Navigating global mobility: a comparative study of nursing education in Nepal and Australia

Design

This study employed a descriptive qualitative design, underpinned by a constructivist philosophical paradigm, to investigate the undergraduate nursing curricula of Nepal and Australia from the viewpoint of final-year nursing students [37], 38]. A constructivist approach recognizes that knowledge is not passively received but actively constructed by individuals through their interactions with the world and others [39]. This philosophical stance aligns with the study’s aim to understand the students’ subjectively constructed realities and their interpretations of their educational experiences. The descriptive qualitative design was chosen for its ability to provide a rich, detailed account of participants’ perspectives on the structure, content, and implications of their respective curricula without imposing pre-determined theoretical frameworks [40]. Focus group discussions were selected as the primary data collection method for their capacity to facilitate interactive discussions and generate nuanced data on shared experiences and perspectives, particularly valuable in multicultural settings [41]. This interactive approach encourages participants to build upon each other’s ideas, challenge assumptions, and explore diverse viewpoints, fostering a deeper understanding of the complexities of the phenomenon under investigation [42]. In this study, we adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines to ensure a comprehensive and transparent research process and reporting of findings [43].

Participants and recruitment

We used purposive sampling to recruit 14 participants, seven from each country. This sample size aligns with recommendations for qualitative research, particularly for studies aiming for in-depth understanding within relatively homogenous groups [44], 45]. Although we aimed for thematic saturation as opposed to data saturation [46], it is crucial to recognize that the viewpoints of final-year nursing students may differ from those of newly qualified nurses who have gained more direct experience in the workforce.

The research was carried out at a large public university located in Melbourne, Australia, alongside Chitwan Medical College [47], a private urban tertiary institution affiliated with Tribhuwan University, located in Bharatpur, Nepal. The selection criteria for participants were: (a) enrollment in the last semester of the final year of the Bachelor of Nursing program in Nepal and Australia; (b) completion of at least 75 % of their required clinical placements; and (c) willingness and ability to participate in an online focus group discussion.

The demographic characteristics of the study sample align with notable trends within the nursing profession in both nations. The exclusively female composition of the Nepalese participant group reflects the prevailing situation in Nepal, where nursing is overwhelmingly a female-dominated profession. This is substantiated by World Health Organization (WHO) data indicating that the nursing workforce in Nepal is entirely female [48]. Conversely, the Australian nursing workforce, while still predominantly female with 87.9 %, has experienced a significant increase in male representation, now accounting for 12.1 % [48]. The inclusion of one male participant from the Australian cohort is consistent with this documented trend towards greater gender diversity in nursing within Australia.

Furthermore, the age distribution observed in the sample – a relatively younger cohort among Nepalese students compared to a wider age variation among their Australian counterparts – corresponds with distinct educational and societal norms in each country. In many Asian contexts, including Nepal, direct progression from secondary education to university is common, and societal or systemic factors often result in lower participation rates for mature-aged students in initial undergraduate degrees [49]. In contrast, the Australian higher education system frequently incorporates pathways for mature-age entry into professions like nursing, accommodating individuals pursuing career changes or further education later in life [50]. Thus, the age profiles within our sample reflect these differing national contexts regarding entry into nursing education. It is important to note, however, that while the participant demographics show alignment with broader national trends, the non-probability sampling approach (purposive and snowball) utilized was designed to capture information-rich perspectives relevant to the research questions, rather than to achieve statistical representativeness of the entire student population.

Potential participants were invited through flyers distributed on university campuses and online platforms featuring a QR code for self-registration. This approach allowed for convenient self-selection of individuals motivated to share their experiences. We initially employed purposive sampling [51], focusing on students in the final semester of their undergraduate nursing program to ensure they had completed the majority of their clinical placements and coursework. We then sought variation in age and sex (self-identified at the time of data collection) to capture a wider range of perspectives [52]. Following this, we utilized a snowball technique [53], asking participants to recommend other eligible students. While snowball sampling can potentially introduce bias by recruiting individuals with similar viewpoints, it was deemed valuable in this context for reaching a wider network of potential participants within the specific target population. The participants’ sociodemographic characteristics are summarized in Table 1.

