Factors affecting progress of Australian and international students in a ...

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tional, in the Bachelor of Medicine degree course at the. Faculty of Medicine and Health Sciences, The Uni- versity of Newcastle, New South Wales, Australia.
Research papers

Factors affecting progress of Australian and international students in a problem-based learning medical course Carla Treloar,1 Natalie McCall,2 Isobel Rolfe,3 Sallie-Anne Pearson,4 Gail Garvey5 & Andrew Heathcote6

Context Research on the factors affecting progress in medical schools has typically focused on mainstream (non-Indigenous Australian, non-international) students in traditional, didactic programmes. These results may not be applicable to students, particularly those from culturally diverse backgrounds, undertaking problem-based learning courses.

Results Participants identi®ed both positive and negative experiences related to the course structure, which were consistent with previous ®ndings. The participants' experiences demonstrated a relationship between sense of `belongingness' to the medical school community, participation in learning opportunities and progress through the course.

Objective This study used qualitative methodology to explore and compare factors affecting progress for mainstream Australian students (non-Indigenous Australian, non-international) and international students (full fee-paying students who had relocated countries to study) in a problem-based learning medical course. Intervention strategies were devised on the basis of the participants' experiences.

Conclusions The results suggest that interventions aimed at reducing barriers to progress need to promote students' con®dence, motivation and subsequent participation in course learning opportunities. These results have application to other problem-based learning courses particularly those which face the challenge of providing an optimal learning environment for students from diverse backgrounds.

Methods Six focus group discussions were conducted (three with mainstream Australian and three with international participants). Transcripts of these discussions were coded and analysed independently by two researchers and discussed until consensus was attained.

Keywords Australia; education, medical, undergraduate; Great Britain; problem-based learning, *education; travel.

Introduction Successful completion of a medical degree is a complex process requiring the negotiation of many stressors and 1 Centre for Clinical Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, The University of Newcastle, Australia 2 Hunter Area Health Service, New South Wales Department of Health, New South Wales, Australia 3 Medical Education, Faculty of Medicine and Health Sciences, The University of Newcastle, New South Wales, Australia 4 Programme Evaluation, Faculty of Medicine and Health Sciences, The University of Newcastle, New South Wales, Australia 5 Discipline of Aboriginal Health Studies, Faculty of Medicine and Health Sciences, The University of Newcastle, New South Wales, Australia 6 Department of Psychology, Faculty of Science and Mathematics, The University of Newcastle, New South Wales, Australia

Correspondence: C. Treloar, David Maddison Building, Royal Newcastle Hospital, Newcastle NSW 2300 Australia

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barriers.1 These have been associated with high levels of psychological distress2,3 and substance abuse among medical students.4 Research on the factors affecting progress in medical degrees has typically been conducted in North America and has focused on mainstream (non-Indigenous, non-international) students in traditional, didactic programmes.1,2,4 Thus the results may not be applicable to all students and also to those undertaking problem-based learning courses. Research with mainstream students has found that aspects of problem-based learning courses result in both positive and negative experiences and, as such, have an impact on learning. Problem-based learning courses have been found to promote independent learning, critical thought and motivation to study.5±9 However, the problem-based learning structure also engenders anxiety, because of reported lack of guidance

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for learning, inef®ciencies in learning, gaps in knowledge and reinforcement of inaccurate information.6,7 Group learning has been found to promote mutual support and assistance between students. Poor group dynamics and group intolerance of individual differences has been reported to hinder learning.7 Learning in a clinical setting has been reported both as a primary motivator for learning7 and as a source of tension, frustration, powerlessness and anxiety.3,4 Research indicates that international students (full fee-paying students who had relocated countries to study) undertaking non-medical traditional courses often experience dif®culties with mainstream usage of English,10 social interaction11 and general study and writing skills.10,12 Hence, problem-based learning courses which employ group and self-directed learning methods, may be dif®cult or inappropriate for international students because of the reliance on verbal interaction, independent learning and group interactive learning. This study sought to explore the experiences of two groups of students, mainstream Australian (non-Indigenous Australian, non-international) and international, in the Bachelor of Medicine degree course at the Faculty of Medicine and Health Sciences, The University of Newcastle, New South Wales, Australia. This degree employs a problem-based learning programme which emphasizes the integration of basic and clinical sciences, self-directed learning and communication skills.13 This study aimed to: 1 explore the factors within the Newcastle medical course structure, and the social and cultural environment of the university and community, that affected students' ability to progress; 2 compare the experiences of these factors between mainstream Australian and international participants; 3 recommend appropriate intervention strategies.

