Exploring Ethical, Cultural, and Transnational Competence Among International Healthcare Management Students: An Australian Perspective

Abstract

Introduction

Healthcare leaders face complex ethical challenges that can impact patient care and organizational integrity. For international healthcare management students pursuing leadership roles in Australia, these challenges are heightened by ethical, cultural, and transnational differences. This exploratory study examined the challenges faced by these students to establish foundational understanding of the competencies needed for effective ethical decision-making, cultural integration, and transnational readiness in diverse healthcare environments.

Methods

Using a composite theoretical framework incorporating Cultural Relativism, Ethical Climate Theory, Institutional Theory, and Transnationalism, a 35-item instrument was adapted from three validated sources. A cross-sectional survey of 35 international postgraduate health services management students collected quantitative and qualitative data. Quantitative data were summarized using descriptive statistics, while thematic analysis, informed by the Gioia methodology, was applied to qualitative responses.

Results

Key ethical challenges identified included healthcare inequity, resource allocation, and patient safety. Effective leadership practices emphasized fostering supportive work environments and promoting diversity. Participants demonstrated strong cultural competence, particularly in cultural awareness and cross-cultural communication, but highlighted the need for enhanced preparation in ethical decision-making and navigating transnational healthcare systems.

Conclusion

The findings underscore the importance of transnational training programs that integrate cultural orientation, healthcare-specific language support, and ethical decision-making simulations. The Ethical, Cultural, and Transnational framework developed in this study provides a practical guide for embedding these competencies into leadership curricula, equipping international students to navigate the complexities of globalized healthcare systems effectively.

Plain Language Summary

This study explored the challenges international healthcare management students face and emphasizes the importance of developing ethical, cultural, and transnational competencies to meet the expectations of Australia’s healthcare system. These students often encounter significant differences between their cultural values and the ethical standards of their host country. Building these skills is essential for ensuring they can provide ethical and culturally sensitive care while preparing for leadership roles in diverse healthcare environments. To understand these challenges, researchers surveyed 35 postgraduate healthcare management students from various cultural backgrounds. The survey explored their experiences with ethical issues in their home countries, their views on adapting to Australian healthcare standards, and their awareness of cultural diversity and preparedness to address ethical dilemmas. Participants also shared insights into effective leadership practices that promote ethical behavior. Key findings revealed that students identified major ethical challenges, including issues in healthcare access, resource allocation, and patient safety. While students showed strong abilities in cross-cultural communication and cultural awareness, they emphasized the need for more support in ethical decision-making. They highlighted the importance of leadership practices such as fostering inclusivity, transparency, and supportive work environments. This study suggests that international healthcare students need targeted support and training in cultural and ethical competence to prepare for leadership roles in countries like Australia. Education institutions can help students develop these skills to improve the quality of care for diverse populations and strengthen ethical practices in the global healthcare workforce.

Introduction

Healthcare leaders face numerous ethical challenges, requiring them to navigate complex issues while demonstrating ethical and cultural competence^1,2 and, transnational competence for international healthcare professionals.³ These competencies are integral to effective leadership, particularly in globalized healthcare systems where diverse cultural and ethical norms intersect.^1–5 Ethical competence involves upholding moral principles such as accountability, transparency, and integrity in decision-making, ensuring that actions align with ethical standards.^1,4 Similarly, cultural competence refers to the ability to acknowledge, respect, and respond effectively to diverse cultural backgrounds of individuals.² Transnational competence complements these skills by equipping leaders to address the complexities of working across diverse healthcare systems and cultural boundaries.³

While the importance of these competencies is well-established, existing literature offers only some insights into how healthcare leaders navigate the practical realities of ethical dilemmas in multicultural contexts. For example, healthcare leaders may face challenges when differing cultural interpretations of autonomy clash with established informed consent practices. These situations can lead to conflicts, miscommunication, and ultimately, compromised patient safety and care quality.^6–10

Healthcare professionals from cultures that prioritize holistic medicine may encounter conflicts when required to practice evidence-based approaches.¹¹ Similarly, workplace norms such as informal payments or gifts, common in some countries are deemed unethical and in most cases illegal in Australia.¹² Navigating Australia’s multicultural healthcare environment presents additional challenges, particularly around inclusivity norms and workplace dynamics, where societal differences may lead to misunderstandings and hinder cross-cultural functioning.^13,14

Recent discussions with international healthcare management students at an Australian university highlighted these challenges in practice. Students from various Asian and African countries shared experiences of inequity, bribery, abuse, racism, and corruption. While these narratives differ from the Australian healthcare context, they offer valuable insights into diverse ethical perspectives and the importance of understanding global variances in ethical practices. For international healthcare professionals and aspiring healthcare managers, adapting to the Australian healthcare system requires a deliberate approach beyond intuition and past experiences.¹⁵

Effectively addressing these issues requires healthcare managers to demonstrate ethical leadership by aligning their actions with local and organizational norms and values.^16–18 While intuition and past experiences can expedite decision-making in fast-paced healthcare environments, studies have identified that this approach often fails to account for cultural nuances and divergent ethical standards.^11,19,20 Instead, successful adaptation requires strategic approaches such as cultural awareness training and the integration of diverse cultural viewpoints to foster an ethically robust healthcare environment.²¹ This underscores the importance of deliberate, informed approaches to ethical leadership that address the intricacies of multicultural healthcare contexts.

