Learning journeys and identity transformation of foreign undergraduate nursing students in China: a journey mapping study

Abstract

Background

With the internationalization of higher education, foreign undergraduate nursing students studying in China need to adapt not only to a new cultural and academic environment, but also to nursing-specific learning requirements and emerging professional roles. Existing studies have provided valuable insights into international students’ challenges and coping strategies, but less attention has been paid to how learning adaptation, intercultural experience, and identity reconstruction unfold together over time. This study used journey mapping to explore the learning journeys and identity transformation of foreign undergraduate nursing students in China.

Methods

A descriptive qualitative design was adopted. Semi-structured interviews were conducted with 23 foreign undergraduate nursing students studying in China between May 2025 and March 2026. Data were analyzed using conventional content analysis, and journey mapping was used to organize students’ experiences along a temporal and process-oriented trajectory.

Results

The learning journeys of foreign undergraduate nursing students in China involved four interrelated stages: initial entry, negotiated exploration, adaptive development, and transformative reconstruction, which were further refined into 12 substages. Students moved from early disorientation and classroom uncertainty to help-seeking, strategy formation, intercultural integration, and identity reconstruction. The four-stage model represents a synthesized developmental tendency rather than a uniform linear pathway followed identically by all participants.

Conclusions

Foreign undergraduate nursing students’ adaptation in China is shaped by language-related challenges, pre-arrival preparation, cultural environment, classroom norms, nursing-specific learning requirements, and support resources. The findings suggest that adaptation may develop into learner identity reconstruction and future professional orientation. Nursing education should provide staged and sustained support to help foreign students adapt to cross-cultural learning and transform their experiences in China into resources for professional growth.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12909-026-09847-8.

Introduction

With the continuing internationalization of higher education, an increasing number of students are pursuing tertiary education across national borders, and nursing education has likewise become increasingly international and intercultural in nature [1]. Compared with many other disciplines, nursing education is characterized by strong professional, practical, and context-dependent features. Students are required not only to acquire systematic professional knowledge and skills, but also to adapt to the classroom norms, communication patterns, and assessment systems embedded in specific educational contexts [2, 3]. For international nursing students, challenges related to language use, cultural differences, classroom participation, and professional practice are common, regardless of the country in which they study [4]. China provides a particularly meaningful context for examining this process because foreign nursing students study within a host environment in which academic, cultural, and professional transitions overlap. They need to adapt to daily life and campus communication in China, understand classroom expectations and learning norms in Chinese universities, and engage with a nursing curriculum that includes discipline-specific terminology, practice-oriented learning tasks, and preparation for future clinical roles. For this cohort, adaptation is therefore not only a general international student experience, but also a process of professional socialization within nursing education. The Chinese nursing education context allows this study to examine how cross-cultural learning, professional learning, and identity reconstruction are intertwined.

Existing studies have provided valuable insights into international students’ learning experiences in intercultural educational contexts, particularly in relation to language barriers, cultural conflict, academic stress, social integration, and adaptation strategies [5–7]. These studies have made important contributions by identifying the major challenges students encounter and the ways in which they respond to them. However, adaptation, learning participation, and identity-related change have often been discussed as relatively separate aspects of international student experience. Less attention has been paid to how these elements unfold together over time, and how international nursing students move from early cross-cultural disorientation toward learning strategy formation, intercultural integration, and professional identity reconstruction. In this context, challenges related to language, culture, classroom participation, professional terminology, and practice-oriented learning do not occur in isolation; rather, they intersect throughout the learning process as academic tasks progress and intercultural contact deepens [8–10]. A process-oriented perspective is therefore needed to understand not only what difficulties students encounter, but also how these difficulties become turning points for learning reorganization, self-understanding, and future professional development.

Furthermore, changes in students’ cross-cultural learning are reflected not only in the types of difficulties they encounter or in their adaptation outcomes, but also in how they reinterpret themselves, negotiate roles, and construct meaning through continued participation and ongoing adjustment. In recent years, educational research has increasingly shifted from a sole focus on learning outcomes toward greater attention to learners’ developmental processes, particularly their self-understanding, role adjustment, and identity construction within specific educational contexts [11, 12]. Previous studies have suggested that learning is not merely a process of acquiring knowledge and skills, but also a process through which learners continuously adjust their self-perceptions, reconstruct their role positions, and make meaning within a given educational setting [12, 13]. In cross-cultural learning contexts, differences in pedagogical norms, interactional patterns, and value orientations may intensify cognitive conflict and role adjustment, thereby triggering identity-related changes [14, 15]. For foreign undergraduate nursing students studying in China, the learning process involves not only academic adaptation, but also how they understand themselves, position themselves within a new educational culture, and gradually develop views about their future development [16]. Therefore, examining their learning process from an identity transformation perspective may provide deeper insight into the internal mechanisms of cross-cultural learning adaptation.

In this study, identity transformation was understood not as a fixed outcome, but as a dynamic process through which students reinterpret who they are, how they learn, and what kind of professionals they are becoming within a new educational and cultural context. From this perspective, international students’ adaptation is not limited to overcoming language barriers or adjusting to unfamiliar classroom norms. It also involves ongoing negotiation between previous learning experiences and new educational expectations, between personal agency and institutional support, and between learner identity and emerging professional identity. For foreign undergraduate nursing students, this process is particularly significant because nursing education is not only knowledge-based but also practice-oriented, relational, and closely connected to professional socialization. Students are therefore required to adapt to new academic routines while also gradually making sense of nursing values, clinical expectations, communication practices, and their future roles as nurses. This study was informed by this conceptual lens, viewing learning journeys as temporally unfolding processes in which intercultural adaptation, self-formation, and professional identity reconstruction intersect.

