Europe’s healthcare systems are facing increasing pressure due to demographic change, population ageing, workforce shortages, and the growing complexity of care needs (OECD/European Commission 2024). The proportion of people aged 65+ is projected to reach 30% of the EU population by 2050, significantly increasing the demand for long-term care and specialised health services (European Commission 2021), while many countries already face challenges in recruiting and retaining qualified healthcare professionals (WHO Europe 2022). Finland is no exception.
In this context, internationally educated professionals represent an important workforce resource. However, insufficient proficiency in local languages can often lead to deskilling and limited career opportunities in Europe (e.g. Vartiainen 2021; Kamau et al., 2022).
At the same time, the number of culturally and linguistically diverse (CALD) students in Finland has increased significantly (Finnish National Agency for Education 2025), which highlights the need to recognise and understand the cultural differences they experience and to integrate these in the planning and implementation of education (e.g. Repo Jamal et al., 2024a).
In response to the growing shortage of qualified nurses, the Finnish Ministry of Education and Culture assigned Metropolia University of Applied Sciences and Tampere University of Applied Sciences in 2021 to develop and pilot a functionally bilingual nursing education programme TOKASA. The programme allows students to enroll without prior knowledge of Finnish, with the aim that graduates acquire not only the required professional competence but also sufficient proficiency in the Finnish language.
TOKASA follows European standards (2013/55/EU), comprising 210 ECTS credits over a period of 3.5 years. Teaching is initially conducted in English, while the target language (Finnish) is systematically integrated into nursing studies through collaboration between nursing and language teachers. Language learning is based on a functional approach, through which students learn how language is used in professional interactions and how to apply it for communicative purposes across diverse clinical contexts, rather than relying primarily on traditional grammar-based instruction. (Repo Jamal 2024b.)
This evaluation study followed the first groups of TOKASA students, who began their studies in January 2022. Data were collected through thematic interviews after the first semester in spring 2022 (n=24) and again in spring 2024 (n=16). The data were analysed using inductive content analysis (Graneheim & Lundmark 2024). Cultural differences were categorized into those related to education, language learning, and healthcare. All of the comments below related to these categories are quotations from the data collected at Metropolia UAS and Tampere UAS.
Adjusting to Finnish higher education pedagogy
Cultural differences were evident in students’ experiences of education. The European higher education context, which emphasises independent learning and student responsibility, was unfamiliar to many. Students were often accustomed to teacher-centred lectures and examination-based assessment and surprised by the extent of independent study and collaborative group work required. In addition, functional teaching methods, such as simulations, drama, and game-based learning, were new to many students.
“The amount of independent work increased uncertainty: have I done everything correctly?”
“I have in this culture shock. Because in my country, we are expecting to just listen and get everything from teacher. We are not supposed to ask question or even make a comment.”
The relatively low degree of hierarchy between students and teachers, as well as teachers’ friendly and encouraging approach, differed from students’ previous experiences. Students were actively encouraged to ask questions and participate in dialogue, which required adjustment for some. At the same time, some students reported a strong fear of making mistakes, rooted in their cultural background or earlier educational experiences, which could affect their engagement and learning processes.
The same applied to clinical practice: some students were afraid of making mistakes during clinical placements, both in their nursing tasks and in their use of the Finnish language, which may have hindered their learning during the placement.
“I am just afraid to make mistakes and that’s something that probably language teaching cannot really affect on that much. That’s just something that I have to deal with.”
“In my home country, teachers cannot be addressed by their first name. Here, everyone is equal.”
Prior experiences influenced language learning
Cultural differences also shaped students’ experiences of language learning. Previous experiences of learning foreign languages influenced how students approached language acquisition, and for many, the principles of functional language learning were unfamiliar.
Some students expressed a need for more structured support, such as textbooks and explicit grammar instruction alongside communicative approaches. At the beginning of their studies, many wished for a Finnish-speaking peer with whom they could practice the language in an authentic and supportive context.
Students also noted that, unlike in some of their prior educational environments, there was no culture of punishing or humiliating students for making mistakes in Finnish. Instead, teachers were perceived as supportive and fostering an environment in which students could experiment with the language and learn through trial and error. Language teachers, in particular, emerged as an important source of support, helping students navigate both linguistic and cultural aspects of learning.
“Their encouragement really got me, where I’m today.”
“Here people are happy when you try to speak Finnish. They do not laugh at you or point out mistakes.”
On the other hand, some students felt that during certain clinical placements their Finnish language skills were judged too critically.
“Everyone was kind of watching me closely, as if under a microscope, to see if I would cope.”
Many aspects of healthcare were experienced unfamiliar
Students encountered several cultural differences in healthcare settings that shaped their learning experiences. Low hierarchical structures were particularly notable, as staff interacted openly across professional roles, shared meals, and participated collectively in nursing care.
“It was quite unbelievable that doctors, nurses, and students all sat at the same coffee table, talking together.”
At the same time, students observed differences related to the concepts of time, privacy, physical distance, and touch. It was important to be punctual and to adhere to agreed schedules. Many students reflected on physical touch, questioning which forms of contact are considered appropriate in Finnish culture and in which situations. Finns were perceived to value privacy and to maintain relatively large physical distance in interpersonal interactions.
“The privacy and physical distance of Finnish people initially seemed amusing, but I have come to appreciate it myself.”
