professionals' shortages and intention to leave the profession (Smith-Wacholz et al. 2019;Marafu et al. 2021).

Background
CALD nursing students experience linguistic challenges , Onovo et al. 2019 CALD nursing students experience clinical placements as stressful. They feel different from the other students and that they are perceived as unmotivated. The situation affects their learning . Students who represent an ethnic minority experience discrimination during clinical placements from peers, nursing staff, and patients. Moreover, they feel they are not evaluated objectively (Graham et al. 2016). CALD nursing students would like to be better prepared for clinical placements (Lin et al. 2021). They desire and benefit from more support during clinical learning , Lin et al. 2021. Language skills are challenging for some CALD students, but sufficient language skills are essential for clinical learning 2017 CALD nursing students . Also, intercultural communication is nowadays essential in the health care settings (Abu-Arab & Parry 2015).
CALD nurses may face abuse that draws on the stereotypes associated with their cultural or ethnic background and they are not prepared to deal with inappropriate treatment (Philip et al. 2019). This is why a support network is critical for CALD nurses (Philip et al. 2019). Furthermore, superiors and colleagues largely affect CALD nurse's intention to stay in their current job (Goh & Lopez 2016).
Positive interactions in multicultural teams can improve the integration of CALD nurses into working life (Ham 2020). Contemporary health care organisations need to ensure high levels of cultural competence and individualised support (Philip et al. 2019). The challenges that CALD employees face outside of work should also be acknowledged to make integration easier (Chok et al. 2018).
CALD nursing students' experiences of integration into working environments, perceptions of their possibilities for employment in health care, and thoughts regarding which support they need to evolve their cultural competence and language skills, are a research gap which needs to be addressed to better plan educational interventions and transition policies to maximize academic success and organizational outcomes. There is currently limited evidence for how academic support and clinical experiences affect CALD nursing students' intentions to stay in the profession and in a foreign country; for this reason, we aimed to explore CALD nursing students' experiences of clinical practice and their perceptions of their career path.

Research design
This study adopted a qualitative descriptive design based on inductive content analysis. Focus group semi-structured interviews were performed (Kyngäs 2020).

Research aim and research question
This study aimed to describe culturally and linguistically diverse students' experiences of clinical practice, perceptions of their career path, and intentions to stay in the nursing profession.
J o u r n a l P r e -p r o o f

Journal Pre-proof
Research question was: What kind of experiences do culturally and linguistically diverse students' have of their clinical practice, their perceptions of career path, and intentions to stay in the nursing profession?

Participants
Purposive sampling was adopted together with the following inclusion criteria: 1) culturally and linguistically diverse background; 2) mother tongue different from Finnish, Swedish or Sami; 3) attending a degree in nursing in Finland, 4) experiences of clinical placements.
Sampling continued until data saturation was reached (Kyngäs 2020a). Potential participants were identified through an invitation for focus group interviews, sent by lecturers. Participation was voluntary.

Data collection
CALD nursing students from six universities of applied sciences were interviewed during May and June 2021. A total of nine focus group interviews were performed online in Teams (Microsoft Corporation, Redmond, WA) due to the COVID-19 pandemic restrictions by the Finnish authorities. Focus group interviews were chosen because this method is an effective way to gather rich data from several people at the same time (Polit & Beck 2021, 515). The main themes of the focus group interviews were participants' experiences of Finnish language and culture, Finnish health care settings and education, clinical experiences, career plans and future professional goals, and staying in Finland. Participants were able to choose whether they wanted to be interviewed in English or in Finnish.

Data analysis
The interviews were saved in Teams and then transferred to an external hard disc. Inductive content analysis was conducted. The content was split into meaningful expressions, which were then reduced into codes (n=762) and organised into sub-categories (n=165), categories (n=31), and main categories (n=5) (Kyngäs 2020b).

J o u r n a l P r e -p r o o f
Journal Pre-proof

Ethical considerations
Ethical approval was not required according to the Finnish National Board on Research Integrity.
The study followed ethical principals in accordance with the Declaration of Helsinki (2008)

Participants
A total of 22 CALD nursing students from six Finnish universities participated. The students had a mean age of 31 years (range: 20-43), 82% (n=18) female and 18% (n=4) male. The students had been in Finland for either less than one year (n=1), 2-3 years (n=8), 4-6 years (n=11), or 10 years or more (n=2). The participants estimated their Finnish skills as beginner (n=5), intermediate (n=14), or advanced (n=3). Prior to their nursing studies, the participants had finished high school/vocational school (n=3), a Bachelor´s degree (n=12), a Master´s degree (n=5), or other (n=2). They had been studying nursing for one (n=2), two (n=7) or three (n=13) years and had participated in one to six clinical placements in Finland. The participants had 0-13 years of working experience in nursing. Of the participants, four were completing their nursing studies in Finnish, while the rest (n=18) in English. The participants were from Africa (n=10, 45 %), from Europe (n=6, 27 %), and from Asia along with North-and South America (n=6, 27 %). The participants spoke 16 different mother tongues, some of them had several mother tongues. English was the mother tongue of six of the participants.