As ethical challenges have grown more complex, healthcare ethics has expanded beyond the Hippocratic principle of “Do no harm” to embrace broader values such as justice, duty, and fairness.¹⁷ However, as Sheperis, Henning, and Kocet (2016) and Martinelli (2022) suggest, widely accepted values such as honesty, equity, and transparency can vary across cultures. These variations arise from cultural and societal norms that shape health beliefs and practices, ultimately influencing ethical decision-making.^4,22

Expanding further, the literature on transnational competence (TC) explores the multifaceted challenges of navigating diverse global settings and interactions. Emerging in the late 1990s during accelerated globalization, TC equips professionals and students with the skills to effectively navigate diverse national, cultural, and institutional contexts. It encompasses a broad spectrum of competencies critical for management and leadership in a globalized world. These include analytical abilities to interpret complex international events, understand the interplay between global and local healthcare contexts, and address challenges that transcend borders. Additionally, TC requires cross-cultural communication skills, practical proficiencies that promote multicultural appreciation, and personal traits such as adaptability, flexibility, and self-awareness, all vital for thriving in unfamiliar and diverse environments.³

A critical insight from the literature on TC is the importance of preparation, “although transnational competence can be enriched by informed experience, its foundational components require advance preparation”.³ This highlights that TC development relies not only on experience but also on thorough preparation and education, significantly enhancing one’s ability to operate in transnational settings.

In summary, the key themes identified in the literature—ethical leadership, cultural competence, multicultural settings, ethical decision-making, and the influence of past experiences—provide critical insights into preparing international students for leadership roles in healthcare. However, despite research on the challenges faced by international students, such as cultural adaptation, navigating academic expectations, and addressing ethical dilemmas, there remains a notable gap in integrating these themes into a cohesive approach that equips international students with the specific competencies, skills and insights needed for healthcare leadership in multicultural contexts.^23–26

Current approaches to addressing these challenges vary across healthcare leadership programs. The American College of Healthcare Executives (ACHE) and the Australasian College of Health Service Management (ACHSM) have established competency frameworks that guide the integration of ethical, cultural, and leadership competencies into educational programs. The ACHE framework emphasizes professionalism and cultural dynamics within healthcare organizations, while the ACHSM framework specifically addresses the need for health service managers to navigate diverse cultural contexts. To meet these accreditation competencies educational programs typically employ a combination of theoretical and experiential learning approaches, including case studies, simulations, and field placements.^27,28 However, the effectiveness of these approaches in preparing international students specifically for leadership roles in culturally diverse healthcare settings remains unclear. A systematic scoping review by Jongen et al highlighted that while cultural competency training improves practitioners’ knowledge, attitudes, skills, and behavior, there are concerns regarding the strength and quality of evidence supporting these interventions, indicating a need for further research and standardization in this area.²¹

This study utilized a survey to examine the ethical, cultural, and transnational challenges international healthcare management students potentially face as they prepare for leadership roles in Australia. By investigating how these experiences can shape a students’ readiness for leadership, this initial research aimed to establish foundational understanding of the competencies and skills required for ethical decision-making, cultural integration, and transnational readiness for international healthcare leaders in diverse healthcare environments.

Theory

Guided by McGregor²⁹ a step-by-step approach was taken to ensure our study would be grounded in an appropriate foundational theoretical framework. As the research sought to explore the confluence of cultural and transnational dimensions, and the ethical understanding of international students, it became evident that more than a single theoretical perspective would be required. Such a unidimensional approach would risk oversimplifying the rich complexities and interplay of the students’ backgrounds, experiences, and aspirations in ethical decision-making within multicultural healthcare settings. The decision to adopt a composite theoretical framework was made.

Selecting and forming the composite framework involved an iterative process of aligning the study’s aims with established theoretical perspectives. This commenced with a comprehensive review of individual theoretical perspectives pertinent to the study’s key themes identified in the literature. After identifying seven initial theories, a matrix was developed and a systematic comparison was made between each Theory and key themes identified in the literature. Three of the seven theories were excluded based on their limitations in providing a comprehensive framework for exploring the themes. The theories best aligned with the key themes and study’s aims are Cultural Relativism, Ethical Climate Theory, Institutional Theory, and Transnationalism.

To operationalize the study’s composite theoretical framework, a conceptual framework was developed to map the alignment between the key themes from the literature, corresponding concepts, definitions, and theories. This framework served as a foundation for understanding how the identified competencies—ethical, cultural, and transnational—intersect to shape leadership readiness. Table 1: Conceptual Framework illustrates how these elements were systematically integrated to underpin the survey design and study purpose. It highlights the relationships between themes, theories, and measures.

Table 1.

