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Lecturers' experiences of participating in an international exchange
Nurse Education Today 31 (2011) 541–546
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Nurse Education Today j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / n e d t
Lecturers' experiences of participating in an international exchange Karin Enskär ⁎, Inez Johansson, Gunilla Ljusegren, Ingrid Widäng Department of Nursing Science, School of Health Sciences, Jönköping University, Sweden
a r t i c l e
i n f o
Article history: Accepted 7 October 2010 Keywords: Lecturers' experience International exchange Nursing education Sweden–Africa
s u m m a r y Globalization is a trend in higher education and is judged to be essential to quality; however, there is a lack of publications on the outcome of lecturers' exchange. The aim of this study was to describe lecturers' experiences of participating in an international exchange. Twenty-six lecturers who had taken part in an exchange were invited to participate through writing a narrative. Data was analyzed with a qualitative method, and five categories emerged: Preparation and timing, challenges in teaching, demanding but worthwhile, broadening perspective and expanding network. The overall result showed that participating lecturers judged their international exchange to be a positive experience that had resulted in personal as well as professional development. However, a successful exchange requires planning, support and an open mind from all involved lecturers and institutions. © 2010 Elsevier Ltd. All rights reserved.
Introduction Nursing is an international profession, and there is a growing need for nurses to be able to work across and within national borders. The trend toward globalization in areas of human activity is also starting to influence the professional training that universities offer students and lecturers. Already in Roucek, 1958 described the benefits of student and lecturer exchange. Later, Burn (1980) argued that, despite their importance, international exchange programs involving higher education students and lecturers remain distressingly limited and need to be expanded. Forest (2002) claimed that academic staff are aware of the global trends and respond with a range of exchange programs and curricular initiatives. An international survey of the academic staff indicated that they supported these efforts. However, this support was weaker among lecturers compared to researchers. Internationalizing the nursing education program is essential for encouraging a global perspective and provides nurses with cultural competence. Study-abroad programs can take a variety of forms, including exchange between institutions that provide students, lecturers and researchers with health care experiences in other countries. Exchange programs form an important tool in European nursing education programs for increasing students' cultural perspective. The literature on the internationalization of university education
⁎ Corresponding author. Department of Nursing Science, School of Health Sciences, Jönköping University, PO Box 1026, S-551 11 Jönköping, Sweden. Tel.: + 46 36 10 12 37; fax: + 46 36 10 12 50. E-mail addresses: [email protected] (K. Enskär), [email protected] (I. Johansson), [email protected] (G. Ljusegren), [email protected] (I. Widäng). 0260-6917/$ – see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2010.10.018
suggests that the types of benefits that participants in study-abroad programs gain include an expanded international perspective as well as intellectual and personal development (Green et al., 2008). However, little empirical research has been undertaken to confirm that such benefits are in fact obtained (Duffy, 2005; Inglis et al., 1998). Most publications accounts of presenting international program or curriculum development (Lange and Ailinger, 2001; Robinson et al., 2006). In recent years, some research has been published regarding students' experiences of international exchange. A literature review by Button et al. (2005) identified professional and personal growth among nursing students who had undertaken an international exchange/placement during their training. A better understanding of cultural differences was also reported, which has been confirmed in other studies (Green et al., 2008; Callister and Cox, 2006; Pross, 2003). Another way of providing a cultural perspective is to allow the exchange lecturers to be engaged in all aspects of teaching and learning (internationalization on home ground) (Ogilvie et al., 2003). Input from visiting lecturers was appreciated by students (Hussler et al., 2003). Publications on faculty exchange focus mostly on program development (Lange and Ailinger, 2001; Robinson et al., 2006), but evaluation of these exchange programs is limited. However, Chauke and Mokoena (2006) found that participants in an exchange program were positive and found the exchange beneficial and challenging. Also, Sandgren et al. (1999) found that lecturer exchange experience abroad enhances cultural awareness as well as self-awareness. Aim The aim of this study was to describe lecturers' experiences of participating in an international exchange.