CALD-nursing students' perceptions
The students' experiences of clinical practice and competence development were organised into five main categories, including: 1) Importance and inadequacy of support; 2) Necessity of equality in and Changes in career growth as a result of clinical practice experiences (see Table 1).

Importance and inadequacy of support
The university supported students in developing their language skills by organising Finnish language courses, providing support from a Finnish language teacher, and by addressing students' self-directed learning. However, the students felt that there was an insufficient amount of language teaching, and it was offered mainly during the first year of studies. The participants felt that they needed more time to learn the language. They also hoped for more interaction with their Finnish peers. The students mentioned that the need for language studies should be evaluated individually, as some of them already knew the basics. They also voiced concerns that the objective of achieving language level B1 would not be sufficient in health care.
Support from educators was considered important. Some of the students expressed a need for more support, especially during clinical placements. Some of the students wanted universities to provide better placement deals, as many of clinical placements had limited the number of English-speaking students. CALD nursing educators were identified as important role models, to achieve a successful career in nursing in Finland.
"They encourage you to speak the language. When you make mistakes, they correct you. 009P1" Most of the CALD students reported receiving support from health care personnel; however, some participants did experience little or no support at all. Support was described as an understanding of language difficulties, constructive feedback, respect for students, help when learning the language, mentoring, and a positive atmosphere. Students with poor Finnish skills felt they were dependent on their mentors. The language barrier was not a problem if the mentor was motivated. Moreover, a mentor's English skills ensured mutual understanding. The mentors also had a role in improving students' language skills by encouraging them to speak Finnish. The students felt that they learned the most when mentors promoted their autonomy. Clinical placement experiences affected students' career preferences. Participants felt peer support was important. They mentioned that students helped each other with language problems. The participants felt that it was easiest to ask someone speaking their mother tongue for help. The students felt that society supported their studying and staying in Finland. Good occupational health services, quality of life and standard of living, and human rights and equality, along with respect for the nursing profession and satisfactory working conditions were mentioned to be positive things and support retention. A nurse's salary was described in two wayseither as a reason to stay in Finland or a reason to leave.

Necessity of equality in education and working life
Some participants experienced that the nursing degree programme in English did not offer the same variety of courses, the same options for advanced studies, or same career possibilities as the Finnish programme. Some experienced that they were forced towards a career in elderly care, while some felt that the Finnish degree students had better competence.
"Some of us will do wonderfully in elderly care. Nevertheless, I think that should be our choice rather than the direction we are being manipulated into. 004P1" The wards often limit the number of English-speaking students to one. Students felt that this practice prevented them from getting the jobs they wanted. Some students felt that the placements they were offered did not support their goals. Many of the CALD nursing students shared experiences of not being accepted to a placement because of their poor language skills. This was experienced as discrimination, with some students stating that getting a placement should not depend on language skills. Other interviewees shared that the period of their studies was a learning process which also included language skills. For this reason, the participants felt that language should not be an entry requirement, but part of the learning goals.
"I have had experiences, when you apply for a placement, then you get rejected immediately even without the person knowing your level of the Finnish language. 004P2" J o u r n a l P r e -p r o o f Journal Pre-proof CALD nursing students also expressed that nursing concepts can be learned and understood without knowing the Finnish language. They emphasised that a lack of language skills did not translate to a lack of nursing competence. However, some students felt that they were considered incompetent because of their limited Finnish.

Nursing competence
All of the participants mentioned the importance of language and communication skills. The students considered Finnish to be a challenging language because of many synonyms, differences between spoken and written language, and differences between pronunciation and writing. Poor language skills prevented them from acting according to their clinical skills. Moreover, many students left things unspoken because of their limited Finnish. Students also felt that they were being evaluated for their language skills. For this reason, they considered fluency in spoken Finnish necessary for finding a clinical placement, a job, andlatera satisfactory career.
"We have a lot within, but because of the language barrier, we're not able to express it. 006P2"

"I can't work as a nurse or achieve my dreams if I cannot speak the language. 003P2"
The CALD nursing students also considered clinical skills as important. The participants felt that these skills evolved during clinical placements, and some thought that these were the skills which they needed to compensate for the lack of language skills. In addition, they mentioned that cultural competence, which includes being knowledgeable of and accepting cultural differences, is important for the nursing profession. For example, students mentioned that the way they spoke sometimes made their colleagues think that they were angry. The CALD students considered tolerance to be an important aspect of being culturally competent. Students recognised their personal qualities such as motivation, a correct attitude, self-evaluation skills, and personal ways to cope with challenging situations to be important attributes.