Conceptual Framework

Themes from the Literature	Concepts Identified	Definitions of Concepts	Underpinning Theory	Purpose	Measures to be Surveyed
Cultural competence Multicultural settings	Cross cultural transitions	Adaptation to a new cultural environment, including new norms, values, language, and behaviors.1–3	Cultural Relativism & Transnationalism	To examine how cultural adaptation influences students’ preparedness for leadership in diverse healthcare systems	Cultural Competence
Ethical leadership Ethical decision-making	Perceived Ethical Norms	Understanding and interpreting moral rights/wrongs in different contexts.16–18	Cultural Relativism & Ethical Climate Theory	To understand how perceptions of ethical norms influence decision-making in healthcare leadership.	Ethics Awareness
Organizational practices	Organizational Norms	Shared expectations and rules guiding behavior in organizations.4,17,22,23	Ethical Climate Theory & Institutional Theory	To explore how organizational ethics shape leadership behaviors and align with institutional values.	Ethical Challenges & Ethical Leadership Practices
Transnational readiness	Global versus Local Norms	The ability to reconcile global ethical standards with local practices.3,14	Institutional Theory & Transnationalism	To assess how international students balance global best practices with local healthcare contexts.	Transnational Competence & Preparation Strategies

The theoretical perspectives selected for this study serve as the foundation for understanding and analyzing the key concepts outlined in Table 1. Each theory offers unique insights into the ethical, cultural, and transnational dimensions critical for preparing international students for leadership roles in multicultural healthcare contexts. Below, we discuss how each theory aligns with and informs the study’s purpose.

Cultural Relativism

Cultural relativism, first identified in early 20th-century anthropological theory, was developed to understand how individuals interpret their world through cultural and intellectual lenses.³⁰ This concept has evolved to emphasize the importance of fostering global cultural understanding, especially as specific cultural contexts shape moral values and ethics.³¹ In this study, cultural relativism is crucial for understanding how international students reconcile their cultural beliefs with the ethical norms of the Australian healthcare system. This approach highlights the necessity of adapting to new ethical standards while respecting students’ diverse cultural values.

Ethical Climate Theory (ECT)

Ethical Climate Theory (ECT), introduced by Victor and Cullen in the late 1980s, is a crucial framework for understanding ethics in organizational contexts. Using sociological and philosophical theories, ECT analyzes how organizational environments shape ethical decision-making and behavior.³ For example, nurse managers frequently encounter ethical issues related to organizational policies and resource allocation, often exacerbated by conflicting values and limited resources, which can lead to moral distress among healthcare professionals.²³ For international students, understanding the ethical climate in their host country, such as Australia, is crucial, as it directly impacts their decisions and actions in healthcare. Ethical norms, including those on patient confidentiality and informed consent, often vary across cultures, potentially creating ethical dilemmas when students’ practices from their home country conflict with Australian standards.^24,32,33 This theory underscores the importance of understanding these climate differences to provide culturally competent and ethically sound care.³⁴

Institutional Theory (IT)

Institutional Theory, pioneered by Max Weber (1864–1920), explores how social structures, norms, and values shape human behavior and organizational practices. This theory posits that societal norms and legal frameworks significantly influence individual behavior.³⁵ For international students, Institutional Theory underscores the importance of aligning with the Australian healthcare system’s ethical standards while being mindful of institutional influences from their home countries. This dual alignment is crucial for ethical adaptation in a multicultural healthcare context.

Transnationalism

Transnationalism is a relatively recent theory that examines the connections individuals maintain across national borders. Unlike other theories, transnationalism emphasizes the multifaceted identities shaped by diverse national contexts, showing how these influences intersect and impact decision-making.³⁶ In this study, transnationalism is particularly relevant for understanding how international students navigate dual or multiple affiliations, bridging the ethical expectations of their home countries with those of Australia. This lens underscores the need for a nuanced approach to ethical decision-making that incorporates global and local considerations.

Grounded in the conceptual framework, which was informed by the composite theoretical framework, this study formulated four research questions to guide its exploration of how international students navigate the ethical, cultural, and transnational dimensions of leadership in host healthcare systems:

RQ1. What ethical challenges do international students believe a manager might face in a healthcare setting?

RQ2: What leadership practices do international students believe could promote ethical practices?

RQ3: What ethical challenges have the participants of this study perceived or experienced in their home countries, and how do they think these experiences have or would influence their ethical decision-making?

RQ4: What strategies do the participants of this study perceive as useful in preparing for ethical, cultural and transnational readiness before relocating for study and work?

Method

This study employed a cross-sectional survey design to gather both quantitative and qualitative data, allowing for a comprehensive analysis of international students’ perspectives on ethical, cultural, and transnational insights. A cross-sectional survey design is particularly suitable for exploratory research, as it enables the collection of rich data from a specific population at a single point in time, facilitating an initial understanding of complex phenomena such as competencies and insights.³⁷ Ethics approval was obtained from the University of South Australia ethics committee on the 30th of March 2023. Participation in the online survey was voluntary, and a third party administered the survey (not the academics undertaking the study) to ensure objectivity and to reassure students that their participation, or lack thereof, would not affect their grades.

Survey Development

The survey instrument was developed using our conceptual framework and a targeted literature review to identify validated instruments addressing the research questions. This process identified three relevant sources: the Cultural Competence Self-Assessment Checklist (CVIMS), the Ethics Position Questionnaire (EPQ-5), and the Transnational Competence Framework (TCF).