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Table 1 Description of participants, home and host universities, and length of exchange. Sweden n = 10 Home university
Age
Sex Position Years of experience as lecturer
Number of exchanges
Total number of exchange weeks
Host university
University of Limpopo — Medunsa campus, South Africa Mpumalanga Nursing College, South Africa University of Cape Town, South Africa University of Botswana, Botswana Nkinga Nursing College, Tanzania Jönköping University, Sweden 30–39 40–49 50–59 N 60 Female Male Lecturer PhD, senior lecturer b 5 years 5–10 years 10–20 years 20–30 years N 30 years 1 2 3 4 5 6 b5 5–9 10–15 N 15 University of Limpopo — Medunsa campus, South Africa Mpumalanga Nursing College, South Africa University of Cape Town, South Africa University of Botswana, Botswana Nkinga Nursing College, Tanzania Jönköping University, Sweden
Method
– – – – – 10 – 1 3 6 10 – 7 3 – 1 3 2 4 4 1 – 1 3 1 3 3 – 4 3 3 2 1 5 –
African n = 16 5 2 2 2 5 – 4 5 6 1 12 4 10 6 1 3 8 3 1 11 4 1 – – – 7 5 4 – – – – – – 16
Total n = 26 5 2 2 2 5 10 4 6 9 7 22 4 17 9 1 4 11 5 5 15 5 1 1 3 1 10 8 4 4 3 3 2 1 5 16
established between Jönköping University and nursing schools in and nursing schools in Botswana, South Africa and Tanzania.
Design Participants A qualitative design was chosen with the intention to gain the lecturers' views and to understand their experiences of an international exchange. Using narratives, it is possible to gain access to the participant's experiences and perceptions (Holloway and Wheeler, 2010). Ethical approval was granted by the heads of the participating universities. The lecturers' participation was based on informed consent, and they were informed that they could withdraw any time without explanation or consequences. The narratives were made anonymous before reading in order to ensure confidentiality.
Setting The Linnaeus–Palme (L–P) Programme is similar to ERASMUS but addresses developing countries outside Europe and the United States. The L–P Programme is supported by grants from the Swedish Government, and its aim is to strengthen the collaboration between higher education institutions and provide an opportunity to broaden the experience and understanding of each other's cultures and values. A project can receive funding for a maximum of eight years for Swedish lecturers and students going abroad as well as to lecturers and students coming to Sweden (the International Programme Office for Education and Training, 2010). The lecturer exchange should last three to five weeks. For the past ten years, the Department of Nursing Science, Jönköping University, has received funding from the L–P Foundation for the exchange of faculty and students. Exchange projects have been
Lecturers who have participated in at least one international exchange period within the L–P Programme, a total number of 35 lecturers, were invited to participate. Twenty-six lecturers, 10 of 12 from Sweden and 16 of 23 from Botswana, South Africa and Tanzania, replied after one reminder (see Table 1). Some lecturers had left their position, which could be a reason for their not participating. Data collection and procedure In order to capture the lecturers' narratives, a questionnaire with one open-ended question was developed: “Describe your experience of participating in an international exchange.” The participants were also asked about background variables. The questionnaires were distributed via e-mail together with an invitation letter. Twenty-four of the questionnaires were returned by e-mail and two by mail. It was voluntary to reply in English or Swedish. Two of the Swedish participants and all Africans wrote their narratives in English, while the remaining answered in Swedish. Data analysis The analysis followed the description by Holloway and Wheeler (2010): Each narrative was read through several times to obtain a sense of the content. Two of the authors analyzed the narratives of the African lecturers while the remaining two analyzed those of the Swedish ones.
K. Enskär et al. / Nurse Education Today 31 (2011) 541–546
Core units were identified, describing different experiences of the exchange. The core constructs and the related text were organized in a coding sheet, and the codes based on the same content were sorted into themes, with five themes ultimately being confirmed. Hereafter the authors traded data, in order to review and confirm the themes and to achieve trustworthiness. Trustworthiness Trustworthiness (Guba and Lincoln, 1989) was strived for through prolonged involvement until all authors were familiar with the context, and by trading the data during the analysis process as an investigator triangulation. Three of the four authors have participated as exchange lecturers and are included in this study. To minimize the risk of bias, these participants answered the questionnaire prior to reading the others' narratives. To consider the pre-understanding, the themes were scrutinized and discussed several times by all authors. Following recommended analyses and confirming themes with significant quotations strengthens trustworthiness.
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Challenges in teaching For the visiting lecturer it was a challenge to adjust to the new pedagogical approach, teaching methods and facilities at the host university. The lecturer had to balance the teaching in order to refer both to the local cultural perspective and circumstances as well as to the lecturer's own pedagogical approach. Being on exchange inspired the visiting lecturers to use different teaching methods. The experience was that the exchange contributed to a professional development in the form of a deeper and broader understanding of nursing. Participating lecturers noted the value of sharing experiences in teaching, which they considered beneficial to both institutions. The exchange gave the lecturers ideas about how they could improve their teaching, for example implementing team teaching, using reflection as a learning tool, using a skill lab and employing new forms of assessment. “We have been able to exchange ideas and compare approaches to teaching and learning, and we believe this has benefited both parties” (South Africa, 3).