Journey mapping, originally developed in service design and user experience research, has increasingly been introduced into educational research in recent years [17]. By presenting key events, emotional fluctuations, changing needs, and experiential touchpoints along a temporal trajectory, this method can effectively reveal the dynamic features of learning processes [18]. Compared with conventional qualitative approaches, journey mapping focuses not only on “what happened”, but also on “when it happened”, “how it changed”, and “which points constituted meaningful turning points” [19]. It is therefore particularly suitable for examining staged learning experiences in complex educational contexts. However, its application in nursing education remains relatively limited, and it has rarely been used to explain the cross-cultural learning processes and identity transformation of foreign undergraduate nursing students studying in China [20, 21].

Accordingly, this study used journey mapping to explore the learning journeys and identity transformation of foreign undergraduate nursing students in China. Specifically, it aimed to examine how students’ learning experiences, emotional responses, adaptation challenges, support needs, and identity-related changes unfolded over time; to identify key turning points in their learning journeys; and to develop a process-oriented understanding of how intercultural adaptation and professional self-formation are shaped within the Chinese nursing education context. By doing so, this study seeks to extend existing international student adaptation literature by linking staged learning experiences with identity reconstruction and future professional orientation.

Methods

Study design

A descriptive qualitative design was adopted to explore the learning experiences and identity transformation of foreign undergraduate nursing students in the Chinese learning context. Journey mapping was used to analyze and visually present the dynamic evolution of these experiences over time. In this study, conventional content analysis was used to identify recurrent meanings, codes, and categories across interview transcripts, whereas journey mapping added a temporal and process-oriented layer to the analysis. Specifically, journey mapping enabled the research team to organize these categories along students’ learning timelines, connect key events with emotional responses, challenges, support needs, and identity-related changes, and identify turning points that would have been less visible through conventional content analysis alone. This study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) to enhance methodological rigor and transparency in reporting [22].

Semi-structured individual interviews were used as the primary method of data collection. Journey mapping served as both an analytical and presentation framework to identify the key events, emotional changes, adaptation challenges, support needs, and identity-related developmental pathways experienced by students during their studies in China. The research team included members with backgrounds in nursing education and qualitative research. At the time of the study, the three interviewers included two university faculty members engaged in nursing education and research and one undergraduate nursing student; two were female and one was male. Before formal data collection, all interviewers received training in reflexive interviewing, neutral probing, and bracketing of preconceptions. None of the interviewers was involved in participants’ course teaching, academic assessment, or routine student management, which helped minimize the potential influence of power relationships on participants’ accounts.

Participants

Purposive sampling was used to recruit foreign undergraduate nursing students from a university in Hangzhou, China, between May 2025 and March 2026. To capture a diverse range of learning experiences in China, students from different academic years, with varying lengths of study in China and different cultural backgrounds, were included.

The inclusion criteria were as follows: (1) being a foreign undergraduate nursing student studying in China; (2) currently enrolled in nursing courses at a Chinese university; (3) aged 18 years or older; (4) able to communicate in English and willing to share their learning experiences; and (5) voluntarily agreeing to participate and to have the interview audio-recorded. Students who were on leave, unable to complete interviews, or who had insufficient course attendance to recall learning experiences clearly were excluded.

Recruitment information was distributed through course announcements and other relevant channels, and snowball sampling was also used to identify additional participants. There were no prior personal relationships between the research team and the participants. Before the interviews, all participants received detailed information about the study and provided written informed consent. The sample size was determined by data saturation, and recruitment was stopped when consecutive interviews generated no new themes or important information [23]. Data collection and preliminary analysis were conducted concurrently to allow ongoing assessment of saturation. This study was approved by the ethics committee of the authors’ institution (Approval No. 20240705-1).

A total of 23 foreign undergraduate nursing students participated in the study. Participants were aged 19–32 years and included 18 female and 5 male students. They were enrolled across different academic years, including Year 1 to Year 4, and came from 12 countries. Their length of study in China ranged from 7 months to 3 years and 8 months. Fourteen participants had clinical experience, while nine had not yet entered clinical learning. Eighteen participants were interviewed once, and five participants were interviewed twice to clarify and enrich key themes. Detailed participant characteristics are presented in Table 1.

Table 1.

Demographic characteristics of participants (n = 23)

ID	Gender	Age (years)	Academic year	Country	Length of study in China	Clinical experience	Number of interviews
N1	Female	26	Year 1	Sri Lanka	8 months	No	1
N2	Female	21	Year 1	Uganda	10 months	No	1
N3	Female	22	Year 1	Ghana	9 months	No	2
N4	Female	19	Year 1	Morocco	7 months	No	1
N5	Female	20	Year 2	Burundi	1 year 4 months	No	1
N6	Male	22	Year 2	Sierra Leone	1 year 6 months	No	1
N7	Female	21	Year 2	Nigeria	1 year 8 months	No	2
N8	Female	21	Year 2	Morocco	1 year 5 months	No	1
N9	Female	22	Year 2	Uganda	1 year 7 months	No	1
N10	Female	20	Year 3	Yemen	2 years 2 months	Yes	1
N11	Female	30	Year 3	Ghana	2 years 6 months	Yes	2
N12	Female	24	Year 3	Nigeria	2 years 4 months	Yes	1
N13	Male	24	Year 3	Ghana	2 years 3 months	Yes	1
N14	Male	25	Year 3	Nigeria	2 years 1 month	Yes	1
N15	Female	24	Year 3	Zimbabwe	2 years 5 months	Yes	1
N16	Female	22	Year 3	Zimbabwe	2 years 7 months	Yes	2
N17	Female	25	Year 3	Zimbabwe	2 years 3 months	Yes	1
N18	Male	27	Year 4	Burundi	3 years 2 months	Yes	1
N19	Female	32	Year 4	Nigeria	3 years 6 months	Yes	1
N20	Female	29	Year 4	Nigeria	3 years 4 months	Yes	1
N21	Male	26	Year 4	Rwanda	3 years 5 months	Yes	2
N22	Female	27	Year 4	Gabon	3 years 3 months	Yes	1
N23	Female	25	Year 4	Ethiopia	3 years 8 months	Yes	1