J o u r n a l P r e -p r o o f
Journal Pre-proof

Importance and difficulty of integration
Integration into working life affected the decision to stay in Finland; many of the students hoped to stay in Finland if they get a job or if they sufficiently integrate into society. Others were uncertain about staying in Finland, with some participants citing moving to a different country for better working conditions. Also, integration into civil life was considered important; some students said they would stay in Finland because they have a stable living situation, while others mentioned leaving Finland for family reasons.
CALD nursing students experienced the workplace as a good environment for learning language skills. The participants reported two ways to get a job: proving own skills during the placement, or a job was available because of the nurse shortage or vacancies. The participants felt that employers were interested in them, but also that Finnish-speaking candidates were often chosen first for vacancies.

"So, as you progress from the three-and-a-half years, you're expected to know more Finnish. If you're not able to, or you don't have a practice placement that allows you to evolve in your
Finnish, then you get left behind. 006P6" Most students studied in English and did their placements in Finnish. Thus, they needed to learn the professional vocabulary in two languages. Students found it hard to get a job when adequate Swedish skills were also expected. Students felt that a multicultural team increased cultural competence in the workplace, and they expressed a desire to integrate in a workplace that included other international nurses.
"I'm a foreigner, I'm struggling to learn one language, and you expect me to learn another one (Swedish). So, I just put in my head that okay, maybe I will never get a permanent job. 009P1" The participants felt that health care professionals had unrealistic expectations for their language skills, and sometimes also for their clinical skills. The students also reported cases of prejudice. The placement was occasionally rejected before the student's language skills became clear.
The participants experienced depression, offence, worthlessness, loneliness, anxiety, frustration, and uncertainty during clinical placements. Some feared communication problems while others did J o u r n a l P r e -p r o o f Journal Pre-proof not want to talk about their problems due to a fear of reprisal on evaluation. Certain students felt that they were not trusted or respected. For example, some of them reported that they were considered practical nurses even though they had completed a nursing degree, or that they were considered incompetent because of their language skills.
"The problem is that usually you end up working like a practical nurse. 006P3" "We have been judged in this way just because we could not express ourselves in Finnish. 004P2" Some of the students did not dare to dream about a career in health care according to their interests.
Instead, their plan was to graduate as a nurse, learn the language, and get any job as a nurse. Some of the CALD students did not have any career plan or felt that licenses and finances should be secured first. The students with career plans dreamed about working in acute nursing or as nursing specialists. Others aspired to continue their studies. All the students wished that their future job would be interesting, challenging and give them possibilities to develop. That would increase their retention in the Finnish healthcare.
Integration into working life affected the decision to stay in Finland; many of the students hoped to stay in Finland if they get a job or if they sufficiently integrate into society. Others were uncertain of staying in Finland, with some participants citing moving to a different country for better working conditions. Also, integration into civil life was considered important; some students said they will stay in Finland because they have a stable life situation, while others mentioned leaving Finland for family reasons.

Changes in career growth as a result of clinical practice experiences
The participants felt that some of the experiences, feelings and feedback they got in the clinical placements motivated them. Constructive and positive feedback was considered supportive, and it increased professional self-knowledge. The CALD nursing students also felt that unpleasant mentoring experiences increased their persistence and determination to improve their skills. The fear of communication problems gave the students a reason to study Finnish.
"The positive feedback I've gotten from my mentors had also been a kind of driving force that makes me want to be the best. 003P2" J o u r n a l P r e -p r o o f Journal Pre-proof "The negative experience made me be stronger actually. 009P1" Negative experiences and career expectations decreased some of the CALD students' motivation.
For example, the students felt less motivated to learn the clinical skills required in acute care if their most realistic career expectations were in elderly care. Feelings of inadequacy decreased the CALD students' self-confidence and well-being. This, with constantly defensing oneself, was perceived to disturb learning.
"If you're made to feel inadequate in one way, you feel inadequate as a nurse and in your studies as well. 004P1"