Results Preparation and timing The respondents stated that both personal and professional preparation were essential prior to the exchange. Preparation includes gathering information about the content of one's teaching responsibilities and preliminary schedule. Furthermore, time should be allocated to plan teaching activities. If the preparation is inadequate, this creates a stressful situation for the lecturer. Preparation also includes synchronizing the period of the exchange with the lecturer's competence in the expected teaching subject at the host university. The lecturer's responsibilities at the home university also must be considered. It was stated that trying to be fully prepared before leaving could be stressful. Introduction to the education program, the university, the health care system and social structure, as well as cultural aspects contributes to an understanding of the context of the exchange activity. “A teaching plan was sent early on for timely preparation, which made it easy to prepare for the lesson” (Sweden, 7).“The program was explained clearly and the areas of exchange activities were mutually established” (Botswana, 10).
Planning and accomplishing the teaching could sometimes be a challenge due to the need to use unfamiliar equipment. For other lecturers a shortage of academic libraries and a lack of computers and the Internet were a challenge. “I have seen the need to use other didactic tools, adapting to the students in front of me, which has enhanced my teaching skills and my sensitivity to people with different backgrounds and ways of thinking” (Sweden, 4). The lecturers experienced that they had the possibility to share their knowledge with colleagues and students. New knowledge was acquired, which they brought home and used as examples from other contexts. They were also more prepared to inform exchange students. “It gave me the opportunity to share my expertise with the students from different countries, including two lecturers from the United States…” (South Africa, 1).“…giving examples from my own experiences (of being an exchange teacher) is a strength in teaching…” (Sweden, 10). Demanding but worthwhile
Two lecturers from the same institution being on exchange during the same period provides an opportunity to share, support and reflect on experiences during as well as after the exchange period. It was stated that when the same lecturer had been on exchange to the same institution several times it promoted closer links between the faculty and the participating lecturer. Shorter exchange periods were mentioned as negative. “That the same lecturer participates in the exchange continuously means that the contact with lecturers at the host university can deepen the relationships, which could contribute to confidence and friendship” (Sweden, 2). Practical support and personal engagement contribute to a successful time for the visiting lecturer, for example being met at the airport and being introduced to the accommodations and the institution were seen as important and made the exchange lecturer feel wanted and welcome. A lack of support led to negative feelings and could even override positive experiences. “Staff members have been extremely helpful in assisting us in coping with the challenges of language and other practical difficulties involved in living in a different culture” (South Africa, 3).
The task of carrying out an exchange was seen as demanding but worthwhile at the same time. The lecturers expressed that they felt dual expectations — duties to teach at the host university and simultaneously maintain their duties at the home university. Taking up the gauntlet of visiting another country, meeting new people and teaching at another institution was seen as an advantage and led to personal growth. Being left to rely on him/herself, in teaching sessions as well as during spare time, forced the lecturer to become independent and self-confident. The exchange period also provided time for reflection, to become aware of oneself, to be more openminded and to trust oneself, which led to increased self-confidence and self-esteem. “First I was very happy when I got the chance…after that followed worry…would I manage?” (Tanzania, 15).“…the challenges in the exchange have made me grow as a person…” (Sweden, 4). Taking part in an exchange was seen as an important part of their future career. “…It enhanced my career…added the teaching experience to my CV…” (South Africa, 1).
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Swedish lecturers experienced that using English when teaching was a challenge, but also an opportunity to improve their language skill. The language barrier was described as an obstacle to interaction, and could prevent visitors from taking part in activities like seminars and staff meetings. This is mentioned specifically by visitors coming to Sweden, where English is not the official language. “…being an exchange lecturer is a challenge when it comes to teaching in English, in a different cultural context, and being left to one's own resources…” (Sweden, 10).“Language barriers…as Swedish was a medium of communication outside the class, that limited social interaction” (South Africa, 8). Visiting another nursing school could lead to feelings of loneliness. For some participants the exchange visit was a sacrifice involving leaving their family, and feelings of homesickness were expressed. Feeling lonely was less obvious if the lecturers travelled together in a pair or if the visiting lecturer met and socialized with other guest lecturers. “It is good to be two teachers coming from the same college, as this can minimize loneliness” (Tanzania, 15). The visiting lecturers found that the allowance they received was not in harmony with living costs in Sweden, and they therefore could not travel or take excursions like they saw the Swedish lecturers do during their exchange periods.