Data collection

The data collection process comprised three online focus group interviews, each lasting approximately 120 min. All three focus groups included 14 participants (seven from Nepal and seven from Australia) to foster direct comparison and interaction between the two groups. The primary interviewer (AG) conducted the sessions, with the second author (MSN) acting as a co-facilitator. No prior relationship existed between the interviewers and interviewees. The decision to conduct combined focus groups rather than separate groups for each country was driven by the comparative nature of the research. Bringing students from both countries together allowed for real-time discussion and exploration of the differences and similarities in their educational experiences. This approach was chosen over individual interviews to leverage the benefits of group dynamics, where participants could build upon each other’s ideas, challenge assumptions, and provide richer, more nuanced perspectives [41], 42]. Online focus groups via a secure video conferencing platform were selected due to the geographical distance between participants in Nepal and Australia and offered a practical and efficient means of data collection.

The first focus group interview explored topics related to clinical hours, curriculum, and program length. The second focused on the subjects studied, clinical placements, and national licensure examinations. The third focused on global mobility prospects. The semi-structured interview guide (Table 2) was developed based on a thorough review of the literature and the first author’s first-hand teaching experience in both countries. The interview guide was reviewed for content validity and clarity by two experienced nurse educators, one from each participating institution, who were not directly involved in the study. While a formal pilot study was not conducted, the interview guide was refined based on the feedback from the nurse educators and the first author’s teaching expertise informed question phrasing and sequencing to ensure relevance and comprehensibility for the target population.

Data analysis

The audio recordings of the focus group interviews were transcribed verbatim by the authors (AG and MSN). It is important to note that the language of instruction for the Bachelor of Science in Nursing program in Nepal is English. All Nepalese participants were fluent in English and chose to speak in English during the focus group discussions, eliminating the need for translation and minimizing the risk of misinterpretation during transcription. Following the interviews, transcripts were returned to all participants for member checking, allowing them to review their contributions, add new information, and clarify their responses. This post-interview validation process is crucial in ensuring the trustworthiness and credibility of qualitative data [54].

Both researchers (AG and MSN) independently engaged in the data analysis process, enhancing inter-coder reliability. Cycle coding, a method well-suited for analyzing qualitative data from multiple participants and time points, was used to guide the analysis [55], 56]. The first coding cycle involved applying a priori codes derived from the interview guide and the research question. The second cycle involved inductive coding, where the researchers independently identified new codes and categories emerging directly from the data. Following independent coding, the researchers met to compare their codes, discuss discrepancies, and reach a consensus on a final coding framework. This iterative process involved multiple reviews and discussions, allowing for the refinement of the codes and identification of patterns and relationships within the data. The discussions also served as a crucial mechanism for reflexivity, allowing the researchers to critically examine their own biases and assumptions and ensure that the emerging themes accurately captured the participants’ experiences and perspectives. The final coding framework, along with illustrative examples, is presented in Table 3.

Rigor

The rigor of this qualitative study was ensured through a systematic approach to enhance the trustworthiness of the findings, guided by the framework of Lincoln and Guba [54]. This framework encompasses four key criteria: credibility, transferability, dependability, and confirmability.

Several strategies were employed to ensure the credibility of the findings. Member checking, a crucial technique for establishing credibility, was conducted by returning transcripts to participants for review and verification, allowing them to confirm the accuracy and authenticity of their responses and to add any further information or clarification. The prolonged engagement with the data, through multiple readings of transcripts and iterative coding, also contributed to credibility. To enhance transferability, we provided detailed descriptions of the participant demographics, the research context (nursing education in Nepal and Australia), the data collection methods, and the analysis procedures. This description allows readers to assess the potential applicability of the findings to other similar contexts.

The dependability of the study was enhanced through several strategies. The involvement of two researchers in the data analysis process, including independent coding followed by collaborative theme development and consensus building, fostered inter-coder reliability [57]. A detailed description of the research methods, including the interview guide and coding process, provides a clear audit trail, allowing for replication of the study. Confirmability was addressed through a comprehensive audit trail, meticulously documenting all stages of the research process, including data collection (audio recordings and transcripts), data analysis (coding decisions and thematic development), and researcher reflections. This audit trail allows for external scrutiny of the research process and helps to ensure that the findings are grounded in the data rather than solely in the researchers’ biases.