Journey map construction

The construction of the journey map followed established methodological procedures [24] and aimed to present, in temporal sequence, changes in the experiences of foreign undergraduate nursing students within the Chinese learning context. In this study, journey mapping was not used merely as a tool for presenting findings, but as an integrative analytical framework for systematically organizing students’ learning activities, emotional experiences, adaptation challenges, support needs, and changes in identity-related understanding throughout the learning process.

At the initial stage of the study, the research team developed preliminary analytical dimensions based on a literature review [1, 10, 12] and team discussions. Using a descriptive qualitative approach [23], semi-structured interviews provided authentic experiential narratives, and key narrative segments reflecting participants’ learning experiences in China were coded to refine and enrich the preliminary analytical framework. Particular attention was paid to behavioral adjustments, emotional fluctuations, critical turning points, and students’ reinterpretations of their own roles during the learning process.

In this study, the operationalization of journey mapping focused on organizing students’ experiences along a temporal learning trajectory. During the construction process, the research team paid attention to five key elements: learning-related events, emotional responses, adaptation challenges, support needs, and identity-related reflections. These elements were first identified from interview narratives and then compared across participants to examine how students’ experiences changed over time. Journey mapping was therefore used not only to summarize themes, but also to connect key experiences, emotional changes, and turning points within a staged learning process.

During analysis, the research team used constant comparison to compare data across participants and integrated these comparisons longitudinally according to participants’ timelines of studying in China. Through repeated induction and clustering, experience patterns with clear temporal progression were gradually identified. On this basis, the stage structure of the learning journey and its corresponding identity-related changes were developed.

As data collection and analysis progressed, the research team continuously revised and refined the journey structure through multiple rounds of discussion, peer debriefing, and repeated checking against the original data. To enhance the credibility of the findings, several participants were invited to provide feedback on the preliminary learning journey model, so that its consistency with their actual learning experiences could be assessed. The final model was further optimized based on this feedback.

Development of the interview guide

The semi-structured interview guide was developed based on the study aims, relevant literature, and the characteristics of foreign students’ learning experiences in China. The interview questions focused on students’ expectations before coming to China, their learning experiences after arrival, major difficulties in learning and daily life, emotional experiences, adaptation strategies, support needs, and changes in their understanding of their self-role and learner identity during the learning process.

The interview guide was reviewed by two experts in nursing education to assess its scientific relevance, appropriateness, and cultural suitability. A pilot test was then conducted with two international students who were not included in the final sample to examine the clarity, comprehensibility, and logical sequence of the questions. Based on their feedback, minor revisions were made to the wording of several questions and to the interview procedure.

During the formal interviews, the guide was used as a flexible framework. The researchers asked follow-up questions according to participants’ responses to further explore key experiences and identity-related changes during their studies in China. The full interview guide is provided in Supplementary File 1.

Data collection

All interviews were conducted face to face by trained researchers. All interviews were conducted in English, which was the shared language between the interviewers and participants. The audio recordings were transcribed verbatim in English. Because the interviews and transcripts were both in English, translation into English was not required. When quotations were presented in the manuscript, only minor grammatical smoothing was made where necessary to improve readability, without changing the original meaning. The interview locations were quiet, private, and comfortable for participants, including campus meeting rooms, hospital meeting spaces, or relatively independent public areas.

Before each interview, the researcher established rapport with the participant and explained the study purpose, confidentiality principles, and voluntary nature of participation. During the interviews, the researcher maintained a neutral stance, avoided leading questions, and encouraged participants to express their experiences freely. Each interview lasted approximately 25–45 min, was audio-recorded with the participant’s consent, and was accompanied by field notes during and after the interview to capture non-verbal information and researcher reflections. Follow-up interviews were conducted with some participants when necessary to further clarify or enrich key content. Data collection continued until data saturation was reached.

A total of 28 interviews were conducted. Eighteen participants were interviewed once, while five participants (N3, N7, N11, N16, and N21) took part in a second interview to further clarify and elaborate on key themes. The cumulative interview duration was approximately 756 min, generating a total of 58,643 words of transcribed data.

Data analysis

Audio recordings were transcribed verbatim within 24 h after each interview, and NVivo 14.0 was used for data management and analysis. Data were analyzed using conventional content analysis, which involved the following steps [25]: (1) repeatedly reading the transcripts; (2) identifying meaning units; (3) conducting open coding; (4) grouping codes into categories; and (5) abstracting themes.

To enhance the consistency and trustworthiness of the analysis, three researchers independently coded a subset of the interview transcripts and reached consensus through discussion, thereby developing an initial coding framework. This framework was then continuously revised and refined during analysis of the full dataset. During analysis, 186 initial codes were generated from the interview transcripts. These codes were then compared and grouped into broader categories according to similarity in meaning and temporal position in the students’ learning journeys. Categories that reflected related experiences within a similar period of the learning process were further organized into substages, and substages with shared temporal and developmental features were integrated into four major stages.