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explore commonalities and differences in experiences. The study was approved by The University of Newcastle Human Research Ethics Committee. Participants

Participants were in their second or subsequent year of candidature and were offered reimbursement (A$25) for participation costs. First-year students were excluded as the academic year had recently commenced and their experiences of the programme would have been limited. The Faculty admissions database was used to exclude students who had identi®ed as Aboriginal or Torres Strait Islanders (Indigenous Australians). A total of 16 full fee-paying international students were identi®ed by the Faculty admissions database and were individually invited to participate. Those students not identi®ed as Indigenous Australian or international were considered to be `mainstream Australian'. Two research assistants attended a ®xed resource session (lecture) for students in the second, third, fourth and ®fth years of the course and invited mainstream Australian students to participate. A total of 30 students agreed and provided their details to the research assistants. Pilot study

Pilot interviews were conducted with eight students (four mainstream medical Australian students, two Indigenous Australian and two international students from other problem-based learning or nursing courses) to develop the focus-group discussion guide. Pilot interviews were not conducted with international medical students in order to maximize the number of students eligible for the main study. A pilot focus group discussion was conducted with two second-year and ®ve fourthyear mainstream Australian medical students (who were excluded from participation in the main study) to train the group facilitator. These data were not analysed.

Method Main study Study design

This study was part of a larger project to explore the perceived factors affecting the progress of Indigenous Australian, international and mainstream Australian students enrolled in the Bachelor of Medicine degree course, The University of Newcastle in 1997. Qualitative methodology was used to capture personal and sensitive information from a perspective, especially cultural, which the majority of researchers did not share. Focus group discussions were used to fully

The focus group discussions were conducted by a member of the research team (N.M.) who was not involved in delivery of any component of the medical course. The aims of the study were explained to the participants and their voluntary consent gained after assurances of anonymity and con®dentiality. The focus group discussions were audio tape-recorded for transcription. Participants completed a short demographic questionnaire at the conclusion of the discussion. No participants wished to read and comment on the tran-

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scripts. Three focus group discussions each were conducted with mainstream Australian and international students (six focus group discussions in total). No further groups were arranged as the data had reached `redundancy': no new information was elicited in the ®nal group.14 Data analysis

Transcripts were proofread for accuracy before analysis. Two researchers developed a code and de®nition list from the literature and insights from pilot interviews, based on ®ve broad categories (support, academic background, course structure, experiences based on culture, and emotional reactions). The two researchers independently coded the transcripts and discussed until consensus was reached. The Ethnograph V4á015 was used to organize and search for data under each code. The two researchers independently summarized the emergent themes under each code and discussed until reaching consensus. Analysis was conducted so that the conclusions drawn could be traced to the original data. Quotations are reported verbatim and with attribution of main quotes to the participants' group (i.e. I1, I2 or I3 for international participants and M1, M2 or M3 for mainstream participants). Single words or phrases frequently expressed in the groups have not been attributed.

Results

Table 1 Demographic characteristics of mainstream Australian and international participants Mainstream Australian

International

Males Females Mean age, years

9 (39%) 14 23

9 (90%) 1 24á2

Marital status Single Married/de facto Divorced Other

19 (83%) 3 (13%) 1 (4%) 1 (4%)

9 (90%) 1 (10%) 0 0

No. with children Year of course 2 3 4 5

0 5 7 5 6

0 (22%) (30%) (22%) (26%)

5 (50%) 0 4 (40%) 1 (10%)

and problem-based learning was `fun', `fostered their independence', resulted in `integrated learning' and facilitated the development of `lifelong' learning skills. Others felt `frustrated' spending time on `irrelevant' or `peripheral' (i.e., unexamined) material. All participants reported that the course lacked `guidance' and `direction' and, consequently, were unsure `how much to learn of a certain topic' (M2). Participants consistently stated that `some of the subjects in medicine are not very well taught' by self-directed learning: `you just can't teach yourself anatomy' (I3).