I have gained an increased understanding of peoples' different lives and circumstances…” (Sweden, 10).
Expanded network An international exchange provided opportunities for new contacts, leading to professional relationships that lasted far beyond the visit. This new network included friendship with colleagues and staff members at the host university, other visiting lecturers, international students and people in society. Meeting and sharing professional knowledge also led to collaboration such as research and publications. Another spin-off effect was an exchange of nursing staff between a Swedish and an African hospital. Lecturers travelling in pairs relied on each other and experienced a closer friendship. On the other hand, lecturers travelling on their own seemed to be more involved in activities at the host university and thereby established new contacts with their host colleagues. “I have participated in writing a chapter in a book and in a research project…this has been a contribution to my professional development to a great extent…” (Sweden, 5).“…very rewarding, and friendships have been established across the sea. I have made friends…lecturers from the US, and kept contact since 2001” (South Africa, 9).
Discussion “…I experienced a culture shock in the shops when I realized how expensive food was. …very high prices for food” (South Africa, 9).
Broadening perspective Visiting another country entailed that the lecturers faced a different culture. They expressed that the exchange gave them opportunities to meet colleagues in their natural environment, which enhanced their understanding of cultural similarities and differences. The exchange increased the lecturers' understanding for a different society, causing them to reflect on their own as well as other cultures. “Meeting other teachers and students from different countries, learning about one's own culture, recognizing the differences and adapting your behaviour to appreciate and accommodate those differences” (Tanzania, 14).“…having respect for the differences, seeking comprehension for things you don't have knowledge about…accepting the fundamental elements in the culture…” (Sweden, 9). The lecturers noticed the different living conditions when they were on exchange. Available resources influenced both the education and the health care system. The African lecturers noticed the well equipped hospitals and high number of staff, as well as how the health care system is organized to take care of care for the elderly and mentally disabled. On the other hand, the Swedish lecturers stated that it is possible to provide care in spite of shortage of resources. Being on an exchange arose questions on global distributions of resources and lack of equity. “I have obtained that Human basic needs are equal irrespective of where coming from, therefore as we are talking about globalization there is a need to address health problems globally and also ensure the equal distribution of resources so that people can access health service and other basic needs …” (Tanzania, 14).“… in some way the world has become bigger and more concrete and
The overall result showed that participating lecturers judged their international exchange to be a positive experience that resulted in personal as well as professional development. A positive outcome requires an open-minded approach by the participating lecturer as well as support from the organizations involved. Limited research was found on lecturers' experiences of international exchange. However, a number of studies have been conducted among students. Since similar results have been found among individuals who have participated in international exchange, the results will be discussed in relation to those experiences. All the authors are engaged in international work and also represent the same, Swedish university, which can be seen as a limitation. This fact might have influenced their objectivity. To avoid this, the analysis was presented and discussed with colleagues in South Africa, which can be seen as contributing to trustworthiness (Guba and Lincoln, 1989). Also the fact that English is not the mother tongue for any of the participants can be seen as a limitation. But to participate as exchange lecturer it is necessary to be fluent in English. The lecturers participating in this study described their experiences as leading to personal growth and increased self-confidence. This has also been confirmed in earlier studies (Button et al., 2005; Lee, 2004; Rantz et al., 2004; Sandgren et al., 1999). In this study, the lecturers described the exchange as demanding but worthwhile which is in line with an earlier study (Chauke and Mokoena, 2006). Being left to rely on oneself in teaching sessions as well as during spare time allowed time for reflection (Bower, 2004). Students reported the exchange as a stressful experience and a challenge, but overcoming challenges made them work on their own values and beliefs, which led to increased selfconfidence and self-awareness (Masano, 2009; Lee, 2004; Sandin et al., 2009). This is in line with our interpretation that lecturers described personal growth despite some hardship. A lecturer who has had the possibility to do something different from his/her daily activities and business has been given the chance for personal and professional renewal (Bower, 2004). On the other hand, there is also research reporting that participants in an exchange program had learned a great deal, but the academic outcome of the program was still not impressive (Inglis et al., 1998).