DISCUSSION
This study aimed to describe CALD nursing students' experiences of clinical placements as well as their career plans. This is relevant to promote CALD nurses' retention and effective integration which benefit both to CALD nurses' well-being and to the health care settings. The results revealed that CALD nursing students felt that they receive partial support from their universities. The participants shared that the support was concentrated on the first year, after which it rapidly decreased. As such, the students hoped for more support at later phases of their studies. Previous findings have suggested that CALD nursing students receive inadequate support and mentoring (Onovo et al. 2019). A language skill assessment at the beginning of their studies could be worthwhile. Nursing education covers a wide spectrum of content, so it is difficult to consider that certain students would drop some nursing-related credits in favour of language credits. It may be beneficial to tailor the nursing education to CALD students; as such, language courses should be suggested based on each student's needs.
Educators' support and encouragement can advance the careers of CALD nursing students. The students viewed international educators as important role models. Unfortunately, not all of the participants were able to be in contact with such a role model as there are not many international nursing degree educators in Finland (Mikkonen et al. 2020).

J o u r n a l P r e -p r o o f
Journal Pre-proof clinical placement. In this case even the language barrier was not a problem. The attitudes of other health care personnel were also influential. The participants also stated that they avoided talking about their negative experiences due to fears that this would affect their evaluation. It is thus important that CALD nursing students benefit from non-judgemental support from their educators.  have stated that nursing staff needs support for mentoring CALD nursing students. The interviews also revealed that clinical placement experiences affect the career plans of CALD nursing students.
Some students felt that the English nursing degree programmes did not provide equal career possibilities. They felt as though they were pushed into a career in elderly care. They also felt that they had a narrower spectrum of choices for advanced studies when compared to their Finnish peers. Advanced studies could be offered in English nationwide. As EU-directive 55 (2013) regulates the current competence requirements, this cooperation could be organised at the national and international level in a way that advanced studies would be available for CALD nursing students.
The participants felt that they were often considered incompetent in their clinical placements because of their poor Finnish skills. Many of them had already worked as registered nurses in their home countries, and they understood the concepts and practices relevant to nursing. They wanted their competence to be respected. A lack of professional respect towards CALD nurses has also been previously stated (Covell et al. 2016). Students felt they were sometimes evaluated based on their language skills rather than on their nursing skills. This supports previous findings, which have reported that CALD nursing students sometimes feel that they are not evaluated objectively (Graham et al. 2016).
The B1-level of Finnish was not enough in practice. The participants felt unfair that a university has an official nursing degree programme in English, yet in practice it is not considered as valuable as the Finnish nursing degree programme. The students also felt that the ward staff had unrealistic expectations regarding their language skills. Several other studies have extensively focused on language problems among CALD nursing students , Onovo et al. 2019.
It is crucial to promote CALD nursing students' integration and retention after completing their studies. Educational institutions should identify more effective strategies to learn Finnish. The J o u r n a l P r e -p r o o f CALD nursing students mainly believed that they will stay in Finland if they get employed, and particularly in a specialty of their interest. Immigrants' needs for support are highly personal (Philip et al. 2019), and individualised support has previously been found to be effective (Ramjan et al. 2018).
A peculiar dynamic was uncovered based on the CALD nursing students' clinical placement experiences -both good and bad experiences induced motivation and professional development. However, some bad experiences, when combined with poor career expectations, decreased students' motivation. According to our results, the students who need the most support are the ones with the worst language skills. This supports previous findings on the same subject (Mikkonen et al. , 2017.

Study trustworthiness and limitations
The study's trustworthiness is strengthened by data saturation, a good number of participants for a qualitative study and by the representation of six different higher education institutions in Finland.
The data analysis was confirmed by several researchers in the study and authenticity has been ensured by direct quotations. The meticulous reporting enhances transferability of the study (Polit & Beck 2021, 569-570 pandemic restrictions, the interviews were conducted online, which could have affected the feeling of safety of the participants during the interviews. The participants came from different higher education institutions, which might have influenced their experiences by the regional differences and diversity found in healthcare organizations. mit to workplaces and the Finnish healthcare system. Students who require additional support need to be better recognised and supported, especially those with poor language skills. Advanced educational tracks for CALD nursing students could be designed at the national and international level.
Moreover, new technologies should be integrated into nursing education to ensure more effective ways of learning the Finnish language. For example, the applications of virtual reality in this context or clinical environment-related interventions potentially improving CALD students' academic performance would be interesting topics to study.
sities with specific reference to nursing students: A narrative literature review. Nurse Education J o u r n a l P r e -p r o o f

Categories Main categories
Higher education institutions organize teaching and support in the language Importance and inadequacy of the support More language teaching and using is wished Higher education institutions support should be more regu-