The main themes are summarized in Table 2, and are described in more detail below.

Group learning Most international participants experienced `isolation' as a result of their different cultural background during group learning: `if two people are interacting, if they have the same sort of background¼ the same way they think, the same cultural values, the same language, the same environment, it is easier for them to interact' (I2). Most international and a small number of mainstream Australian participants reported feeling `dominated' by other members of the group. Both of these experiences resulted in these participants `avoiding' or `dreading' group learning sessions. Participants indicated that some tutors managed these group processes and facilitated group cohesion by providing `balance' between information and discussion. Conversely, tutors who provided little or too much direction created an environment without `scope' to learn and `ripped the group apart' (I3).

Course structure The majority of mainstream Australian and international participants reported that self-directed learning

Clinical learning All of the participants reported that clinical learning increased their `motivation' to become a doctor, by

Participants

Seven of the 30 mainstream Australian students who agreed to participate did not attend the scheduled discussions. Six of the 16 international students declined to attend because of time commitments. Thus a total of 23 mainstream Australian and 10 international students participated. Table 1 presents the demographic characteristics of the participants. Although the majority of international participants (70%) were of Asian background, the data from international participants were examined in aggregate form to prevent identi®cation of individuals. Themes

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Table 2 Main themes emerging from focus group discussions Course

Lifelong learning skills Lack of guidance and direction Not appropriate for some subjects

Group learning

International participants can feel isolated Tutors can have positive and negative impacts

Clinical learning

Provides motivation to learn Frustrating because of shallow knowledge base

Assessment

Gap between course and assessments Oral assessments perceived to be unstandardized and unfair

Pro®ciency with mainstream Australian English, international participants

Dif®culty understanding Australian English Slower in day-to-day work

Support: medical school peers

Mainstream: debrief with peers International: easy to feel isolated

Support: senior medical students

Invaluable for guidance

Support: non-medical friends

Refreshing for mainstream

Support: family, international participants

Homesickness Holiday breaks are `precious family time'

Support: Faculty

Faculty members both positive and negative in¯uences Lack of female role models

Support: programme, international participants

Lack of support

Financial pressures

Hidden expenses Mainstream participants juggle part-time work International participants have made high ®nancial sacri®ce

Discrimination: racial, international participants

Dependent on verbal ¯uency and western accent Determinant of alienation Some Faculty members perceived as `racist'

Discrimination: gender

`Chauvinism' among doctors

Discrimination on basis of entry into the course, international participants

Lowered con®dence International students `talked about behind their back'

Stability, international participants

Living in a totally different environment Time and energy focused on surviving

providing a `taste' of clinical work and opportunities to `get used to patients and feel comfortable with them' (I3). Clinical exposure was also perceived to facilitate learning. However, participants were acutely aware of their `shallow' knowledge base and felt `frustrated' and `insecure' when speaking to patients. This acted as a catalyst for further learning.

examination papers. Some participants perceived that this approach undermined learning because `knowledge de®ciencies' could be `hidden'. Many of the participants perceived that `personalities' and differing assessors' `expectations' rendered oral assessments `staggeringly unstandardized' and `blatantly unfair' (M3).