For example, the raw statement “When I first started classes, the teacher spoke very fast. I had not learned many nursing terms before, so I easily fell behind” was first interpreted as a meaning unit reflecting difficulty following classroom teaching because of fast teaching pace and unfamiliar nursing terminology. It was coded as “difficulty understanding nursing terminology” and grouped into the broader category of classroom disorientation. Because this experience occurred when students first entered formal course learning and reflected early uncertainty in the classroom, it was assigned to the substage “entering the classroom” within the “initial entry” stage. Similarly, the statement “Later, I began to ask the teacher specific questions after class. I used to think I should solve these problems by myself, but later I realized that it didn’t work” was coded as “active help-seeking from teachers,” grouped into the category of help-seeking and adjustment, and assigned to the substage “active help-seeking and adjustment” within the “negotiated exploration” stage. Through this iterative process, the research team moved from initial codes to categories, substages, and stages while repeatedly comparing the developing structure with the original transcripts.

Based on the thematic findings, the research team further organized students’ learning experiences along the temporal logic of studying in China, identified key transition points, important influencing factors, and identity-related developmental pathways, and ultimately constructed the journey map.

To enhance the credibility of the findings, multiple-researcher analysis, peer debriefing, and member checking were conducted. In addition, research logs, coding records, analytic memos, and records of model revision were retained to establish an audit trail and improve the traceability of the research process.

Researcher reflexivity and methodological rigor

This study followed the COREQ guidelines and ensured methodological rigor through researcher reflexivity, team consultation, and transparent reporting. The research team kept reflective memos throughout the study and continuously reflected on their own research backgrounds, cultural positions, and potential biases. Because the researchers had backgrounds in nursing education and qualitative research and were situated within the Chinese educational context, they might have brought pre-existing assumptions when interpreting the learning experiences of foreign students in China. Therefore, during data analysis, the team used constant comparison, repeatedly returned to the original data, and engaged in team discussions to ensure that the findings were grounded in participants’ accounts rather than researchers’ prior assumptions.

Credibility was supported through member checking, multiple-researcher coding, and repeated team discussions. Dependability was enhanced by detailed documentation of the research process. Transferability was supported by providing sufficient descriptions of the participants, educational context, and cultural background. Confirmability was strengthened through reflective records, team review, and checking against the original data. Participants’ privacy and anonymity were strictly protected throughout data collection, transcription, storage, analysis, and reporting.

Results

Based on the analytic process described above, four interrelated major stages and 12 substages were identified, illustrating the dynamic process through which foreign undergraduate nursing students in China moved from pre-arrival expectations, arrival in China, and initial classroom entry to gradual adaptation, intercultural integration, and identity reconstruction (see Fig. 1).

Fig. 1.

Journey map of foreign undergraduate nursing students’ learning adaptation and identity transformation in China

The four-stage journey should be interpreted as a synthesized process model rather than a uniform linear pathway followed identically by all participants. Participants differed in academic year, prior learning experience, cultural background, length of study in China, clinical exposure, language confidence, and access to support. These differences influenced the pace, intensity, and emotional tone of their adaptation. Some students moved relatively quickly from early uncertainty to active adjustment, whereas others remained longer in hesitant participation or returned to earlier uncertainty when encountering new assessments or practice-related learning tasks. Therefore, the stages represent common patterns across the dataset while allowing for individual variation and recursive movement.

A journey map typically presents experiences along a temporal trajectory, with the horizontal axis representing stages over time and the vertical axis representing key experiential or analytical dimensions [24]. Figure 1 presents a process-oriented journey map of foreign undergraduate nursing students’ learning adaptation and identity transformation in China. The horizontal axis shows four major stages and 12 substages, while the vertical axis summarizes core experience, key mechanisms or turning points, identity movement, emotional trajectory, support focus, and related stakeholders. The trajectory shown in the map should be interpreted as a synthesized developmental tendency across participants, rather than a uniform linear pathway or continuous emotional improvement experienced by every student.

Initial entry stage: entering with expectations and encountering reality

This stage comprised three substages: pre-arrival expectations, arrival in China, and entering the classroom. During this stage, students moved from positive expectations about studying in China into the realities of a cross-cultural learning environment. They began to experience pressures related to daily life adaptation, cultural unfamiliarity, and classroom disorientation. Emotionally, this stage was characterized by a mixture of expectation, nervousness, and confusion.

This stage was not simply a period of environmental adjustment. It represented the first confrontation between students’ imagined expectations of studying nursing in China and the actual academic, cultural, and professional demands of the new learning context. This mismatch temporarily weakened students’ sense of being competent learners and created the initial conditions for later adjustment.

Pre-arrival expectations: coexistence of idealized expectations and limited preparation

Before coming to China, students often viewed studying in China as an important opportunity to broaden their horizons and enhance their professional competence. As a result, they generally expressed strong expectations and curiosity. However, these expectations were often based on relatively vague imaginings, and students had limited concrete understanding of course formats, classroom modes, and learning requirements in Chinese nursing education. As one participant stated:

“Before coming to China, I thought it was a really good opportunity. I could learn nursing, and also experience a different way of learning and a different culture.” (N4).

At the same time, some students mentioned that they had limited knowledge of the actual learning context before departure and only had a general sense that “things would be different.”

“I knew I was coming to China to study nursing, but I didn’t really know what the classes would be like. I just felt that the way of learning here might be different from that in my home country.” (N8).

Arrival in China: environmental unfamiliarity and early adaptation pressure

After arriving in China, students first encountered a sense of unfamiliarity with both the living and cultural environment. Issues related to accommodation, food, campus surroundings, daily communication, and enrollment procedures emerged simultaneously, making students feel anxious and pressured even before they formally entered course learning. As one participant described:

“When I first arrived, everything was unfamiliar. Even simple things took time to figure out. During that time, I felt really nervous.” (N7).

Some students also mentioned that, in the absence of a familiar support network, daily communication and environmental adaptation often had to be explored independently.

“I knew people were friendly, but at first I still didn’t dare to ask questions because I was afraid I couldn’t express myself clearly.” (N2).