The involvement of two researchers with extensive and complementary expertise contributed significantly to the study’s overall rigor. The first author (AG), a nurse educator in both Nepal and Australia with personal experience as an international student and migrant nurse, possessed in-depth knowledge of the nursing curricula, regulatory contexts, and the lived experiences of nurses in both countries. The second author (MSN), a nursing education scholar specializing in curriculum development and evaluation, brought expertise in qualitative research methodologies and data analysis. This combined expertise ensured a comprehensive, nuanced, and contextually relevant interpretation of the data.

Ethical considerations

Ethical approval for this study was obtained from the Monash University Human Research Ethics Committee (MUHREC-44525), the Nepal Health Research Council (NHRC-111/2024), and the institutional review board of Chitwan Medical College (CMC-IRC/081/088–147). Participation in the focus groups was voluntary, and all participants were assured that their involvement and responses would not affect their academic standing. Participants were fully informed about the study’s aims, procedures, potential risks, and benefits, and provided written consent before participating.

Clinical hours and hands-on experience: implications for perceived competence and recognition

Variations in clinical hours and hands-on experience between Nepal and Australia have a direct impact on how prepared graduates feel for the practice and how their qualifications might be perceived internationally. This theme explores the contrasting approaches to clinical training in Nepal and Australia. The extensive clinical exposure in Nepal, exceeding 3,900 h over four years, fosters confidence and competence in diverse clinical settings [1].

We complete over 3,900 h of clinical placement over four years. This certainly has given us the confidence to go out and start working as registered nurses. (P1)

With extensive clinical placement and exposure to diverse specialties, we feel well-prepared to handle various clinical scenarios. This extensive training has given us the skills and confidence to start working as registered nurses after graduation. (P2)

The diverse placements across various specialties further enhance their preparedness.

We have to do clinical placements in every specialty including maternity, pediatrics, medical, surgical, community, psychiatry, operating theatre, emergency, ICU […]. This was great because we went on to different settings each time, when we commenced placement. (P3)

Australian nursing students complete 800 h of clinical placement over three years [17]. The emphasis is on shorter durations with dedicated preceptors, ensuring quality learning experiences and immediate feedback.

We complete 800 hours of clinical placement over 3 years. We are assigned preceptor(s), and we work under the guidance of preceptors, who help us develop confidence in our skills. (P9)

We do not have to do clinical placements in every specialty […]. I am about to graduate and haven’t done any placements in pediatrics or ICU […] (P10)

Our preceptors supervise us closely, and we also have a university facilitator with whom we debrief every day after we finish our placement and clarify any questions we may have. (P14)

The close supervision and daily debriefing sessions with university facilitators further contribute to their skill development and confidence. The significant disparity in clinical hours between the two countries raises potential concerns about the international recognition of qualifications in some contexts. While Australian nursing degrees are widely accepted globally [58], and Nepalese graduates, with their extensive clinical experience, may be perceived as more readily prepared for practice. Australian graduates may still face scrutiny regarding their practical readiness [59], particularly in jurisdictions with higher minimum clinical hour requirements.

Differing Program Lengths: impact on curriculum depth and international equivalency

The differing lengths of nursing programs in Nepal and Australia impact the depth of curriculum coverage and influence the perceived equivalency of qualifications internationally. The four-year Nepalese program allows for comprehensive coverage of theory and practice.

Our academic structure includes two 16-week semesters per year. (P4)

The extra year in our program is invaluable. It allows us to not only grasp the theoretical foundations but also to refine our clinical skills through extensive practice. For instance, we had the opportunity to spend several weeks in rural health camps, providing care to underserved populations and gaining a deeper understanding of the social determinants of health. This experience broadened our perspectives and prepared us to be adaptable and resourceful nurses in any setting. (P7)

The four-year program allows us to delve deeper into both theoretical and practical aspects of nursing. (P5)

The Nepalese students highlighted the value of the extended program in providing a solid foundation in nursing knowledge and skills. The opportunity to engage in diverse clinical experiences, such as rural health camps, further enriched their learning and fostered a deeper understanding of healthcare challenges in different contexts. However, in an Australian context, students highlighted:

Our academic year comprises two 12-week semesters. (P12)