K. Enskär et al. / Nurse Education Today 31 (2011) 541–546
Being an exchange lecturer led to new contacts with people from different countries and universities. Some of the lecturers in this study have maintained this contact after the exchange. Nurses around the world benefit from networking. Global nursing exchange programs have been described as a welcoming, unstructured environment that connects colleagues in deeper ways, with the collective wisdom demonstrated by the nursing exchange helping to stimulate dialogue, cultivating a new reality for all involved (Rantz et al., 2004). Meeting individuals from different countries is a powerful way to learn about different cultures and understand people's different ways of living (Button et al., 2005; Sandin et al., 2009). Greatrex-White (2008) found that close relationships developed with people of other nationalities, cultures and disciplines form a powerful base for support during the exchange. In this study, the lecturers stated that their time spent in another context led to a broader understanding of each other's living conditions and insights into different ways of organizing education, teaching and health care. In a study by Sandin et al. (2009) students experienced culture shock when undertaking fieldwork in Tanzania, but at the same time they gained understanding for a different society. The lecturers also experienced frustration when it became obvious how different economic conditions influenced people's health care, education and personal life. Hopefully, this eye-opener led to an engagement in issues of human rights and equity. The lecturers from Africa experienced the Swedish language as a hindrance in both social and academic aspects. Inability to speak the language of the host country may render one reliant upon the willingness of the hosts to translate and their ability to speak English, which might increase feelings of dependency, worthlessness and being the outsider (Greatrex-White, 2008). Furthermore, there were two other concerns that could affect the equality: The limited funding and the initiatives and decisions in the program. It is therefore important to address the issues of reciprocity and equality. This requires a process of communication and decision-making (Ogilvie et al., 2003), thereby allowing both universities to benefit from the program and learn from each other (Khalil, 2006). Being an exchange lecturer implied the need for a balance in adjusting to teaching methods at the host university and still maintain one's own teaching approaches and habits. African lecturers stated that they had adopted new and different pedagogical approaches such as critical thinking, reflection, team teaching, seminar work and group discussions. The teaching approach in Africa was experienced as hierarchic, as opposed to the individual autonomy found in Sweden (Sandin et al., 2009). Lecturers in this study described that the exchange resulted in their reflecting on their own attitudes and values, in which brought about new ways of teaching and interacting with students. African lecturers visiting Sweden stated that the interaction between students and lecturers in Sweden was on a more equal basis, but that despite this friendly tone the Swedish lecturers still kept their professional demeanor (Chauke and Mokoena, 2006). According to the Swedish Higher Education Act, internationalization is an essential part of higher education (SFS 1992:1934) and is judged by Swedish university lecturers to be a marker of quality (Widäng, 1993). Internationalization has also been found to open opportunities for empowerment in lecturers in South Africa (Cornes and Mokoena, 2004). An international perspective can be partly achieved through allowing visiting lecturers or by taking advantage of lecturers who have been on exchange. Faculty and students who remain at home but attend presentations by visiting lecturers could also benefit (Ogilvie et al., 2003). A positive exchange experience requires an open mind, engagement and time. University schedules, climate and personal responsibilities will affect the outcome. In order to ensure a successful exchange, the home university has to plan and organize the exchange period in collaboration with the participating lecturers as well as with the participating institution. It is equally important that the lecturer receive
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personal and professional support (Lee, 2004; Sandin et al., 2009). An obstacle to a successful exchange involves expectations from the home university that have to be taken into consideration when choosing a suitable period for the exchange. Being met at the airport as well as being involved in different activities and receiving support during the exchange is important for a fruitful exchange. This was also confirmed by Lee (2004). For lecturers who have international experience of their own, this is a natural way to meet a colleague — but could be a challenge for the faculty. Involving visitors in activities during evenings and weekends should be as natural as involving them in academic activities. African lecturers did not find the funding provided by the L–P Programme sufficient, and felt frustrated when facing the high living costs in Sweden. They found it difficult to participate in activities such as travelling and sightseeing. As mentioned earlier, the aim of the L–P Programme is to strengthen the collaboration between higher education institutions and to provide an opportunity to broaden the experience and understanding of each other's cultures and values. This study provides evidence that the lecturers gained a broader understanding of cultures and values and were provided an opportunity to reflect on their own professional