Assessment Participants perceived that examination questions had `very little focus' or `relationship' with the course, and did not re¯ect the `time' spent learning throughout the year: `there is this gap between the way we should approach it, and what we have to get in the end' (M1). In the absence of `guidelines' and `direction' for examination preparation, participants relied on past

Pro®ciency with mainstream Australian English International participants reported that while they were conversant with the `Queen's English', they had dif®culty understanding `Australianized' English: `you have to synthesise your thoughts very succinctly, and be able to present it so you don't make a fool of yourself' (I1). This caused some participants to decrease their participation in discussions, case presentations and lec-

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tures. Completing examinations and written work on a day-to-day basis also took more time for international participants with language dif®culties, as their rate of language processing was `slower'. Support: medical school peers Mainstream Australian participants found it helpful to `bounce ideas off' (M3) each other, and `reassuring' to empathize about study demands. Some used `debriefing' to alleviate feelings of `depression', particularly after witnessing a dramatic event (e.g., death of a patient). Many of the international participants felt it was `easy to feel isolated' (I2). Australians were perceived to `do their own thing' and the international participants were `expected to join in' (I2). Some of the international participants felt that other students `did not want to be friends' with them: `I feel that I want to make friends, but I don't feel that people want to make friends with me' (I2). Several international participants felt that their level of `happiness' and `motivation to learn' increased once they began `meeting Australians and doing things' and `getting to know others' (I1). The social arm of the medical student body was particularly valuable as it provided international students with the opportunity for a `minimum amount of social contact' (I1). Support: senior medical students Mainstream Australian participants considered contact with senior medical students and graduates an `invaluable' source of support as they provided `guidance' regarding the depth of information required to pass. Support: non-medical friends Mainstream Australian participants perceived that contact with non-medical peers facilitated a `broader', `refreshing' focus. However, most perceived that there were few opportunities to form these friendships because of the `all encompassing' nature of medicine and the lack of `integration' across University services and timetables. This created a sense of `ostracism', `elitism' and `prejudice', which contributed to the `sense of social¼ and intellectual isolation' (M3). Support: family All international participants experienced `homesickness' as a result of being `so far away' from their family. Students who fail are invited to sit `post-examinations' in the holiday break. These post-examinations caused international participants to `miss precious family time' and `shattered' their expectations of the holiday season, something they `looked forward to throughout the whole year' (I2). Further, these students were left to

study in Newcastle without peer support. Participants reported that this was a `demoralising' experience and a `dif®cult time to study' (I2). In contrast, only a few mainstream Australian participants perceived that their `ability' was adversely affected by the reduced level of contact with their family. Support: Faculty Both groups of participants reported that most Faculty members were `understanding', `helpful', `responsive' and `¯exible', which was a `real con®dence booster' (M1) and increased `motivation' to learn. However, some Faculty members were perceived to be unresponsive and unapproachable and `played' on students' inability to answer questions during ward rounds. The lack of female role models was both a positive and negative in¯uence for mainstream Australian female participants: I vacillate between the `I'm going to be a physician¼ because there are no other women out there doing it' and then the next thing I think is `Oh, stuff it, it's just too much a battle, I'm not going to play in those boys' games' (M3). Support programme The lack of programme support for international students was described as `disappointing' and reinforced their perception that `all they [the Faculty] want is our money' (I2). Financial pressures All participants indicated that the high level of `hidden expenses' such as professional clothing, equipment, textbooks, travel and parking fees created ®nancial pressures. Mainstream Australian participants ineligible for government assistance found it dif®cult to `juggle' and `cope' with the demands of the course while working part-time. Learning opportunities were limited because of ®nancial pressures: I'm missing my country term [rotation to a rural hospital] but I intend to take country electives at a time when it is easier to go away¼ when you don't have the same sort of ®nancial commitments (M1). Most of the international participants experienced `huge pressure' to pass because of the high level of ®nancial `sacri®ce' made by their families: `essentially you have mortgaged your life' (I3). Discrimination: racial Some international participants perceived that less racism was directed against those with high verbal

