Language barriers

Language barriers were the most frequently reported challenge amongst CALD students on RT clinical placements (Figure 2). These findings are consistent with those cited in previous studies involving occupational therapy and medical CALD students, who encountered challenges with verbal communication linked to local slang, accents and varying interpretations of words. ^{Reference Law, Masterson-Ng and Pollard28,Reference Morgan38} However, our data suggest this challenge persisted even in final-year students, indicating that difficulties may not diminish over time. Second language anxiety among CALD students can lead to stress, reduced self-confidence and feelings of inadequacy. ^{Reference Khawaja, Chan and Stein20}

Effective communication is one of the HCPC SoPs, ⁹ requiring TRs to communicate verbally and non-verbally with service users, carers and colleagues. In clinical practice, RT students should use professional language to explain medical information and colloquial language to build rapport. ^{Reference Kelly, Thompson, Surjan, Rinks and Warren-Forward11} Effective communication supports the delivery of high-quality care by addressing patients’ needs and concerns. ^{Reference Kelly, Thompson, Surjan, Rinks and Warren-Forward11} Mattarozzi et al. ^{Reference Mattarozzi, Fino, Panni, Agostini, Morganti and Russo39} reported that greater patient satisfaction with communication correlated with a lower intensity of pain experienced during RT. However, CALD students often face difficulty with clinical communication skills such as introducing themselves, engaging in small talk with patients, and interpreting non-verbal cues. ^{Reference Brewer, Jackson and Bartle40} A scoping review by Brewer et al. ^{Reference Brewer, Jackson and Bartle40} found that pre-placement interventions, including videos, role-play, simulated patients and feedback, enhanced CALD students’ confidence and prepared them well for clinical placement. The HCPC requires TRs whose first language is not English to provide certified evidence of the International English Language Testing System (IELTS) tests with a minimum score of 7.0. ⁴¹ These tests aim to forecast students’ ability to study in an English-speaking educational environment and minimise language barriers. ^{Reference Ross, Ta and Grieve23} However, these assessments may not accurately reflect language proficiency, requiring further support throughout the programme. ^{Reference Ross, Ta and Grieve23}

Cultural differences

Around half of the participants ‘strongly agreed’ or ‘agreed’ that cultural differences posed challenges (Figure 2). This supports findings reported by Goodwin and Mbah, ^{Reference Goodwin and Mbah42} whereby CALD students’ self-confidence levels and placement experiences were negatively affected by their unfamiliarity with UK workplace values and practices. ^{Reference Goodwin and Mbah42} This aligns with findings reported by Högstedt et al., ^{Reference Högstedt, Engström, Eriksson and Jansson43} whereby CALD nursing students in Sweden faced challenges adapting to a new culture and clinical environment.

The RT workplace culture impacts TRs and service users, directly affecting the quality of care. ^{Reference Lohikoski, Roos and Suominen44} As data on participants’ backgrounds were not collected, any relationships between cultural differences could not be explicitly identified. CALD students may face cultural shock when adjusting to new clinical placements, depending on the differences from their home culture. ^{Reference Law, Masterson-Ng and Pollard28} Law et al. ^{Reference Law, Masterson-Ng and Pollard28} found that occupational therapy CALD students from Confucian-based backgrounds exhibited greater cultural shock during clinical placements in the UK, struggling to set objectives and adapt to the shift from didactic educational environments to self-directed learning approaches. To overcome cultural differences, CALD students are encouraged to engage with national, academic and clinical cultures. ^{Reference Law, Masterson-Ng and Pollard28}

Following the Equality Act, ⁹ individuals with protected characteristics and cultural differences must be treated equally and with dignity. In this study, participants’ protected characteristics included their different nationalities, races, beliefs and religions. During placements, qualified TRs should respect students’ cultural differences, including values, beliefs and personal biases. ⁹ Despite this, a qualitative study by Korhonen et al. ^{Reference Korhonen, Tuomikoski, Oikarainen, Kääriäinen, Elo and Kyngäs13} found that many CALD students experienced mistreatment by staff or mentors, often attributed to a lack of cultural competence. Cultural competence enables safe, comprehensive care that addresses cultural differences and supports non-discriminatory practice, as highlighted by the HCPC SoPs. ^{9,Reference Reeve and Lavery45} Although the HCPC standards include equality, diversity and inclusion principles to promote cultural competence among staff, ⁴⁶ CALD students are not particularly specified. Ross et al. ^{Reference Ross, Ta and Grieve23} also noted a lack of guidelines regarding how to support, assess and interact with CALD students. Mikkonen et al. ^{Reference Mikkonen, Elo, Tuomikoski and Kääriäinen31} emphasised the role of positive intracultural mentoring in creating a welcoming environment for CALD students and mediating cultural differences to reduce social isolation. ^{Reference Mikkonen, Elo, Tuomikoski and Kääriäinen31}