Our three-year program is incredibly fast-paced and demanding. We’re constantly challenged to apply theoretical knowledge to clinical scenarios, and there’s a strong emphasis on critical thinking and problem-solving. It’s intense, but it ensures that we graduate with the essential skills and confidence to hit the ground running as registered nurses. (P11)

Sometimes, I feel like we’re rushing through the material, and I don’t always have enough time to fully grasp the concepts before moving on to the next topic. However, I also appreciate the efficiency of the program and how it prepares us for the fast-paced healthcare environment. (P10)

This adds another dimension to the Australian students’ perspectives, acknowledging the intensity of the program while also appreciating its focus on efficiency and practical application. These differences in program length create challenges in establishing international equivalency, requiring additional assessment or bridging programs for nurses seeking to work across borders [60].

Curriculum Content and Specialization: balancing breadth and depth for global practice

Differences in curriculum content and the degree of specialization offered in Nepal and Australia influence graduates’ breadth of knowledge and skills, which can impact their adaptability to different healthcare systems internationally. The Nepalese nursing curriculum adopts a comprehensive approach, mandating core subjects across various specialties to provide students with a broad foundation in nursing knowledge and skills.

Our curriculum includes compulsory subjects in pediatrics, maternity, and psychiatry. We can choose to work in either of these areas as a graduate nurse if we wish to. (P6)

This mandatory inclusion of core subjects ensures that all graduates possess a minimum level of competency in essential areas of nursing practice, equipping them to work in diverse healthcare settings and address a range of patient needs.

In contrast, the Australian nursing curriculum offers greater flexibility, allowing students to tailor their education towards specific career goals and interests.

We do not study maternity as a core unit. If we want to qualify as midwives, then we have to study one extra year and do a double degree in nursing and midwifery. That way, we have dual registration as a Registered Nurse and Registered Midwife. (P13)

This flexibility enables students to specialize in areas of interest while potentially requiring further education to gain competency in other areas. While this approach allows for greater individualization, Australian students expressed a desire for a broader curriculum that includes core subjects in all major specialties.

Including subjects like maternity and extending the program length to four years would provide more opportunities and better prepare us for diverse roles in the healthcare sector. Having a longer program could mean more hands-on experience and a better understanding of various specialties. (P14)

I appreciate the flexibility of the Australian curriculum, as it allows me to focus on my passion for critical care nursing. However, I do feel that having some exposure to areas like pediatrics and maternity would be beneficial, even if it’s not a full specialization. (P9)

This highlights the perceived benefits and drawbacks of the flexible curriculum and showcases the diversity of perspectives among Australian nursing students. The variation in curriculum content, particularly the degree of specialization, raises questions about the transferability of skills and knowledge across different healthcare systems, requiring IENs to demonstrate competency in specific areas not covered in their original education [61].

National licensure examinations: assessing competency and supporting or restricting mobility

National licensure examinations play a crucial role in ensuring the competency and readiness of nursing graduates before they enter professional practice [62]. The presence or absence of a national licensure examination has a direct impact on the process of obtaining registration as a nurse, both domestically and internationally [63]. In Nepal, passing the National Licensure Examination is a mandatory requirement for registration as a registered nurse [64]. This examination serves as a standardized assessment to ensure that all graduates meet a minimum level of knowledge and skills required for safe and effective practice.

The National Licensure Examination after graduation is another hurdle we must clear before we can register (P2).

The licensure exam is tough, but it guarantees that we meet a basic standard of competence before starting our professional careers (P4).

The mandatory nature of this examination emphasizes the importance placed on standardized competence and public safety in the Nepalese nursing context.

In contrast, Australian nursing graduates from accredited universities are exempt from a national licensure examination [9]. The accreditation process ensures that nursing programs meet rigorous standards and graduates are deemed competent to practice upon completion of their degree [9].

Studying in an Australian university exempts us from taking any licensure exam. After graduation, we can apply for registration if we meet other requirements, such as English language and background checks (P8).

This exemption streamlines the registration process for Australian graduates, allowing for a quicker transition into the workforce. However, it also raises questions about the comparability of standards and the potential for variations in graduate preparedness across different institutions.