Entering the classroom: classroom disorientation and heightened learning uncertainty

After formally entering the classroom, students began to experience the learning pressures of nursing education more directly. Language barriers, difficulty understanding professional terminology, a relatively fast teaching pace, and unfamiliar patterns of classroom interaction were the most prominent challenges at this stage. Many students described a sense of classroom disorientation, characterized by difficulty understanding the content, keeping up with the pace, and expressing themselves. One participant stated:

“When I first started classes, the teacher spoke very fast. I had not learned many nursing terms before, so I easily fell behind.” (N3).

Another participant described uncertainty about the depth of their understanding:

“Sometimes I roughly understood what the teacher was talking about, but when there were many professional details, I suddenly felt unsure about how much I really understood.” (N11).

At the same time, difficulties in classroom expression led many students to remain silent and observe rather than participate actively.

“At that time, I basically just followed the PowerPoint and took notes. I didn’t dare to speak because I was afraid of making mistakes, and also afraid that others would not understand what I was saying.” (N21).

Some students clearly expressed a need for clearer course explanations and language support.

“If the teacher had explained more clearly at the beginning how to study the course and what the key points were, I might not have felt so panicked.” (N10).

These accounts suggest that early classroom disorientation was closely related to the professional nature of nursing learning. Students were not only adapting to a new classroom environment, but also trying to understand nursing-specific terminology, professional details, and expectations for learning and expressing professional knowledge in a new educational context.

Negotiated exploration stage: tentative participation and exposure of difficulties

This stage comprised three substages: tentative participation, difficulty exposure, and active help-seeking and adjustment. Compared with the initial entry stage, students were no longer only passively experiencing the impact of an unfamiliar environment. Instead, they began to approach the classroom, participate in learning activities, and gradually recognize the gap between themselves and current learning requirements through repeated setbacks. Emotionally, their experiences shifted from simple nervousness and confusion to a mixture of hesitation, frustration, and hope.

The key mechanism in this stage was the transformation of vague discomfort into visible learning gaps. Through examinations, assignments, classroom interaction, and practice-related learning tasks, students began to recognize where their previous learning habits did not fully match current expectations. This recognition became a turning point that pushed some students from silent endurance toward help-seeking and active adjustment.

Tentative participation: moving closer to the classroom while remaining cautious

As students became initially familiar with course arrangements and classroom formats, some began to participate in learning in relatively low-risk ways, such as speaking during group discussions, asking classmates questions after class, or attempting to complete assignments independently. This substage was marked by students’ attempts to engage more actively while still remaining cautious.

“After some time, I realized that I could not just sit there and listen all the time, so I tried to say something during group discussions, although I was still not very confident.” (N6).

However, this participation was often limited. Although some students realized that they needed to become more active, they still hesitated in actual classroom situations because they worried about inaccurate expression or not being understood by others.

“I would think about it many times in my head first. If I felt uncertain, I would still choose not to speak.” (N13).

Difficulty exposure: setbacks and emerging awareness of gaps

As students became more involved in learning activities, they began to experience the complexity of learning difficulties more directly. The first examination, setbacks in assignments, difficulties in classroom expression, and challenges in understanding practice-related content often became important triggers at this stage. This difficulty was particularly evident when students were required not only to understand course content, but also to explain, apply, or organize nursing knowledge in ways that matched current course expectations. Students gradually realized that the problems they faced were not limited to language barriers, but also involved differences in learning approaches, assessment standards, and modes of expression.

“After I got the result of the first exam, I felt very discouraged because I had already worked hard, but the result was still not good.” (N3).

Some students mentioned that when sustained effort did not lead to visible improvement, they began to question their own abilities.

“There was a time when I kept thinking about whether I was really suitable for studying nursing here.” (N21).

Active help-seeking and adjustment: from enduring alone to taking action

After repeated setbacks, some students began to realize that it was difficult to solve problems by coping alone. They gradually turned to active help-seeking and started to adjust their learning approaches. Their actions at this stage included consulting teachers, seeking advice from peers and senior students, and actively changing their strategies for previewing, reviewing, and participating in class.

“Later, I began to ask the teacher specific questions after class. I used to think I should solve these problems by myself, but later I realized that it didn’t work.” (N16).

Some students also mentioned that, by observing how others learned or by receiving specific advice through help-seeking, they gradually found approaches that were more suitable for the current learning environment.

“Later, I would actively ask senior students. They told me which content was more important and how I should prepare, and that made me feel much more reassured.” (N7).

Adaptive development stage: gradual familiarization and strategy formation

This stage comprised three substages: gradual familiarization, strategy formation, and steady learning progress. Compared with the previous stage, students’ sense of unfamiliarity with the nursing education context gradually decreased. They began to understand course arrangements, classroom rhythms, and learning requirements, and gradually developed relatively stable learning approaches through repeated attempts. Emotionally, their experiences shifted from earlier fluctuation and frustration toward greater stability, engagement, and a stronger sense of control.

The significance of this stage was the emergence of learning agency. Students were no longer only reacting to immediate difficulties, but began to organize their learning more actively through previewing, reviewing, peer discussion, note-taking, and time management. This shift from coping with tasks to managing learning helped stabilize their participation and strengthened their sense of control.

Gradual familiarization: recognizing learning rules amid earlier confusion

As coursework continued and campus life became more stable, students gradually became familiar with course structures, teaching styles, and assessment methods. They also developed a clearer understanding of the basic rules of the nursing education environment. This substage reflected students’ gradual movement from earlier confusion toward a clearer understanding of learning rules.

“Later, I found that things were not as confusing as they were at the beginning. Although there were still difficult parts, at least I knew where to start.” (N14).