role. The long term consequences are not evaluated in this study but it was evident that participating in an exchange lead to professional development for the lecturer. If the involved institutions are taking advantage of the gained experiences it might lead to improved teaching methods as well as curriculum development. Conclusion The overall result showed that participating lecturers judged their international exchange to be a positive experience that resulted in personal as well as professional development and form a base for future development. However, since the L–P projects are limited in time there is a risk that they might “fade out” when their financial support ends. On the other hand, this could be a trigger for seeking and disseminating future international collaboration. A positive outcome requires an openminded approach by participating lecturers as well as support from the organizations involved. Acknowledgement Thanks to all who contributed with their narratives. References Bower, K.A., 2004. Retreats as a foundation for change. The global nursing exchange as a retreat. Nursing Administration Quarterly 28 (1), 3–5. Burn, B.B., 1980. Study abroad and international exchanges. Philadelphia: Annuals of American Academy of Political & Social Sciences 449, 129–140. Button, L., Green, B., Tengnah, C., Johansson, I., Baker, C., 2005. The impact of international placements on nurses' personal and professional lives: literature review (2005). Journal of Advanced Nursing 50 (3), 315–324. Callister, L.C., Cox, A.H., 2006. Opening our hearts and minds: the meaning of international clinical nursing electives in the personal and professional lives of nurses. Nursing & Health Sciences 8 (2), 95–102. Chauke, M., Mokoena, J.D., 2006. The experiences of African nurse educators regarding their participation in an overseas exchange program. Africa Journal of Nursing and Midwifery 8 (2), 54–60. Cornes, D., Mokoena, J.D., 2004. Capacity building: the enhancement of leadership and scholarship skills for nurse educators in South Africa. Nursing Update 28 (3), 32–33. Duffy, M.E., 2005. We can learn so much from our colleagues in other countries. International Nursing Review 52, 4–11. Forest, J.J.F., 2002. Globalisation, universities and professors. Cambridge Review of International Affairs 15 (3), 435–450. Greatrex-White, S., 2008. Uncovering study abroad: foreignness and its relevance to nurse education and cultural competence. Nurse Education Today 28 (5), 530–538. Green, B., Johansson, I., Rossner, M., Tengnah, C., Scott, J., 2008. Studying abroad: a multiple case study of nursing students' international experiences. Nurse Education Today 28, 982–993. Guba, E., Lincoln, Y., 1989. Fourth Generation Evaluation. Sage, Newbury Park. Holloway, I., Wheeler, S., 2010. Qualitative Research in Nurses. Blackwell Oxford.
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Hussler, S., Paavilainen, E., Åstedt-Kurki, P., 2003. Finnish students' perceptions of a visiting professor. Journal of Professional Nursing 19 (2), 99–105. Inglis, A., Rolls, C., Kristy, S., 1998. The impact of participation in a study abroad programme on students' conceptual understanding of community health nursing in a developing country. Journal of Advanced Nursing 28 (4), 911–917. Khalil, D.D., 2006. Experiences of teaching nursing in four countries. Nursing Forum 41 (2), 88–94. Lange, I., Ailinger, R.L., 2001. International nursing faculty exchange model: a Chile–USA case. International Nursing Review 48, 109–116. Lee, N.-J., 2004. The impact of international experience on student nurses' personal and professional development. International Nursing Review 51 (2), 113–122. Masano, R. 2009. International Experiences of Tanzanian Nursing Students in Sweden. Bachelor Thesis. University of Jönköping, School of Health Sciences, Department of Nursing. Ogilvie, L., Allen, M., Laryea, J., Opare, M., 2003. Building capacity through a collaborative international nursing project. Journal of Nursing Scholarship 35 (2), 113–118. Pross, E., 2003. International nursing students: a phenomenological perspective. Nurse Education Today 23 (6), 396–403. Rantz, M., Zazworsky, D., Zerull, L.M., Cohen, E., Weydt, A., 2004. The power of dialogue with the global nursing exchange. Nursing Administration Quarterly 28 (1), 19–25.
Robinson, K., Sportsman, S., Eschiti, V.S., Bradshaw, P., Bol, T., 2006. Preparing faculty and students for an international nursing education experience. Journal of Continuing Education in Nursing 37 (1), 21–31. Roucek, J.S., 1958. Sociological implications of studying abroad. Journal of Human Relations 6 (2), 118–132. Sandgren, D., Elig, N., Hovde, P., Krejci, M., Rice, M., 1999. How international experience affects teaching: understanding the impact of faculty study abroad. Journal of Studies in International Education 3, 33–56. Sandin, I., Grahn, K., Kronwall, E., 2009. Outcomes of Swedish nursing students' field experiences in a hospital in Tanzania. Journal of Transcultural Nursing 15 (3), 225–230. SFS, 1992:1434. Higher Education Act (Högskolelag in Swedish). http://www.notisum. se/rnp/sls/lag/19921434.HTM1992:1434(Found 2010-04-08). The International Programme Office for Education and Training. The Linnaeus–Palme Programme. http://www.programkontoret.se/sv/Program-Stipendier/Program1/Linnaeus-Palme/ in English http://www.programkontoret.se/sv/languages/english/ (Found 2010-01-26). Widäng, I., 1993. “Högskolemässighet” Karakteristika för utbildning och undervisning vid högskola och universitet – ur ett lärarperspektiv (Characteristics of education and teaching in higher education – from a lecturer's perspective. In Swedish). Universitetet i Linköping Hälsouniversitetet. FoU-rapport vid Institutionen för omvårdnadsforskning Nr 1.