The first clinical placements took place in various elderly care settings, which were unfamiliar to many students. In their source countries, care for the elderly was often primarily provided by family members, making institutional elderly care a new experience. Some students found this arrangement emotionally challenging, while others perceived that the elderly receive higher-quality care in professional settings. For example, the physical facilities of care institutions were often considered to be of a very high standard. The relative absence of family members in care situations also contrasted with students’ prior experiences, where family involvement may play a more central role.
“In my home country, there is no formal elderly care, as children take care of their own parents. When I was a child, my grandparents lived with us.”
Supporting CALD students through culturally responsive pedagogy and practice
Findings of the study indicate that CALD students experienced many cultural differences in relation to education, language learning, and healthcare. Key takeaways can be summarised as follows:
- A pedagogy that emphasizes the student’s independent role and functional teaching methods may be unfamiliar to many CALD students.
- Students’ previous experiences of language learning influence their learning of a new language.
- In healthcare workplaces, frequently emerging cultural differences should be considered in supervising students’ clinical practice.
Cultural differences became particularly evident during their first semester of education. During the follow-up period, the students’ language proficiency had improved significantly, they had completed several clinical practices, and their studies had progressed.
The students had integrated mainly well: many had found employment in the field of healthcare, made Finnish friends, and begun using Finnish as their everyday language. Nevertheless, some students perceived the independent student role and the functional approach as unfamiliar and preferred a more traditional pedagogical approach similar to their previous experiences. Some students also reported difficulties adapting to the Nordic low-hierarchy culture; this challenge was accompanied by stress related to concerns about making mistakes in both classroom and work placement settings.
Recognising and understanding the cultural differences experienced by CALD students and integrating this understanding into both educational practices and guidance as well as supervision in clinical practice is important, particularly in a context where the number of CALD students is rapidly increasing (Finnish National Agency for Education 2025).
Culturally responsive pedagogy supports the smooth progression of studies and the integration of students (Repo Jamal 2024a). It is important for teachers and supervisors to understand that CALD students do not automatically assimilate into a new culture, but these processes require deliberate attention and support throughout their studies.
Students’ backgrounds and previous educational experiences strongly influence how they position themselves in their current studies. Some students experienced a strong fear of making mistakes, stemming from their cultural background or previous educational experiences. Therefore, it is important for teachers to engage in continuous dialogue with students about the principles of functional pedagogy and the expectations placed upon them. In addition, teachers, as well as supervisors in clinical practice, should create a safe and supportive learning environment in which making mistakes is allowed and continuous feedback is provided. (e.g. Repo Jamal 2024a.)
References
European Commission. 2021. Long-term care report: Trends, challenges and opportunities in an ageing society. Publications Office of the European Union. Accessed 28 April 2026.
European Parliament and Council. 2013. Directive 2013/55/EU.
Finnish National Agency for Education. 2025. Opetushallituksen mediatilaisuus: Ulkomaalaisten tutkinto-opiskelijoiden työllistyminen Suomessa.pdf. Accessed 28 April 2026.
Graneheim, U. H. & Lundman, B. 2004. Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Education Today, 24(2), 105–112.
Kamau, S., Koskenranta, M., Isakov, T.-M., Kuivila, H., Oikarainen, A., Tomietto, M. & Mikkonen, K. 2022. Culturally and linguistically diverse registered nurses’ experiences of integration into nursing workforce – A qualitative descriptive study. Nurse Education Today, 121, 105700.
OECD/European Commission. 2024. Health at a Glance: Europe 2024: State of Health in the EU Cycle. OECD Publishing, Paris.
Repo Jamal, H. 2024a. Kieli- ja kulttuuritietoinen työote opetuksessa ja ohjauksessa. In: Repo Jamal, H. & Laiho, S. (eds.) 2024. Toiminnallisesti kaksikielinen korkeakoulutus – uusia osaajia Suomen työmarkkinoille. Metropolia Ammattikorkeakoulun julkaisuja, TAITO-sarja 146, Helsinki.
Repo Jamal, H. 2024b. Esipuhe. In: Repo Jamal, H. & Laiho, S. (eds.) 2024. Toiminnallisesti kaksikielinen korkeakoulutus – uusia osaajia Suomen työmarkkinoille. Metropolia Ammattikorkeakoulun julkaisuja, TAITO-sarja 146, Helsinki.
Vartiainen, P. 2021. Säädellysti Suomeen – kohti hoitoalan kansainvälisen rekrytoinnin ratkaisuja. Työelämän tutkimus, 19(2), 264–265. Accessed 28 April 2026.
WHO. 2022. Health and care workforce in Europe: time to act. Copenhagen: WHO Regional Office for Europe. Accessed 28 April 2026.
Authors
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Hanna Repo Jamal
Director of Research and Development Programme (Equitable and Diverse Life), Metropolia University of Applied SciencesHanna Repo Jamal is a registered nurse, teacher, researcher, and expert in cultural diversity. She works as Director of Research and Development Programme at Metropolia University of Applied Sciences.
About the author -
Päivi Vartiainen
Senior Expert, Project Manager, Tampere University of Applied SciencesPäivi Vartiainen holds a PhD in Education and works at Tampere University of Applied Sciences in roles related to migration and intercultural competence.
About the author