Developed by the Central Vancouver Island Multicultural Society, the Cultural Competence self-assessment (CVIMS) checklist evaluates cultural competence across three dimensions: awareness, knowledge, and skills, with a focus on cultural understanding, self-reflection, and cross-cultural communication. It also examines adaptability, proactive support for diverse groups, and continuous learning. Permission was granted to use and adapt this tool, which originally comprises 32 questions measured on a 5-point Likert scale.³⁸ Ten statements were selected from the CVIMS checklist for this study. The statements that were selected to be incorporated into the survey for this study were chosen to align closely with the core objective of the study, which focuses on understanding the interplay between cultural competence and ethical decision-making in healthcare leadership. As stated previously, these statements, encompassing the themes of awareness, knowledge, and skills, provide a nuanced exploration of how healthcare professionals perceive and navigate ethical challenges in a culturally diverse environment. Statements such as being aware of one’s discomfort with differences (Statement 4 of original CVIMS survey) and recognizing the influence of personal cultural perspectives on judgment (Statement 7 of original CVIMS survey) delve into the introspective aspects of cultural awareness. Similarly, acknowledging limited knowledge about different cultural groups (Statement 14 of original CVIMS survey) and the multifaceted nature of identity (Statement 16 of original CVIMS survey) reflect an understanding of the complexity and ongoing learning required in cultural competence. The inclusion of skills-related statements, like developing respectful interactions with diverse groups (Statement 23 of original CVIMS survey) and recognizing one’s own cultural biases (Statement 28 of original CVIMS survey), underscores the practical application of this competence in ethical decision-making. The statements that were excluded from the original CVIMS checklist were primarily those that, while valuable in a broader context of cultural competence, did not directly contribute to the specific focus of the study on ethical decision-making in healthcare leadership. For instance, statements pertaining to general awareness of cultural identity and differences (eg, Statements 1–3 of original CVIMS survey) were considered too foundational and not sufficiently focused on the ethical aspects of cultural competence. Similarly, statements related to specific historical incidents of racism (eg, Statement 17 of original CVIMS survey) or family immigration stories (eg, Statement 21 of original CVIMS survey) were deemed less relevant for the international and diverse audience of the study. Skills-oriented statements that emphasized practical actions, such as intervening in discriminatory behavior (eg, Statement 24 of original CVIMS survey) or being involved in diversity initiatives (eg, Statement 27 of original CVIMS survey), were excluded as they leaned more towards external actions rather than internal cognitive processes and ethical considerations. The exclusion of these statements was a strategic decision to ensure that the survey remained tightly aligned with the study’s core objective.

The Ethics Position Questionnaire (EPQ-5), validated in 2021, measures idealism (universal ethical standards) and relativism (context-dependent ethical standards).³⁹ All ten questions were incorporated into the survey for this study to understand how participants’ ethical stances influence their decision-making and judgment in multicultural healthcare settings. Additionally, four tailored questions that were developed based on ethical climate theory and institutional theory to assess behaviors that are important for functioning effectively across different cultural and national settings were included in the final survey. These are the questions that were asked:

1. On a scale of 1–10, how prevalent would you say ethical dilemmas are in your home country’s healthcare system?

2. Describe one significant ethical challenge you have observed or experienced in your home country’s healthcare system.

3. Do you believe your experiences with ethical challenges in your home country might influence your decision-making in the Australian healthcare system?

4. I believe that ethical decision-making is influenced by one’s cultural background?

Five experts on the study topic reviewed each question in the final survey using a content validation form. The expert reviewers included professionals from various healthcare sectors. These comprised a senior healthcare administrator specializing in aged care, a healthcare clinic manager with experience in overseeing culturally diverse teams, and a senior leadership coach and training specialist with expertise in healthcare education for culturally diverse students. Additionally, the panel included a senior pharmacist with a background in ethics and a senior hospital manager working in the public healthcare system, experienced in managing culturally diverse teams and supervising students on placement. Each question was rated on a scale of 1–4 (1 = not relevant, 4 = highly relevant), and the content validity index (CVI) was calculated, yielding a score of 0.98, indicating strong agreement on the survey’s relevance⁴⁰ A pilot test was conducted in December 2023 with 20 graduating international students from the Masters in Health Services Management program. Seven students participated, resulting in a 35% response rate. This pilot test confirmed the survey’s clarity and functionality, and no changes were required before the main data collection.

Data Collection

The sampling frame consisted of 152 international students (132 current students and 20 recent graduates) from the University’s Health Services Management program. Inclusion criteria specified currently enrolled students or recent graduates (within 12 months of completion) with active university Email addresses. This timeframe was selected to ensure currency of experience while capturing perspectives across different stages of the educational journey.

Data collection occurred through a structured three-wave recruitment process between March and May 2024. Each wave involved formal Email invitations followed by reminder emails at two-week intervals. The survey was administered via Qualtrics, incorporating built-in validation checks and required field completion for key questions. The instrument was designed to take approximately 20–25 minutes, with tracking indicating most respondents completed within this timeframe (mean completion time = 22.3 minutes).

This approach is particularly appropriate for an exploratory investigation, as it allows for the collection of diverse and contemporary perspectives from a specific, targeted population. The inclusion of both current students and recent graduates supports the study’s aim of understanding experiences across different stages of their educational journey, providing nuanced insights.³⁷

The survey yielded 35 responses, representing a 23% response rate. While this response rate might initially appear modest, it aligns with documented patterns in healthcare professional survey research. For example, Raby et al⁴¹ reported a 17% response rate from 310 healthcare professionals, and VanderPluym et al⁴² achieved 20.7% among early-career healthcare professionals. Although higher response rates have been observed—Hashemi et al⁴³ achieved 38.6%—the literature indicates significant variability in online survey response rates among healthcare professionals.