Familiarity with the UK healthcare system

Responses regarding familiarity with the NHS varied (Figure 2), which may reflect different levels of preparation across institutions. Unfamiliarity with the healthcare system is a common challenge for CALD students in healthcare professions. ^{Reference Law, Masterson-Ng and Pollard28} Law et al. ^{Reference Law, Masterson-Ng and Pollard28} reported that occupational therapy CALD students (n = 6) lacked prior NHS experience and encountered a healthcare context that differed from their home countries. Many participants had to learn the systems and the policies themselves, indicating the need for greater orientation to the host country’s healthcare context. ^{Reference Law, Masterson-Ng and Pollard28} Baker et al. ^{Reference Baker, Rylance-Graham and Keane47} surveyed CALD healthcare students and emphasised the need to understand the NHS healthcare system prior to attending clinical placements. Despite these findings, the UK Council for International Student Affairs provides guidance to support CALD students in familiarising themselves with the UK healthcare system; ⁴⁸ however, this may not be regularly utilised.

Simulated RT environments can improve students’ confidence and familiarity with the healthcare system prior to attending clinical placement. ^{Reference Bridge, Giles, Williams, Boejen, Appleyard and Kirby49} Several studies have demonstrated improvements in students’ levels of confidence and communication skills within simulated RT cohorts compared to traditional teaching methods. ^{Reference Ketterer, Callender, Warren, Al-Samarraie, Ball and Calder6,Reference Kelly, Surjan, Rinks and Warren-Forward50} However, Cahu et al. ^{Reference Chau, Arruzza and Johnson51} emphasised that simulation should complement, not replace, clinical placement.

Feelings of isolation

Half of the participants reported isolation during placement (Figure 2), which can negatively impact CALD students’ well-being; ^{Reference Korhonen, Tuomikoski, Oikarainen, Kääriäinen, Elo and Kyngäs13} however, the small, gender-homogenous sample may underrepresent other perspectives. Interestingly, first-year undergraduate students within this study reported lower levels of isolation compared to third-year students, which contrasts with previous research that demonstrated that first-year RT students struggled to manage professional socialisation in unfamiliar environments, leading to feelings of isolation. ^{Reference Kelly, Thompson, Surjan, Rinks and Warren-Forward11} CALD students have attributed social isolation to language barriers and discomfort in speaking to staff or patients. ^{Reference Korhonen, Tuomikoski, Oikarainen, Kääriäinen, Elo and Kyngäs13,Reference Mitchell, Del Fabbro and Shaw52} Although social activities can significantly reduce isolation, CALD students may still experience loneliness due to language and cultural barriers; ^{Reference Mitchell, Del Fabbro and Shaw52} however, Cheng et al. ^{Reference Cheng, Taylor, Fitzgerald, Kuo and Graves53} reported no significant difference in baseline isolation scores between national and CALD medical students, despite national students sharing language and culture. Alshaharani et al. ^{Reference Alshahrani, Cusack and Rasmussen54} identified three coping strategies utilised by nursing students to reduce isolation within their first clinical placements: debriefing sessions, observing staff-patient interactions and sharing the experience with friends and family. Wijbenga et al. ^{Reference Wijbenga, Duvivier, Driessen, Ramaekers and Teunissen55} emphasised that effective communication with clinical staff is essential in preventing isolation.

Discrimination in clinical placement

This study showed varied responses to discrimination during clinical placement (Figure 3), with most participants attributing this to interactions with clinical staff (Figure 4). Discrimination and bullying were also reported by CALD students in an earlier study by Korhonen et al., ^{Reference Korhonen, Tuomikoski, Oikarainen, Kääriäinen, Elo and Kyngäs13} however, the source was not specified. Juntunen et al. ^{Reference Juntunen, Kamau, Oikarainen, Koskenranta, Kuivila and Ropponen56} highlighted the negative impact of discrimination on CALD nursing students’ learning experiences and career prospects, stressing the importance of a student-centred approach to foster a safe learning environment. They addressed six categories for supporting CALD students: competence-building, ethics and equality, cultural diversity, student-centred orientation, encouragement and supportive environments. ^{Reference Juntunen, Kamau, Oikarainen, Koskenranta, Kuivila and Ropponen56} The variation in reported experiences may reflect broader structural factors, including unconscious bias, workplace pressures or insufficient staff training. Previous studies on students’ experiences of bullying during clinical placements have explored the concept of organisational culture within the healthcare environment, with the hierarchical structure present in many professions considered to be a contributing factor. ^{Reference Zhou, Wang, Zeng, Zeng, Liu and Tan57} It is postulated that such hierarchical cultures result in a reluctance to challenge staff in senior positions, leading to an acceptance of bullying behaviours within nursing and midwifery placements. ^{Reference Zhou, Wang, Zeng, Zeng, Liu and Tan57,Reference Capper, Muurlink and Williamson58}