Some students mentioned that this sense of familiarity did not emerge suddenly, but was gradually built through repeated exposure to courses and classroom experiences.

“Gradually, I became more familiar with the teacher’s pace and classroom requirements. I was not as lost as before.” (N17).

Strategy formation: from coping with tasks to actively organizing learning

On the basis of gradual familiarization with the learning environment, students began to develop and continuously adjust learning strategies that suited their own needs. Unlike the temporary coping strategies used in the previous stage, adjustments at this stage became more planned and were mainly reflected in previewing, note-taking, after-class review, peer discussion, and time management.

“Later, I realized that I had to read the content before class and write down the key words, so I would not be so passive in class.” (N10).

“In the past, I only studied when I felt pressure. Later, I started to arrange fixed study time for myself, and this made my learning feel more organized.” (N19).

Some students also mentioned that peer collaboration and repeated organization of course content were important ways to help them establish more stable learning methods.

“I would discuss with my classmates after class and listen to how others understood the content. That helped me a lot.” (N8).

Steady learning progress: gaining a sense of control through sustained engagement

As learning strategies gradually took shape and began to work in practice, students’ learning became more stable. This was reflected in their ability to complete course tasks more consistently, participate in classroom activities, and develop a certain sense of control over the learning process. Through sustained engagement, students began to develop a stronger sense of control over their learning.

“I would not say that there were no difficulties at all, but I knew what to do next.” (N18).

Some students also indicated that, as their classroom participation and task completion gradually improved, their initiative in learning became stronger.

“In the past, I was mostly just coping with the tasks. Now I feel that I am really learning, and I know how to make myself learn better.” (N20).

Transformative reconstruction stage: intercultural integration and identity reconstruction

This stage comprised three substages: self-reevaluation, intercultural integration, and identity reconstruction and future orientation. Compared with the previous stage, students’ attention was no longer focused mainly on how to complete current learning tasks. Instead, they began to reinterpret their learning abilities, cross-cultural experiences, and future developmental directions. Emotionally, this stage was characterized more by confidence, openness, and a sense of achievement.

This stage reflected a shift from functional adaptation to identity reconstruction. Students began to reinterpret their previous difficulties as part of their growth, integrate different educational and cultural experiences, and connect their learning in China with their future professional roles as nurses.

Self-reevaluation: from focusing on shortcomings to recognizing growth

As the learning process gradually became more stable, students began to look back and re-examine the changes they had experienced during their studies in China. They developed new understandings of their own abilities, adaptation process, and growth trajectory. At this point, students began to shift from focusing mainly on their shortcomings to recognizing their own growth.

“Looking back at myself when I first arrived, I feel there is a big difference. I used to feel that I was not good enough, but now I know that I can gradually adapt.” (N19).

Some students mentioned that this change did not happen suddenly at a single moment, but was gradually noticed through continuous learning and adaptation.

“One day I suddenly realized that I no longer doubted myself all the time like before.” (N21).

Intercultural integration: from one-way adaptation to mutual understanding

After becoming aware of changes in themselves, students further began to integrate learning experiences from different cultural and educational contexts. They no longer simply positioned their previous learning experiences in opposition to the current classroom context, but instead tried to build connections between two or more ways of learning and develop more flexible understandings and responses. This process indicated a shift from one-way adaptation toward a more reciprocal understanding of different learning cultures.

“Later, I realized that it was not that my previous way of learning was useless, but that I needed to learn how to connect it with what is required here.” (N17).

Some students also mentioned that cross-cultural learning experiences changed not only their understanding of courses, but also the way they interacted with others.

“In the past, I was more likely to understand things only in the way I was familiar with. Now I am more willing to listen to what others think first.” (N11).

Identity reconstruction and future orientation: transforming the China learning experience into a developmental resource

On the basis of continued adaptation and integration, students began to reinterpret their roles as learners and future nursing professionals, and to connect their learning experiences in China with their future development. In this substage, students began to transform their learning experiences in China into resources for future professional development.

“Now I feel that studying in China is not just about completing the courses. It has really changed how I see myself and how I view my future nursing work.” (N16).

Some students mentioned that their learning experiences in China had broadened their imagination of future career development and helped them better understand the value of cross-cultural competence in nursing practice.

“In the past, I only thought about doing well in my major. Now I am more proactive in thinking about what kind of nurse I want to become.” (N22).

These reflections indicate that students’ later-stage identity reconstruction was closely connected with their emerging understanding of nursing as a future profession, rather than only with general academic adaptation.

Discussion

This study used journey mapping to examine the learning journeys and identity transformation of foreign undergraduate nursing students in China. The findings suggest that students’ experiences were not limited to a set of isolated adaptation challenges, but formed a developmental process in which intercultural disorientation, learning negotiation, strategy formation, and identity reconstruction were gradually connected over time. By identifying four interrelated stages, this study provides a process-oriented account of how foreign undergraduate nursing students moved from entering an unfamiliar educational context to developing more active and self-directed learning approaches, integrating cross-cultural learning experiences, and rethinking their future professional roles.

From adaptation to identity reconstruction: extending international student adaptation literature

The main contribution of this study is that it extends existing international student adaptation literature by showing how adaptation, learning participation, intercultural negotiation, and identity reconstruction are connected over time. Previous research has richly documented the language barriers, academic pressures, cultural challenges, emotional responses, and coping strategies experienced by international students [5–9]. However, these issues are often discussed as relatively separate dimensions of adaptation. The four-stage journey model developed in this study suggests that these experiences may form a temporally unfolding process. Initial disorientation exposes the mismatch between students’ expectations and the actual learning environment; repeated setbacks make learning gaps visible and stimulate help-seeking; strategy formation enables more stable participation; and intercultural integration allows students to reinterpret their learning experiences and future professional roles. In this sense, adaptation is not only a process of becoming accustomed to a new educational environment, but also a process through which students reconstruct their learner identity and begin to form a future professional self.