The sample demonstrated strong demographic diversity, with participants representing varied healthcare backgrounds as shown in Table 2.

Table 2.

Demographics

Characteristics	n	%	M(SD)	Range
Gender
Female	28	80
Male	6	17
Non-Binary	1	3
Age in years			29 (10.85)	18–54
18–24	9	26
25–34	19	54
35–44	6	17
45–54	1	3
Ethnic Background
South Asian	18	51
Southeast Asian	9	26
East Asian	3	9
African	4	11
Other	1	3
Professional Discipline
Dentist	10	29
Physiotherapist	6	17
Medical Practitioner	5	14
Nurse	5	14
Other	9	26

Quality assurance was maintained through multiple mechanisms, including pilot testing with seven graduating students, and regular monitoring of response patterns. While acknowledging the response rate as a potential limitation regarding generalizability, the demographic alignment with the broader program population enhances confidence in the findings’ reliability within this specific educational context.

Data Analysis

Data were analyzed using both qualitative and descriptive methods to align with the exploratory aims of the study, which sought to uncover patterns and insights related to international students’ competencies in ethical, cultural, and transnational contexts. Descriptive statistics, including frequencies, means, and standard deviations, were employed to summarize the quantitative variables. To ensure consistency, all scales were standardized on a 1–5 range. Responses such as “Prefer not to say” were excluded from the analysis.

For qualitative data derived from two open-ended survey questions, an adapted version of the Gioia methodology was applied to conduct thematic analysis. Thematic analysis is particularly appropriate for exploratory investigations as it facilitates the identification of patterns and themes in participants’ experiences, allowing for a deeper understanding of complex, context-specific phenomena.⁴⁴ Although the Gioia method is traditionally used for theory-building, it was adapted here to facilitate a rigorous thematic analysis within the study’s theoretical framework. This method supports the exploratory aims by organizing data into meaningful categories that reflect participants’ perspectives on ethical, cultural, and transnational competencies, without attempting to construct a new theoretical model.

The Gioia methodology organizes data into three levels—First-Order Concepts (participant-centric codes), Second-Order Themes (researcher-generated themes), and Aggregate Dimensions (higher-order themes that encapsulate key insights).⁴⁵ Given the smaller dataset, a streamlined approach was used, focusing on identifying primary insights and grouping them into relevant themes. This inductive process enabled us to identify themes reflecting the ethical challenges and adaptive strategies of international healthcare students in a new cultural context. Initial coding was conducted by the primary researcher, MH, and reviewed by KT and RJ to ensure consistency and accuracy until consensus was reached.

Results

Participants

The majority of participants were female (80%), reflecting a gender imbalance likely attributable to higher female enrolment in the university’s postgraduate program. This imbalance may limit the study’s generalizability, as male perspectives are underrepresented. Despite this, a T-test comparing male and female responses regarding their awareness of discomfort when encountering differences in race, religion, sexual orientation, language, and ethnicity yielded a p-value of 0.4274, exceeding the 0.05 threshold. This result indicates no statistically significant difference in responses between genders.⁴⁶ However, the unequal sample sizes may reduce the statistical power of the T-test, potentially obscuring real differences. To address this, a subgroup analysis was conducted, revealing that the mean response for males (3.555) was slightly higher than for females (3.143). Male responses also demonstrated lower variability (SD = 0.982) compared to females (SD = 1.167). The lower standard deviation among males suggests their responses were more consistent, while the higher variability among females indicates a broader range of perspectives.

Most participants were aged 25–34 years (54%) and identified predominantly as South Asian (51%). The largest professional discipline represented was dentistry (27.78%). Descriptive statistics were calculated to summarize the central tendency and variability of responses for each measure, ensuring robust data interpretation. Cronbach’s Alpha was computed for all measures to assess internal consistency^46,47 as shown in Table 3.

Table 3.

Survey Measures

	Survey Measures	Survey Questions	N	Mean	Standard Deviation	Cronbach’s Alpha*
1	Ethical challenges	Q5	35	3.4	0.8	0.85
2	Ethical leadership practices	Q6	35	3.2	0.9	0.82
3	Cultural competence	Q7-16	35	3.6	0.7	0.94
4	Transnational competence	Q17-21	35	3.5	0.8	0.93
5	Ethics awareness	Q22-32	35	3.3	0.7	0.89
6	Preparation and strategies	Q33-35	35	3.4	0.8	0.86

Note: *Cronbach’s Alpha: values above 0.8 indicate good reliability.

The results from the survey are presented below, offering initial insights into each of the survey measures outlined in Table 3. These findings provide a foundational understanding of the ethical, cultural, and transnational competencies of international healthcare management students.

Ethical Challenges

The participants were asked to rank what types of ethical challenges leaders may face in a healthcare setting. A list of ten types of ethical challenges were presented and they were asked to choose their top five challenges and rank them in order as displayed in Figure 1. Addressing health disparities and social determinants of health (Health Equity) (17.4%) and ensuring patient safety and quality of care (16.1%) emerged as the most significant ethical issues.

Figure 1.

Ethical Challenges.

