Advice and development

COVID-19: why we must protect the mental health of international nursing students

The anxiety and isolation caused by the crisis may be particularly acute for this group
Isolated student

The anxiety and isolation caused by the crisis may be particularly acute for overseas students

Picture: iStock

With lockdown measures in full force across the UK due to the COVID-19 pandemic, nurse education has increasingly moved to online learning, with many first-year students having their clinical placements postponed.

Although essential, these moves have isolated students from their support networks and environments that promote their health and well-being at a time when they may be particularly vulnerable to the effects of isolation.

International students may be particularly vulnerable to feelings of isolation

Rising reports of mental health problems among UK university students have prompted calls for higher education to enact its duty of care to protect and promote the well-being of its students, in particular minority student groups who may suffer disproportionate stress while at university. 

One such group is international students, who are studying away from home and family support while encountering new and often stressful life events.

Figures from the Universities and Colleges Admissions Service (UCAS) show that in 2019, about 4% of applicants to undergraduate nursing degrees in the UK were international students, the majority from non-EU countries.

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Overseas students are unable to rely on their usual support networks during the crisis

Supporting the mental health of international students must start with an understanding of their reality, which includes the financial difficulties they face, family expectations and an unfamiliarity with British academia and societal norms.

Together, these can present a ‘perfect storm’ of unrelenting stress, which can be compounded by dissociation from familiar coping mechanisms such as local support networks, religious communities and symbolic traditions and foods. 

The uncertainty posed by Brexit has become a further concern for international students, with the COVID-19 pandemic likely exacerbating these feelings of separateness.

For newly migrated international students, social distancing measures will limit opportunities to make new friends. This can make it more difficult to develop a sense of belonging which is so important to student resilience, and there will be an increased risk that students will become lonely. 

Loneliness has an association with suicide risk in young adults

The Samaritans, which has carried out research showing an association between loneliness and suicide in young adults, advocates a public health approach to tackling loneliness, focusing on improving well-being in young people and helping them to build meaningful relationships within social settings, including schools, colleges and universities. 

While studies of suicide among international university students are limited in the UK, a report from the Australian State Coroner in Victoria highlights the association between university stress and this tragic outcome. 

The report found 27 confirmed suicides, with a potential 16 more among international students in the state from 2009-15. Most of these students were men aged 18-24 years and the majority had no history of mental illness, with no warning signs in evidence among family and friends.

‘A “perfect storm” of unrelenting stress can be compounded by dissociation from familiar coping mechanisms such as local support networks, religious communities and symbolic traditions and foods’

The most common reason for these suicides was deemed to be course failure or fear of course failure and the associated parental disapproval and visa implications. Financial difficulty was also identified as a stressor. 

The financial pressures for international students

The impact of COVID-19 on student financial security is a further threat to well-being. The university fees for international students are roughly double those of their UK peers, and like other students, they often depend on part-time work to support themselves at university.

They are highly reliant on casual work, and the recent job losses in retail and catering will have left many without a reliable income. As non-EU international students have no recourse to public funds, many student fees are supported by family finances, with some families taking out loans on their behalf.

As many international students come from low income families, most from developing nations, families can ill afford to offer further financial help and students can find themselves in a desperate situation.

Emergency legislation that permits final semester nursing students to compete their degree as paid staff during the pandemic goes some way to alleviate financial difficulties. But it also brings concerns about increased exposure to the virus, especially for students who will have no family support here should they become unwell.

A further, and particularly unpalatable, issue is the reported rise in hate crime against international students, and specifically those of Chinese origin.

There have been reports of the coronavirus sparking a tide of xenophobia worldwide, with some Chinese students reportedly leaving the UK in fear after experiencing threats and physical assaults.

How academics and nurse educators can alleviate distress among nursing students

  • Set up virtual learning tutorials in real time that encourage virtual group work within class. This can help support peer engagement
  • Ask international students to contribute to learning scenarios by sharing their professional and life experiences. This can support integration and a sense of value
  • Be flexible with assignment deadlines This can help reduce competing stressors for students, especially those with children at home while the schools are shut
  • Remain visible and responsive to students online Tutors are the first port of call for many students experiencing distress, so continuing access is essential
  • Normalise mental health discussions within learning environments and facilitate mental health literacy. This can enable students to recognise when they need help


International students must be encouraged to talk about their mental health

Some students may come from countries where mental illness is unrecognised or a taboo subject that attracts shame and stigma, so it is important to know how to ask students if they need support. Student disclosure requires a safe and confidential environment.

Staff can develop skills in these areas through mental health training, such as the two-day Mental Health First Aid course offered by many UK universities. 

What organisations can do to help support international students

  • Recognise and include provision for international students in student mental health strategies and operational plans
  • Promote safe environments that encourage social interactions and prevent racism, bullying and harassment
  • Provide a careful and comprehensive student orientation, not only for their immediate academic and clinical environments, but for associated mental health support services
  • Signpost students to local cultural, religious and community groups Guidance and advice on this can be found via organisations such as the UK Council for International Student Affairs 
  • Keep students informed of changes to their nursing degree journey and strategies to support their ongoing progression


Establish well-being champions for international students

While efforts by individual academic staff can no doubt help protect international students’ well-being, a successful strategy requires committed and organised leadership by universities and healthcare settings.

Universities and clinical experience providers can identify staff who are interested in becoming international student well-being ‘champions’ and fund their personal and professional development in this area.

Finally, ongoing research into international student mental health and well-being is essential to inform future support strategies for this vulnerable student group.

Lesley Andrew is postgraduate courses coordinator for public health, school of medical and health sciences, Edith Cowan University, Western Australia