This finding moves beyond a problem-oriented understanding of international student adaptation. Rather than treating language barriers, emotional stress, classroom participation, and help-seeking as isolated challenges, the present study shows how these experiences may become resources for identity-related change. Difficulty exposure, for example, was not merely a negative experience. It created moments in which students became aware of gaps between previous learning habits and current expectations. Similarly, strategy formation was not simply a coping mechanism, but represented a shift toward more active and self-directed learning participation. The later stage of intercultural integration further suggests that students’ adaptation may develop into a deeper reconstruction of self-understanding and future professional orientation.

From the perspective of identity transformation, the learning journey identified in this study can be understood as a gradual movement from externally driven adaptation to internally meaningful self-formation. In the early stages, students’ attention was mainly directed toward understanding the new environment, coping with uncertainty, and meeting immediate academic requirements. As learning became more stable, students began to reflect on their own growth, compare different educational cultures, and reconsider what kind of learners and future nurses they hoped to become. This trajectory indicates that identity transformation did not occur suddenly at the end of the journey, but was gradually shaped through repeated encounters with difficulty, support, reflection, and cross-cultural comparison [26, 27]. This process-oriented understanding adds to existing literature by explaining how adaptation may become a pathway toward learner identity reconstruction and professional self-formation [28].

Chinese nursing education as a context of intercultural and professional socialization

This study also contributes to the literature by clarifying the significance of the Chinese nursing education context. China is not only a geographical site in this study, but also a complex educational and cultural context in which students encountered new institutional routines, classroom expectations, communication norms, daily living practices, and academic requirements. For the participants, early adaptation was shaped by the simultaneous presence of daily life adaptation, cultural adaptation, and academic adaptation. These forms of adaptation overlapped and accumulated, creating an early sense of disorientation that could not be explained by language ability alone [4, 9, 10]. The Chinese context therefore provided a setting in which students had to negotiate multiple transitions at the same time: entering a new country, entering a new educational system, and entering a professional nursing curriculum.

The nursing education context further distinguishes this study from more general research on international student adaptation. Nursing students are not only expected to master disciplinary knowledge, but also to understand professional terminology, practical learning requirements, clinical expectations, communication patterns, and values related to care [2, 29]. In this study, students’ difficulties were often intensified when classroom learning involved nursing-specific concepts, professional details, or practice-related content [29]. Their uncertainty was not only about whether they could understand classroom instructions or course content, but also about whether they could make sense of nursing knowledge in a new educational and cultural environment. This suggests that their adaptation involved both intercultural learning and professional socialization [30].

The process of professional socialization was especially visible in the later stages of the journey. As students gradually developed learning strategies and became more familiar with course expectations, they began to connect their learning experiences in China with their future roles as nurses. For some students, cross-cultural learning broadened their understanding of nursing as a profession that requires communication with people from different backgrounds. For others, the experience encouraged reflection on their strengths, limitations, and future career direction. These findings indicate that the learning journey of foreign undergraduate nursing students cannot be fully understood as general student adaptation. It also involves the gradual formation of a nursing-related professional self, shaped by the interaction between intercultural experience, academic learning, and future professional imagination [31].

The theoretical significance of the four-stage journey model

The theoretical significance of the four-stage journey model lies in its ability to connect temporal progression with identity-related change. The model does not imply that all students followed an identical or strictly linear pathway. Rather, it provides a process-oriented explanation of how foreign undergraduate nursing students may move between disorientation, negotiation, strategic adjustment, and identity reconstruction in a cross-cultural nursing education context. Students differed in the speed, intensity, and depth of these changes, but the model helps reveal how learning difficulties, emotional responses, support resources, and professional self-understanding were interrelated across time.

It is also important to clarify that the overall upward movement shown in the journey model does not mean that students’ experiences were continuously positive or free from setbacks. Rather, the upward trajectory reflects a synthesized developmental pattern identified across participants’ retrospective accounts. Students experienced confusion, hesitation, frustration, and self-doubt, particularly during the initial entry and negotiated exploration stages. However, in the context of this study, these negative experiences did not remain isolated or unresolved. With increasing familiarity with the curriculum, access to teachers, peers, and senior students, and gradual engagement with course requirements, many students were able to transform these difficulties into opportunities for learning adjustment and self-understanding [32]. Therefore, the model should be understood as representing a dominant developmental tendency from disorientation toward greater learning agency and identity integration, rather than a simple linear improvement in emotional state.

The relatively progressive pattern identified in this study may also be related to the specific educational context in which the participants were situated. The participants had sustained exposure to nursing courses over several academic years, and their accounts indicated that teachers, classmates, and senior students gradually became important sources of support [29]. Such contextual resources may have helped students reinterpret difficulties as manageable learning challenges rather than fixed barriers. This may partly explain why the overall journey showed movement toward greater familiarity, strategy formation, and identity reconstruction, even though students continued to encounter challenges during the process [28].

The first stage, initial entry, shows how high expectations and limited preparation can produce early learning disorientation. This stage is theoretically important because it demonstrates that adaptation begins before students fully understand the academic environment. Students’ expectations, imagined opportunities, and limited preparation shaped how they interpreted early difficulties after arrival. The second stage, negotiated exploration, highlights difficulty exposure as a turning point. Setbacks in examinations, assignments, classroom expression, or practice-related learning made students’ gaps more visible, but also created opportunities for help-seeking and strategy adjustment [33]. This finding suggests that difficulty does not only hinder adaptation; under supportive conditions, it can become a trigger for learning reorganization [34].