Leadership Practices

The next question asked the participants to choose their top five leadership practices that promote ethical behavior as displayed in Figure 2. The participants prioritized creating a supportive work environment (15.9%), promoting diversity and inclusion (15.3%), fostering transparency (14.7%), establishing clear roles and responsibilities (12.4%), and encouraging reporting of ethical violations (9.4%).

Figure 2.

Leadership Practices.

Cultural Competence

The responses to questions (Q) 7 to 16 indicated a generally high level of cultural competence among participants. Many reported frequent awareness of discomfort when encountering differences in race, religion, sexual orientation, or ethnicity (Q7), with the majority responding, “Very Well” or “Fairly Often”. A similar trend was observed regarding awareness of personal assumptions about other cultures (Q8). Participants also showed strong awareness of how their cultural perspectives shaped judgments of behavior and communication (Q9), with frequent responses of “Always” and “Very Well”. Many actively sought to learn about cultural differences and establish connections with diverse groups (Q10). Recognition of limited knowledge about certain cultural groups was common, with high levels of commitment to learning more (Q11). Most participants rejected the notion of their own culture as a singular reference point for judging behavior (Q13), and they frequently engaged in respectful and effective interactions with culturally different individuals (Q14). Participants often sought feedback to improve cross-cultural skills (Q15) and demonstrated high awareness of their own cultural biases, striving not to act upon them (Q16).

Transnational Competence

The transnational competence section revealed that participants had varied levels of preparation and adaptability in their host country. A majority rated themselves as “Moderately prepared” or “Very prepared” for relocation (Q17), with efforts to understand key customs and traditions but sometimes missing finer details. In terms of host country knowledge, many had a moderate understanding of major historical events (Q18), though some only knew basic facts. Familiarity with local laws was also moderate, with many expressing a general understanding but lacking detail (Q19). Participants generally rated themselves as “Moderately resilient” (Q20), able to handle challenges and uncertainties but occasionally facing difficulties. High adaptability to new environments was common (Q21), with most participants agreeing they could adjust quickly to new settings.

Ethics Awareness

Results for ethics awareness highlighted strong convictions around ethical norms. Most participants agreed that actions should never intentionally harm others, with “Strongly Agree” and “Agree” being the predominant responses. A similar trend was observed regarding the importance of avoiding risks to others. When asked whether moral standards should vary by context, responses were mixed. Some agreed that ethical standards might shift across situations and societies, while others held more universalist views. Opinions on moral relativism varied, with some supporting an individualistic approach to ethics, while others believed in collective standards. Regarding the influence of home-country experiences on ethical decision-making in Australia, responses varied. Some participants believed their experiences would “Definitely” or “Probably” influence their decisions, while others were more uncertain or did not believe it would have any impact. Question 30 was an open-ended question asking the respondents to describe one significant ethical challenge that they have observed or experienced in their home country’s healthcare system. Four main aggregate dimensions were identified and will be presented next as shown in Figure 3.

Figure 3.

Data Structure (survey question 30).

Resource Allocation and Access Dimension

Respondents highlighted the impact of financial status on the quality of care, the lack of proper insurance schemes, and the disparities in resource allocation during critical situations such as the COVID-19 pandemic. Limited access to healthcare in rural areas and the need for private health coverage due to insufficient public healthcare funding were also noted. For example, a respondent stated that there is “disparity of health resources especially in the marginalised areas”.

Inequality and Bias Dimension

Several responses pointed to the presence of special treatment for certain roles, racial bias, and tribalism within the healthcare system. Disparities in healthcare access between rich and poor, as well as between urban and rural areas, were significant concerns. Judgmental attitudes towards patients’ autonomy and choices further exacerbated these inequalities. For example, a respondent stated, “quality of care will vary depending on your financial status”.

Ethical and Legal Challenges Dimension

The legal and ethical debates surrounding issues such as abortion, patient confidentiality, and organ trafficking were prominent. Instances of corruption, such as demanding money before treatment and misuse of resources by healthcare professionals, were also significant ethical challenges. For example, a respondent stated

A significant ethical challenge is facing corruption in high levels of organisational management, where professionals in important positions make use of resources in unethical ways (personal use, inadequate placement of resources, etc).

Professional and Organizational Issues Dimension

Hierarchical structures and professional dominance, particularly among doctors, were noted to contribute to unequal treatment and limited teamwork. Issues included procedural delays, queue-skipping, and general organizational mismanagement. One participant shared,

Professional dominance leads to hierarchies within the healthcare team, causing unequal treatment and limited collaboration, which ultimately impacts healthcare outcomes.

Preparation and Strategies

Question 35 was the second open-ended question that asked the respondents to “describe what preparation strategies [they would] recommend for International students to take before coming to Australia?” Three aggregate dimensions were identified and will be presented next as shown in Figure 4.

Figure 4.

Data Structure (survey question 35).

Practical Preparation Dimension

Practical steps, including researching Australia’s history, consulting with family and students, setting financial plans, and familiarizing oneself with rules and regulations, were frequently recommended. Participants emphasized academic readiness, understanding the healthcare system, and preparing for life in a multicultural society. A participant suggested, “make a financial plan for completely focusing on studying at least for the first year”.