Contents lists available at ScienceDirect
Nurse Education Today j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / n e d t
Lecturers' experiences of participating in an international exchange Karin Enskär ⁎, Inez Johansson, Gunilla Ljusegren, Ingrid Widäng Department of Nursing Science, School of Health Sciences, Jönköping University, Sweden
a r t i c l e
i n f o
Article history: Accepted 7 October 2010 Keywords: Lecturers' experience International exchange Nursing education Sweden–Africa
s u m m a r y Globalization is a trend in higher education and is judged to be essential to quality; however, there is a lack of publications on the outcome of lecturers' exchange. The aim of this study was to describe lecturers' experiences of participating in an international exchange. Twenty-six lecturers who had taken part in an exchange were invited to participate through writing a narrative. Data was analyzed with a qualitative method, and five categories emerged: Preparation and timing, challenges in teaching, demanding but worthwhile, broadening perspective and expanding network. The overall result showed that participating lecturers judged their international exchange to be a positive experience that had resulted in personal as well as professional development. However, a successful exchange requires planning, support and an open mind from all involved lecturers and institutions. © 2010 Elsevier Ltd. All rights reserved.
Introduction Nursing is an international profession, and there is a growing need for nurses to be able to work across and within national borders. The trend toward globalization in areas of human activity is also starting to influence the professional training that universities offer students and lecturers. Already in Roucek, 1958 described the benefits of student and lecturer exchange. Later, Burn (1980) argued that, despite their importance, international exchange programs involving higher education students and lecturers remain distressingly limited and need to be expanded. Forest (2002) claimed that academic staff are aware of the global trends and respond with a range of exchange programs and curricular initiatives. An international survey of the academic staff indicated that they supported these efforts. However, this support was weaker among lecturers compared to researchers. Internationalizing the nursing education program is essential for encouraging a global perspective and provides nurses with cultural competence. Study-abroad programs can take a variety of forms, including exchange between institutions that provide students, lecturers and researchers with health care experiences in other countries. Exchange programs form an important tool in European nursing education programs for increasing students' cultural perspective. The literature on the internationalization of university education
⁎ Corresponding author. Department of Nursing Science, School of Health Sciences, Jönköping University, PO Box 1026, S-551 11 Jönköping, Sweden. Tel.: + 46 36 10 12 37; fax: + 46 36 10 12 50. E-mail addresses: [email protected] (K. Enskär), [email protected] (I. Johansson), [email protected] (G. Ljusegren), [email protected] (I. Widäng). 0260-6917/$ – see front matter © 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2010.10.018
suggests that the types of benefits that participants in study-abroad programs gain include an expanded international perspective as well as intellectual and personal development (Green et al., 2008). However, little empirical research has been undertaken to confirm that such benefits are in fact obtained (Duffy, 2005; Inglis et al., 1998). Most publications accounts of presenting international program or curriculum development (Lange and Ailinger, 2001; Robinson et al., 2006). In recent years, some research has been published regarding students' experiences of international exchange. A literature review by Button et al. (2005) identified professional and personal growth among nursing students who had undertaken an international exchange/placement during their training. A better understanding of cultural differences was also reported, which has been confirmed in other studies (Green et al., 2008; Callister and Cox, 2006; Pross, 2003). Another way of providing a cultural perspective is to allow the exchange lecturers to be engaged in all aspects of teaching and learning (internationalization on home ground) (Ogilvie et al., 2003). Input from visiting lecturers was appreciated by students (Hussler et al., 2003). Publications on faculty exchange focus mostly on program development (Lange and Ailinger, 2001; Robinson et al., 2006), but evaluation of these exchange programs is limited. However, Chauke and Mokoena (2006) found that participants in an exchange program were positive and found the exchange beneficial and challenging. Also, Sandgren et al. (1999) found that lecturer exchange experience abroad enhances cultural awareness as well as self-awareness. Aim The aim of this study was to describe lecturers' experiences of participating in an international exchange.