Recent research suggests that unconscious bias within healthcare settings can negatively impact students’ placement experiences. ^{Reference Joseph, Flint, Raymond-Williams, Awadzi and Johnson59,Reference Dafny, Snaith, McCloud, Waheed, Cooper and Champion60} Within a study involving UK student nurses, participants from ethnic minority backgrounds described experiencing discrimination related to their race, culture or language. ^{Reference Walker, Gunasinghe, Harwood, Ehsan, Ahmed and Dorrington61} CALD students studying medicine in Australia similarly reported that language barriers impacted their relationships with qualified physicians; ^{Reference Colenbrander, Causer and Haire62} however, a similar study exploring nursing students’ experiences reported that UK CALD students experienced increased discrimination during placements compared to native English speakers, yet this was not reported by Australian participants. ^{Reference Birks, Cant, Budden, Russell-Westhead, Ozcetin and Tee63} Discrimination experienced by CALD healthcare students is a complex issue, impacting students within various professions and countries. Further research into the organisational culture contributing to bullying and discrimination is required, with a particular focus on the qualitative experiences of CALD students within RT.

In the UK, the NHS mandates staff training that includes modules on unconscious bias, equality, diversity and inclusion; ⁶⁴ to practically address the issues reported here, structured mentorship and further staff training on cultural competence and bullying in the workplace are required.

Support offered for CALD students

Around half of the participants were supported by other CALD students (Figure 5), while fewer received support from clinical mentors and supervisors. Previous studies have also concluded that CALD students often shared placement challenges with other CALD friends and family, yet rarely informed their clinical supervisors and internationalisation officers. ^{Reference Wijbenga, Duvivier, Driessen, Ramaekers and Teunissen55}

Clinical mentors play a significant role in shaping positive clinical placement experiences for CALD students. ^{Reference Korhonen, Tuomikoski, Oikarainen, Kääriäinen, Elo and Kyngäs13} Pearson et al. ^{Reference Pearson, Hill, Attrill and Copley65} showed greater satisfaction among CALD students when they had an effective relationship with clinical mentors. Key factors for constructive supervision included mentors’ ability to provide feedback, motivation and cultural competence. ^{Reference Pearson, Hill, Attrill and Copley65} Luukkonen et al. ^{Reference Luukkonen, Kuivila, Kaarlela, Koskenranta, Kaučič and Riklikiene66} reported that mentors’ cultural competence levels varied from intermediate to high, and were positively associated with greater years of experience.

Few CALD students in this study received support from their university, suggesting the need to develop universities’ international student support services. ^{Reference Zhang67} In contrast, a survey by Baker et al. ^{Reference Baker, Rylance-Graham and Keane47} showed that 78% of CALD healthcare students at one institution believed that university support was adequate for their clinical placements. This may imply that CALD students require additional support in engaging with university services when challenges arise. Wawera and McCamley ^{Reference Wawera and McCamley25} surveyed 61 CALD students in the UK and found that 70% of participants accessed university support services when experiencing loneliness; however, 30% did not engage with support services due to lack of time, social anxiety and fear of talking to strangers. Zile et al. ^{Reference Zile68} argued that university support services are under-resourced and may inadequately address CALD students’ mental wellbeing. However, University International Advice and Guidance teams often provide multiple routes for students to engage with support, including online and face-to-face support for language barriers, cultural differences and feelings of isolation. ²⁶ In addition, University Learning and Teaching Support Officers are equipped to direct CALD students to the most appropriate support to meet their needs, ⁶⁹ whilst provision of social and cultural events at the University can support the integration of CALD students with the British culture. ^{Reference Chen70}

Overall clinical placement experience

CALD students within this study rated their overall placement experience as 3·.24/5 (Figure 6). Placement satisfaction has been proven to affect retention in healthcare. ^{Reference Ropponen, Kamau, Koskenranta, Kuivila, Oikarainen and Isakov36} Ropponen et al. ^{Reference Ropponen, Kamau, Koskenranta, Kuivila, Oikarainen and Isakov36} reported factors influencing CALD nursing students’ retention included support during placement and university studies, perceived equality, nursing competence development and social integration. Such factors impact confidence-building, adaptability and dealing with unexpected events, ^{Reference Thomas, Thomas and McLean71} which could help healthcare CALD students develop resilience, an essential skill for protecting well-being and maintaining self-esteem. ^{Reference Ching and Cheung72,73}