The third stage, adaptive development, shows that adaptation becomes more stable when students move from temporary coping to more organized learning strategies [35, 36]. This shift can be interpreted as a movement from reactive adjustment to more active and self-directed participation. Students were no longer simply responding to immediate pressures, but began to organize their learning through previewing, reviewing, peer discussion, note-taking, and time management. The fourth stage, transformative reconstruction, further demonstrates that successful adaptation may lead to more than functional adjustment. Students began to reinterpret their previous learning experiences, integrate different educational cultures, and connect their current learning with future professional development [37]. Therefore, the four-stage model matters theoretically because it explains how adaptation, agency, reflection, and identity reconstruction may be linked in a staged but non-linear learning process.

Implications for staged, reflective, and developmental support

The four-stage model also helps identify when different forms of educational support may be most needed. The findings have implications for supporting foreign undergraduate nursing students in China and similar transnational health professions education contexts. First, support should begin before students formally enter coursework. Because early disorientation was shaped by the coexistence of high expectations and limited preparation, pre-arrival information and early orientation should go beyond general campus guidance. Students may benefit from clearer explanations of course structures, classroom expectations, assessment methods, professional terminology, and common learning challenges in nursing education. Such anticipatory support can help students develop more realistic expectations and reduce the psychological burden of entering an unfamiliar learning context [10, 38, 39].

Second, the negotiated exploration stage should be treated as a critical window for formative support. When students first encounter visible setbacks, they may experience frustration, self-doubt, and restricted participation. However, this stage also provides an opportunity for guided adjustment. Timely teacher feedback, low-threshold opportunities to ask questions, peer discussion, senior student mentoring, and targeted learning strategy guidance can help students transform difficulty exposure into a learning turning point rather than a source of withdrawal [40–42]. For nursing students, this support should also address professional terminology, practice-related content, and the transition from understanding knowledge to expressing and applying it.

Third, support should not end after early adaptation. The adaptive development stage shows that students need sustained support to consolidate learning strategies and maintain engagement. Clearer course navigation, staged learning strategy training, formative feedback mechanisms, and peer collaboration can help students gradually move from coping with tasks to organizing learning more actively [43–45]. This is particularly important in nursing education, where students must progressively integrate theoretical knowledge, practical learning, and professional expectations.

Finally, the transformative reconstruction stage suggests that educational support should extend from helping students adapt to helping them develop. Reflective learning activities, learning growth records, intercultural experience sharing, mentor guidance, career planning support, and discussions about future professional roles can help students interpret their cross-cultural learning experiences as developmental resources [46–49]. Without such reflective and developmental support, students may complete course adaptation but remain at the level of simply “getting through the program.” By contrast, when students are supported to reflect on their growth and future professional identity, studying in China may become a meaningful resource for long-term professional development.

This study has several limitations. First, this was a single-center qualitative study. All participants were foreign undergraduate nursing students studying at the same university in China. Although the sample varied in academic year and length of study in China, the findings mainly reflect learning experiences within a specific educational context, and their transferability needs to be further examined across broader institutional and cultural settings. Second, this study focused on the shared features of foreign undergraduate nursing students’ overall learning journeys and did not further compare differences among students from different national or regional cultural backgrounds, with different levels of language proficiency, or at different stages of study in China. Therefore, it was not able to fully reveal heterogeneity in learning adaptation pathways across different subgroups. Third, although journey mapping was useful for presenting stage-based changes in the learning process, this study mainly relied on retrospective interview data, which may have been influenced by participants’ recall bias. Future studies could combine longitudinal tracking designs, multi-center samples, and observational data to further examine the dynamic features of foreign nursing students’ learning journeys in China. Further research is also needed to explore how cultural background, course type, and support models influence their learning adaptation and identity reconstruction.

Conclusions

Using journey mapping, this study identified four interrelated stages in the learning journeys of foreign undergraduate nursing students in China: initial entry, negotiated exploration, adaptive development, and transformative reconstruction. These stages show how students moved from early disorientation to gradual adjustment, strategy formation, intercultural integration, and identity reconstruction. The findings suggest that students’ adaptation was shaped not only by language-related challenges, but also by pre-arrival preparation, cultural environment, classroom norms, nursing-specific learning requirements, and support resources. The four-stage model further indicates that adaptation may become a process of learner identity reconstruction and future professional orientation. Nursing education should therefore provide staged and sustained support to help foreign students adapt to cross-cultural learning and transform their experiences in China into resources for professional growth.

Authors' contributions

L-Y, N-Y and HY-W designed the study and drafted the manuscript. N-Y, YY-J and C-H collected the data. N-Y, SJ-W, C-H, D-L and SS-C curated the data. N-Y, SJ-W, C-H, D-L and SS-C performed the formal analysis. All authors critically reviewed and revised the manuscript. All authors read and approved the final manuscript.

Funding

This study was supported by the National High Level Hospital Clinical Research Funding, Beijing Hospital Talent Cultivation Project (No. BJ-2024-108); the Provincial Teaching Reform Project of Zhejiang Province during the 14th Five-Year Plan (No. JGBA2024246); the 2026 Teaching Scholarship Research Project of Zhejiang Chinese Medical University (No. AXS25006); and the Research Talent Development Program of Zhejiang Chinese Medical University (No. 2023RCZXZK28 and 2023RCZXZK53).

Data availability

The qualitative data generated and analyzed during the current study are not publicly available due to confidentiality and privacy considerations but are available from the corresponding authors on reasonable request.

Declarations

Ethics approval and consent to participate

Ethical approval for this study was obtained from the Ethics Committee of Zhejiang Chinese Medical University (Approval No. 20240705-1). This study was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants prior to data collection.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.