Cultural and Social Adjustment Dimension

Respondents highlighted the need for cultural awareness and adaptability. Recommendations included researching cultural differences, embracing diversity, learning about community norms, and enhancing communication skills. One participant advised, “…they should be aware of Australian culture, such as food and lifestyle, and have fluent communication skills”.

Ethical and Legal Awareness Dimension

Ethical and legal awareness was deemed essential, with respondents advising research into Australia’s history, laws, and ethical practices to aid in adapting to local norms. One response noted, “International students should raise their awareness about the culture and norms in Australia”.

Discussion

Building on the initial insights presented in the results section, this discussion further unpacks the complexities and nuances uncovered through this exploratory investigation. The findings offer an important starting point for understanding the ethical, cultural, and transnational challenges faced by international healthcare management students and how these experiences shape their preparedness for leadership roles.

Research Question 1, which examined the types of ethical challenges students believe managers face, revealed recurring themes of healthcare inequity, resource constraints, and patient safety. For example, students frequently referenced the difficulty of balancing patient-centered care with organizational policies, particularly when these policies conflicted with ethical standards from their home countries. This aligns with prior literature emphasizing the ethical stakes of healthcare decision-making but highlights a more nuanced layer of cross-cultural tension that was underexplored in the literature.³³

Research Question 2 explored leadership practices that promote ethical behavior. The findings suggest that fostering a supportive work environment and promoting diversity are viewed as essential practices. These align with Ethical Climate Theory, which emphasizes the role of organizational environments in shaping ethical behaviors. However, an unexpected finding was students’ emphasis on the role of peer-to-peer interactions in fostering an ethical climate, suggesting that leadership development programs should not only focus on top-down strategies but also equip students to influence their peers.³⁴

Research Question 3 examined how students’ home-country experiences with ethical challenges influence their decision-making. Participants highlighted issues such as bribery, systemic bias, and discrimination as pervasive challenges in their home countries. These experiences shaped their sensitivity to inequity but also presented adaptation challenges in Australia, particularly when reconciling these practices with stricter regulatory standards. This finding underscores the importance of recognizing the role of systemic and cultural norms in shaping ethical perceptions.⁴⁸

Research Question 4 investigated strategies that students perceive as useful for preparing for ethical, cultural, and transnational readiness. Students emphasized the need for targeted pre-arrival training that includes practical case studies and a deeper understanding of Australian healthcare norms. This finding highlights the gap between theoretical knowledge and practical preparedness, emphasizing the need for more actionable training frameworks.

Theoretical Insights

The findings from this study bring to light the multifaceted realities faced by international healthcare students and their intersections with established theoretical frameworks. At its core, this research emphasizes that transitioning into leadership roles in culturally diverse healthcare settings requires more than theoretical knowledge it requires a nuanced engagement with the challenges of cultural integration, ethical decision-making, and navigating unfamiliar systems.

This study illustrates how students perceive ethical leadership not as an abstract ideal but as a practical, everyday necessity. Participants consistently underscored the value of fostering supportive work environments and creating spaces where ethical dilemmas can be openly discussed. For healthcare leaders, this reinforces the importance of cultivating institutional norms that encourage transparency and open dialogue on ethical challenges.

The tension between home-country values and host-country expectations emerged as a recurring theme. This finding connects directly to Cultural Relativism, which posits that ethical standards are culturally constructed rather than universal.³⁰ For students, this tension often manifested in reconciling deeply ingrained cultural practices with the ethical standards of the Australian healthcare system. For example, a participant highlighted the challenge of transitioning from a system where informal payments were customary to an Australian context with strict anti-corruption policies. Such moments of ethical dissonance, while unsettling, serve as powerful learning opportunities. Leadership programs should harness these real-world experiences, incorporating them as case studies to facilitate discussions about cultural influences on ethical decision-making and self-awareness.

The findings also reveal how many students actively work to bridge the gap between their home-country and host-country contexts, exemplifying the duality of cultural identity described in Transnationalism.^3,26 Rather than abandoning their cultural backgrounds, students integrate these perspectives into their professional roles, striving to lead effectively across borders. However, this adaptive process underscores the need for leadership education to adopt frameworks that address the cultural layers influencing ethical decision-making and the competencies required to develop transnational proficiency.

Practical Implications

The practical implications of these findings point to the necessity of comprehensive pre-arrival and ongoing training programs tailored to the unique needs of international students. The pre-arrival and ongoing support program structures outlined next serve as a foundational blueprint for further exploration:

Phase 1: Pre-Arrival Training

This phase should provide cultural orientation to familiarize students with Australian (or host country) norms, societal values, and the ethical dimensions of healthcare practice. Training formats can include online modules, webinars, and interactive sessions. Recognizing potential systemic barriers faced in students’ home countries, training should also offer strategies for overcoming these challenges. Language proficiency courses tailored to healthcare terminology are recommended to enhance communication skills in medical and ethical contexts.

Additionally, workshops on transnational competence should focus on global healthcare practices, ethical standards, and cultural nuances to prepare students for the transition to the Australian (host country) context. These workshops should emphasize understanding systemic and cultural barriers that may affect ethical leadership.