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¯uency and a western accent. The level of racism experienced was perceived to be `one of the major determinants of how alienated' people felt (I2). While racism lowered most participants' `con®dence', decreased participation and contributed to feelings of `isolation' and `alienation', for a few it strengthened their resolve: `things like this can either make or break you¼ If they can handle all that they get through pretty 1 all right, if they don't fall out in the ®rst few years' (I2). Several mainstream Australian participants described some members of Faculty as `racist', `bigoted' and `condescending' towards international students, particularly Asian students. Most of the international participants stated that Faculty members who showed racism were `subtle about it because they know it is not quite polite to show it' (I1). In clinical settings, some patients had refused to be examined by international students, which caused them to `miss' valuable learning experiences. Discrimination: gender Mainstream Australian participants perceived that `chauvinism is quite inset in many doctors' (M3). Older, male doctors `blatantly' discriminated against female medical students, ignoring them while they focused on the `white males' in the group (M3). Some doctors were perceived to `overcompensate' by being `condescending' and `patronising'. One male mainstream Australian participant stated that some clinicians had advised female medical students to wear `dresses': `it's like [the clinicians are saying] we want you to be feminine and pretty, not powerful, we want you to be decorative, not colleagues'' (M3). Discrimination: on the basis of entry into the course Some international participants held the perception that their mainstream Australian peers had a `preconceived notion' that international students entered medicine `because [they] couldn't do anything else' (I3). One international participant stated that this misconception `really bothered me' and resulted in a conscious effort to `isolate myself' (I3). Another international participant experienced feelings of `insecurity' and lowered `con®dence' concerning academic ability as a result. Some mainstream Australian participants perceived that international students `fell short' of the expectations of a medical student and were `certainly talked about behind their back' (M1). Stability Some of the international participants stated that studying in an overseas country created some `instability' as they had `given up everything' to live and study in

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a `totally different environment' (I2). Consequently, a large proportion of their time and energy was focused on `surviving' during the ®rst few years away from home.

Discussion The ®ndings of this qualitative study are inherently limited. The international participants represented 63% of the eligible population but included only one female, and the results were examined as a homogeneous group. Hence, future research examining cultural groups of international students may be bene®cial. The results from this self-selected small sample of mainstream Australian students (i.e., 23 of approximately 230 eligible students) may not be re¯ective of the broader population. However, the results for both cultural groups reached the point of redundancy, which increases the credibility of the data and the extent to which the research can be more broadly applied. The demographic details of the mainstream Australian participants also indicate that there was broad representation across age, gender and educational background. Participants may have felt inhibited in expressing their criticism of the medical school despite the presence of a non-medical facilitator. Given these considerations, the qualitative approach used in this study allowed links between experiences and learning opportunities to be explored in detail, as well as discussion of sensitive or personal issues. These results con®rmed ®ndings from previous studies regarding positive and negative experiences of students in problem-based learning courses, particularly with regard to the development of independent learning and interactional skills, anxiety created by this method of learning and in¯uences on group learning.5±9 Participants' perceptions of irrelevant and unstandardized assessments, incompatibility of some subjects (i.e., anatomy) with a problem-based learning structure and the positive and negative in¯uences of tutors and Faculty, have not been raised in previous studies of problem-based learning medical degrees. Participants from both groups perceived that dif®culties developing peer supports, reduced access to family support systems, homesickness and ®nancial pressures also hindered their ability to progress through the course. International participants appeared to experience these more intensely than mainstream Australian participants. International participants perceived that their progress through the course was undermined by additional factors such as poor pro®ciency with mainstream Australian usage of English, racial discrimination (from peers, Faculty and community), lack of programme support and discrimination on the basis of entry into the course.

