title: Culturally and linguistically diverse healthcare students' experiences of learning in a clinical environment: A systematic review of qualitative studies.
abstract: BACKGROUND
  Learning in the clinical environment of healthcare students plays a significant part in higher education. The greatest challenges for culturally and linguistically diverse healthcare students were found in clinical placements, where differences in language and culture have been shown to cause learning obstacles for students. There has been no systematic review conducted to examine culturally and linguistically diverse healthcare students' experiences of their learning in the clinical environment.
  
  
  OBJECTIVE
  This systematic review aims to identify culturally and linguistically diverse healthcare students' experiences of learning in a clinical environment.
  
  
  METHODS
  The search strategy followed the guidelines of the Centre of Reviews and Dissemination. The original studies were identified from seven databases (CINAHL, Medline Ovid, Scopus, Web of Science, Academic Search Premiere, Eric and Cochrane Library) for the period 2000-2014. Two researchers selected studies based on titles, abstracts and full texts using inclusion criteria and assessed the quality of studies independently. Twelve original studies were chosen for the review.
  
  
  RESULTS
  The culturally and linguistically diverse healthcare students' learning experiences were divided into three influential aspects of learning in a clinical environment: experiences with implementation processes and provision; experiences with peers and mentors; and experiences with university support and instructions. The main findings indicate that culturally and linguistically diverse healthcare students embarking on clinical placements initially find integration stressful. Implementing the process of learning in a clinical environment requires additional time, well prepared pedagogical orientation, prior cultural and language education, and support for students and clinical staff. Barriers to learning by culturally and linguistically diverse healthcare students were not being recognized and individuals were not considered motivated; learners experienced the strain of being different, and faced language difficulties. Clinical staff attitudes influenced students' clinical learning experiences and outcomes.
  
  
  CONCLUSIONS
  Additional education in culture and language for students and clinical staff is considered essential to improve the clinical learning experiences of culturally and linguistically diverse healthcare students. Further studies of culturally and linguistically diverse healthcare students' learning experiences in the clinical environment need to be conducted in order to examine influential aspects on the clinical learning found in the review.
authors.affiliation: University of Oulu, Finland. Electronic address: kristina.mikkonen@oulu.fi.
authors.forename: Kristina
authors.initials: K
authors.lastname: Mikkonen
authors.affiliation: University of Oulu, Finland.
authors.forename: Satu
authors.initials: S
authors.lastname: Elo
authors.affiliation: University of Oulu, Finland.
authors.forename: Heli-Maria
authors.initials: HM
authors.lastname: Kuivila
authors.affiliation: Oulu University Hospital, University of Oulu, Finland.
authors.forename: Anna-Maria
authors.initials: AM
authors.lastname: Tuomikoski
authors.affiliation: University of Oulu, Finland.
authors.forename: Maria
authors.initials: M
authors.lastname: Kääriäinen
mesh_terms: D018864:Cultural Diversity; D003695:Delivery of Health Care; D007802:Language; D007858:Learning; D008880:Midwifery / Q000193:education; D026741:Physical Therapy Modalities / Q000193:education; D013336:Students, Health Occupations / Q000523:psychology*; D013338:Students, Nursing / Q000523:psychology
keywords: Cultural and linguistic diversity; Learning in clinical environment; Midwifery students; Nursing students; Physiotherapy students; Systematic review; Thematic analysis