Phase 2: Ongoing Support During Study

Continuous support is essential once students arrive in the host country. Mentorship programs pairing new students with mentors who have successfully navigated similar transitions can offer guidance on cultural and systemic challenges. The curriculum should also incorporate cultural competence training through role-playing, case studies of ethical dilemmas in the Australian (host country) healthcare system, and cross-cultural communication strategies. Simulation-based training should mirror real-world healthcare settings, allowing students to practice ethical decision-making and cultural competence in scenarios that emphasize systemic and cultural challenges. Additionally, support services such as counseling, academic assistance, and career guidance, tailored to the unique needs of international students, can aid in their successful adaptation to the Australian healthcare system (host country) and foster their capacity for ethical leadership.

Integrating the Ethics, Cultural, and Transnational Leadership Framework

This study underscores the importance of leadership curricula that focus on preparing international healthcare students for the multifaceted challenges of leadership in multicultural healthcare settings. The Ethics, Cultural, and Transnational Leadership Framework developed from this study provides key topics and focus areas to guide leadership development curricula. Rather than serving as an exhaustive or prescriptive model, the framework highlights the essential competencies, skills, and behaviors that should be embedded into training programs. It offers a structured starting point for developing curricula that emphasize ethical decision-making, cultural integration, and transnational readiness; ensuring students are equipped to navigate the complexities of diverse healthcare environments as shown in Figure 5.

Figure 5.

The Ethics, Cultural, and Transnational (ECT) Leadership Framework.

Strengths and Limitations

This study’s questionnaire demonstrated high content validity, ensuring that the questions were relevant and appropriately framed for the participants. The mixed-methods approach, combining quantitative and qualitative data, provided a robust framework for exploring the ethical, cultural, and transnational competencies of international healthcare management students. The use of thematic analysis further allowed for the identification of meaningful patterns and themes that align with the study’s exploratory aims.

However, as an exploratory study, certain limitations are inherent to its design. The small sample size while sufficient for uncovering initial patterns and insights, limits the generalizability of the findings. This reflects the intent of the study to provide a preliminary understanding rather than definitive conclusions. Similarly, the reliance on self-reported data may introduce response bias, but this is a common trade-off in exploratory research aiming to capture subjective experiences and perceptions.

Thematic analysis, while insightful, could potentially yield more nuanced themes with a larger dataset. Nonetheless, for an exploratory investigation, the approach successfully identified key themes that can inform future, more extensive research. Additionally, the study’s focus on postgraduate students within a single Health Services Management program in Australia restricts the applicability of the findings to other contexts or populations. This was a deliberate choice to narrow the scope and align with the study’s exploratory goals, but it does suggest the need for future research in more diverse settings.

Finally, the demographic composition—primarily young and female participants—limits the representation of diverse perspectives. While this study highlights valuable insights into ethical leadership challenges for this group, attitudes and experiences may differ across age groups, genders, and cultural backgrounds.

Future Research Directions

Building on the insights provided by this study, future research could explore how transnational considerations evolve over time, particularly regarding their impact on long-term professional behavior and ethical decision-making in healthcare settings.

Additionally, examining the effectiveness of the proposed pre-arrival and ongoing support programs presents a critical next step. Pilot studies could assess the impact of structured pre-arrival training programs on cultural competence, ethical awareness, and preparedness to navigate the host country’s healthcare system. Research could also evaluate the long-term effects of ongoing support initiatives, such as mentorship programs and simulation-based training, on students’ adaptation, resilience, and leadership competencies over time.

Expanding the scope of research is another important direction. Extending investigations to other demographics, such as undergraduates or healthcare professionals in non-Australian contexts, would provide comparative insights and enhance the understanding of ethical and cultural competence across diverse settings. Comparative analyses between the ECT Framework and established models (such as ACHE and ACHSM competency frameworks) could identify areas of alignment, unique contributions, and opportunities for integration, strengthening the theoretical foundation of healthcare leadership development. Similarly, cross-cultural validation studies could assess the applicability of the Ethics, Cultural, and Transnational (ECT) Leadership Framework in a range of global healthcare and educational environments. This would include examining the framework’s implementation in leadership curricula across different institutional, cultural, and professional contexts to identify areas for refinement and broader applicability.

Interdisciplinary research efforts are also encouraged, particularly those integrating perspectives from organizational psychology, sociology, and public health. Such collaborations could provide a richer understanding of how ethical, cultural, and transnational competencies contribute to shaping leadership effectiveness in diverse healthcare systems.

By addressing these directions, future research can build on the theoretical foundation established in this study, advancing the practical implementation and global relevance of the ECT Leadership Framework and associated training programs.

Conclusion

This study provides an initial exploration of the significant ethical challenges and essential leadership practices perceived by international healthcare management students in Australia. It underscores the importance of developing cultural and transnational competencies to address ethical challenges effectively in multicultural healthcare settings. By proposing the Ethics, Cultural, and Transnational Leadership Framework and offering preliminary insights into culturally tailored training programs, this research has the potential to contribute to shaping leadership education.

Funding Statement

The research had no specific funding.

Data Sharing Statement

The survey questionnaire and data that supports the findings of this study are available from the corresponding author MH, upon reasonable request.

Ethics Approval and Informed Consent

This study was carried out in accordance with the Declaration of Helsinki. Ethical approval was obtained from the University of South Australia ethics committee (205398) and informed consent was obtained from all the included participants.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising, or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors report no conflicts of interest in this work.