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Regardless of cultural group, a general pattern emerged from the participants' experiences, suggesting the mechanism by which the factors outlined above act as barriers to progress. The data suggest that these factors can undermine con®dence, reduce motivation, decrease participation and create feelings of isolation and alienation. Students who felt alienated and isolated, and subsequently lacked a sense of belonging to the medical school community, withdrew from learning opportunities based largely on verbal interaction and group activities. These results provide the opportunity to reframe the identi®ed barriers to progress as intervention programmes with the aim of fostering environments to support achievement of learning potential. Students' participation in learning opportunities may be maintained by fostering a sense of belonging and reducing feelings of alienation and isolation. The following strategies aim to achieve this by addressing the concerns raised by students and are focused at multiple levels of intervention (i.e., student, tutor, Faculty, course structure). Strategies aimed at reducing alienation and isolation may include: · offering conversational and written English classes; · education of Faculty members and students regarding cultural awareness, particularly discrimination and the requirements for fullfee-paying admission; · promoting contact between senior international students and those in earlier years; · implementing education and skills acquisition programmes for tutors, with particular emphasis on methods for facilitating group cohesion; · implementing ¯exible scheduling arrangements for post-examinations to ensure that all students have the opportunity to minimize disruption of time spent with families; · introducing Faculty-driven programme support for international and mainstream Australian students; · ensuring contact with female medical role models for female medical students. These interventions should be organized on the basis of need rather than culture, to avoid further alienating groups of students who are vulnerable in this regard. Strategies which address participants' concerns about course structure include: · employing appropriate and effective teaching methods on a subject-by-subject basis; · providing broad guidelines which indicate the breadth and depth of material to be covered at each stage of the course;

· employing assessment strategies which re¯ect and measure learning according to these guidelines. Courses which include non-traditional education formats and students from diverse backgrounds face many challenges in providing environments in which these students can achieve their learning potential. These results have provided directions for intervention programmes to meet the needs of mainstream Australian and international students as they perceive them, and have extended knowledge of these students' experiences in a non-traditional, problem-based learning undergraduate medical course. To maximize the success of each strategy, protocols should be developed in consultation with relevant student, academic and community groups. Subsequent research may involve trialing and evaluating the strategies implemented.

Acknowledgements Our thanks to the students who participated and shared their experiences, and also to Ms Vicki Caesar for her efforts in coordinating the study. Funding for this project was obtained from a University of Newcastle Research Management Committee grant and an Australian Research Council special initiative grant.

References 1 Calkins EV, Arnold L, Willoughby TL. Emotional impact of medical school and residency. Acad Med 1994;69 (10):S22± S24. 2 Carmel S, Bernstein J. Perception of medical school stressors: Their relationship to age, year of study and trait anxiety. J Hum Stress 1987;13:39±44. 3 Wolf TM, Scurria PL, Webster MG. A four-year study of anxiety, depression, loneliness, social support and perceived mistreatment in medical students. J Health Psychol 1998;3 (1):125±36. 4 Firth J. Levels and sources of stress in medical students. BMJ 1986;292:1177±80. 5 Albanese MA, Mitchell S. Problem-based learning: a review of the literature on its outcomes and implementation issues. Acad Med 1993;68 (1):52±81. 6 Bernstein P, Tipping J, Bercovitz K, Skinner HA. Shifting students and faculty to a PBL curriculum: attitudes changed and lessons learned. Acad Med 1995;70 (3):245±7. 7 Colditz GA. The students' view of an innovative undergraduate medical course: The ®rst year at the University of Newcastle, New South Wales. Med Educ 1980;14:320±5. 8 Kaufman DM, Mann KV. Comparing students' attitudes in problem-based and conventional curricula. Acad Med 1996;71 (10):1096±9.

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9 Norman GR, Schmidt HG. The psychological basis of problem-based learning: a review of the evidence. Acad Med 1992;67 (9):557±65. 10 Burns RB. Study and stress among ®rst year overseas students in an Australian University. Higher Educ Res Dev 1991;10 (1):61±77. 11 Pedersen PB. Counseling international students. Counselling Psychol 1991;19 (1):10±58. 12 Manese JE, Sedlacek WE, Leong FTL. Needs and perceptions of female and male international undergraduate students. J Multicultural Counseling Dev 1988;16:24±9.

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13 Carr VJ, Hazell PL, Williamson M. Teaching psychiatry in an integrated medical curriculum. Aust NZ J Psychiatr 1996;30:210±19. 14 Patton MQ. Qualitative Evaluation and Research Methods. Newbury Park, California: Sage; 1990. 15 Seidel J, Friese S, Leonard DC. The Ethnograph [computer software]. (Version 4). Amherst: Qualis Research Associates; 1995. 2 Received 7 May 1999; editorial comments to authors 14 July 1999; accepted for publication 13 August 1999

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