I feel like the accreditation system works well in Australia, as it ensures that all nursing programs meet a high standard. However, I can also see the value in having a national exam to provide an extra layer of assurance and ensure consistency across the country. (P11)

This provides a nuanced perspective from an Australian student, acknowledging the benefits of the accreditation system and recognizing the potential value of a standardized national examination.

Global mobility prospects: aspirations, barriers, and the need for harmonization

The differences in nursing education between Nepal and Australia directly influence the perceived and actual barriers to global mobility for nurses from both countries. The prospect of working overseas after graduation is a significant consideration for many nursing students, offering opportunities for professional growth, personal development, and exposure to diverse healthcare systems. However, the complexities of international recognition of qualifications and varying registration requirements across countries present challenges for nurses seeking global mobility in their profession.

In this study, Nepalese nursing students expressed a strong desire to work overseas, motivated by factors such as career advancement, financial security, and the opportunity to experience different cultures. However, they also acknowledged the challenges associated with navigating the international registration process and obtaining recognition for their qualifications.

We know that irrespective of our nursing program length and clinical hours, we will still have to do a National Licensure Exam or a bridging course when we move overseas (P6).

The process is lengthy and time-consuming. I have already started studying for the NCLEX-RN exam for the USA. As soon as I graduate, I will start the process (P1).

I feel like the qualification recognition depends on the country you have studied rather than the curriculum (P3).

These quotes highlight the perceived barriers to international mobility, including additional examinations, bridging courses, and the potential devaluation of qualifications obtained in Nepal. The time commitment and financial burden associated with these requirements can be significant deterrents for internationally educated nurses. Furthermore, Nepalese students also compared the length of the program to their preferred destination countries and explained:

I am considering the UK or Australia. They both have a three-year bachelor’s program; we study for 4 years with over 3,900 hours of clinical placement; however, our qualifications are not equivalent, requiring us to do bridging programs or even study more; it is not an easy process […]. (P7)

These quotes illustrate the proactive steps taken by Nepalese students to prepare for international careers and the frustration and uncertainty associated with navigating the complex landscape of international qualification recognition.

Australian nursing students also expressed an interest in working overseas, primarily motivated by the desire for professional development and exposure to different healthcare systems.

Yes, I would definitely like to go to the UK and work. It is good to know other countries health care systems; it will make us well-rounded nurses (P9).

For Australian graduates, the recognition of their qualifications is often smoother, particularly in countries with similar educational standards and regulatory frameworks.

Initially, I was thinking of going to the USA, but our three-year bachelor’s degree is not enough to get registration there. We need to study more, and I do not want to do that. The UK would be a good option, as our qualifications are equivalent and recognized there (P11).

I think it’s important to have more transparency and clarity around the international recognition of nursing qualifications. It can be very confusing and overwhelming for nurses who want to work abroad, and it can discourage them from pursuing their dreams. (P5)

This emphasizes the need for greater transparency and harmonization in the international recognition of nursing qualifications, highlighting the challenges nurses face when seeking global mobility.

Limitations and areas for further research

Several limitations should be considered when interpreting this study’s findings. Primarily, the sample size of 14 participants, which included seven from each country, limits the ability to generalize the findings beyond this specific group. While qualitative studies prioritize in-depth understanding over broad generalizability, these findings may not be applicable to the broader populations of nursing students or internationally educated nurses in Nepal, Australia, or other countries.

Second, while valuable for accessing a specific population, purposive and snowball sampling introduce potential selection bias. Participants recruited through snowball sampling may share similar perspectives, potentially limiting the diversity of viewpoints represented in the study. Future research should strive to utilize more diverse sampling strategies, such as stratified random sampling, to obtain a more representative sample of nursing students from different backgrounds and institutions.

Third, the study’s focus solely on final-year nursing students means that the findings may not reflect the perspectives of newly qualified nurses, who have had more direct experience in the workforce and may have different insights into the challenges and opportunities related to global mobility. Future research could incorporate longitudinal designs, following nursing students from their final year of education into their early careers, to capture the evolving perspectives and experiences of IENs.

Fourth, the fact that the researchers (AG and MSN) also facilitated the online focus groups and transcribed the data introduces the potential for researcher bias. While steps were taken to mitigate this bias, such as independent coding and member checking, the researchers’ prior knowledge of the topic and their involvement in all stages of the research process could have influenced the data collection, analysis, and interpretation.

Fifth, the study’s focus on two countries, Nepal and Australia, limits the scope of its applicability. While these two countries represent contrasting educational models, they do not encompass the full diversity of nursing education systems worldwide. Further research could explore nursing curricula in other countries, particularly those with high rates of nurse migration in both source and destination countries, to provide a more comprehensive understanding of the global landscape of nursing education and its impact on international mobility.

Finally, the qualitative nature of this study provides rich insights into the experiences and perspectives of nursing students. However, it may not capture the full extent of variations in nursing curricula and their impact on workforce integration. To address this, future research should incorporate a quantitative approach, employing larger-scale surveys and statistical analysis to examine the relationship between curriculum characteristics, licensure requirements, and the professional integration of IENs across various countries. This quantitative data would complement the qualitative findings of this study, providing a more robust evidence base for policy-making and curriculum development in the context of global nurse mobility. For example, large-scale studies could examine the correlation between clinical hours in pre-registration education and IENs’ performance on licensing examinations or their adaptation to host-country healthcare systems. Such research could provide valuable data to inform the development of standardized global nursing curricula and facilitate smoother transitions for nurses across borders.

Conclusion and implication for practice

This comparative study revealed significant variations in clinical hours, program length, curriculum content, and licensure requirements between nursing education in Nepal and Australia. These differences, as demonstrated by the experiences of final-year nursing students, create distinct challenges for internationally educated nurses (IENs) seeking to practice in different countries, impacting their perceived preparedness, the recognition of their qualifications, and, ultimately, their global mobility. These findings underscore the urgent need for global harmonization and standardization in nursing education. This need is amplified by the increasing interconnectedness of healthcare systems and the growing demand for a globally competent nursing workforce.

To facilitate the seamless integration of IENs, policymakers, educators, and regulatory bodies should prioritize developing a standardized global nursing curriculum encompassing core competencies and transferable clinical skills. Such a curriculum would enhance the comparability of nursing qualifications worldwide, ensuring that nurses are adequately prepared to practice in diverse healthcare settings, regardless of their country of origin. This framework should not be a rigid, one-size-fits-all model but rather a set of agreed-upon minimum standards that allow for contextual adaptation to meet local healthcare needs and cultural considerations.

Drawing inspiration from successful international collaborations like the Bologna Process [85], which has facilitated the harmonization of higher education across European countries, the nursing profession can leverage existing frameworks and organizations, such as the International Council of Nurses (ICN) and the World Health Organization (WHO) Collaborating Centres for Nursing and Midwifery [86]. Specifically, these organizations could lead the development of international task forces comprised of nursing educators, regulators, and practitioners from diverse countries to define core competencies, establish guidelines for clinical training, and explore mechanisms for mutual recognition of qualifications. These standards would serve as a blueprint for nursing programs worldwide, ensuring a consistent and high-quality educational experience for all students.

Establishing global standards would streamline the recognition and credentialing of IENs and foster a shared understanding of the nursing profession’s core values, competencies, and responsibilities. This shared understanding would promote greater collaboration and knowledge exchange among nurses worldwide, improving patient outcomes and a more robust global healthcare workforce.

In addition to standardization, addressing the unevenness in quality assurance processes across different countries is essential. This requires establishing a comprehensive framework for evaluating and accrediting nursing programs internationally, potentially through a collaborative effort involving existing accreditation bodies. This framework should include regular audits, site visits, and peer review processes to ensure consistent adherence to agreed-upon standards. This would ensure that all nursing programs meet a minimum set of quality standards regardless of location, providing students with the knowledge and skills necessary to deliver safe and effective patient care in any healthcare setting.

Developing a standardized global nursing curriculum and a robust quality assurance framework is a complex but achievable goal. It requires a concerted effort from all stakeholders and a commitment to ongoing dialogue and collaboration. Educational institutions must be willing to adapt their curricula, professional organizations must advocate for change, regulatory bodies must develop and enforce consistent standards, and policymakers must provide the necessary resources and support. By working together, the nursing profession can create a globally recognized and respected educational pathway that empowers nurses to practice effectively in an increasingly interconnected world, ultimately contributing to a stronger, more resilient, and equitable global healthcare system for all.