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Table 1 Description of participants, home and host universities, and length of exchange. Sweden n = 10 Home university
Age
Sex Position Years of experience as lecturer
Number of exchanges
Total number of exchange weeks
Host university
University of Limpopo — Medunsa campus, South Africa Mpumalanga Nursing College, South Africa University of Cape Town, South Africa University of Botswana, Botswana Nkinga Nursing College, Tanzania Jönköping University, Sweden 30–39 40–49 50–59 N 60 Female Male Lecturer PhD, senior lecturer b 5 years 5–10 years 10–20 years 20–30 years N 30 years 1 2 3 4 5 6 b5 5–9 10–15 N 15 University of Limpopo — Medunsa campus, South Africa Mpumalanga Nursing College, South Africa University of Cape Town, South Africa University of Botswana, Botswana Nkinga Nursing College, Tanzania Jönköping University, Sweden
Method
– – – – – 10 – 1 3 6 10 – 7 3 – 1 3 2 4 4 1 – 1 3 1 3 3 – 4 3 3 2 1 5 –
African n = 16 5 2 2 2 5 – 4 5 6 1 12 4 10 6 1 3 8 3 1 11 4 1 – – – 7 5 4 – – – – – – 16
Total n = 26 5 2 2 2 5 10 4 6 9 7 22 4 17 9 1 4 11 5 5 15 5 1 1 3 1 10 8 4 4 3 3 2 1 5 16
established between Jönköping University and nursing schools in and nursing schools in Botswana, South Africa and Tanzania.
Design Participants A qualitative design was chosen with the intention to gain the lecturers' views and to understand their experiences of an international exchange. Using narratives, it is possible to gain access to the participant's experiences and perceptions (Holloway and Wheeler, 2010). Ethical approval was granted by the heads of the participating universities. The lecturers' participation was based on informed consent, and they were informed that they could withdraw any time without explanation or consequences. The narratives were made anonymous before reading in order to ensure confidentiality.
Setting The Linnaeus–Palme (L–P) Programme is similar to ERASMUS but addresses developing countries outside Europe and the United States. The L–P Programme is supported by grants from the Swedish Government, and its aim is to strengthen the collaboration between higher education institutions and provide an opportunity to broaden the experience and understanding of each other's cultures and values. A project can receive funding for a maximum of eight years for Swedish lecturers and students going abroad as well as to lecturers and students coming to Sweden (the International Programme Office for Education and Training, 2010). The lecturer exchange should last three to five weeks. For the past ten years, the Department of Nursing Science, Jönköping University, has received funding from the L–P Foundation for the exchange of faculty and students. Exchange projects have been
Lecturers who have participated in at least one international exchange period within the L–P Programme, a total number of 35 lecturers, were invited to participate. Twenty-six lecturers, 10 of 12 from Sweden and 16 of 23 from Botswana, South Africa and Tanzania, replied after one reminder (see Table 1). Some lecturers had left their position, which could be a reason for their not participating. Data collection and procedure In order to capture the lecturers' narratives, a questionnaire with one open-ended question was developed: “Describe your experience of participating in an international exchange.” The participants were also asked about background variables. The questionnaires were distributed via e-mail together with an invitation letter. Twenty-four of the questionnaires were returned by e-mail and two by mail. It was voluntary to reply in English or Swedish. Two of the Swedish participants and all Africans wrote their narratives in English, while the remaining answered in Swedish. Data analysis The analysis followed the description by Holloway and Wheeler (2010): Each narrative was read through several times to obtain a sense of the content. Two of the authors analyzed the narratives of the African lecturers while the remaining two analyzed those of the Swedish ones.
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Core units were identified, describing different experiences of the exchange. The core constructs and the related text were organized in a coding sheet, and the codes based on the same content were sorted into themes, with five themes ultimately being confirmed. Hereafter the authors traded data, in order to review and confirm the themes and to achieve trustworthiness. Trustworthiness Trustworthiness (Guba and Lincoln, 1989) was strived for through prolonged involvement until all authors were familiar with the context, and by trading the data during the analysis process as an investigator triangulation. Three of the four authors have participated as exchange lecturers and are included in this study. To minimize the risk of bias, these participants answered the questionnaire prior to reading the others' narratives. To consider the pre-understanding, the themes were scrutinized and discussed several times by all authors. Following recommended analyses and confirming themes with significant quotations strengthens trustworthiness.
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Challenges in teaching For the visiting lecturer it was a challenge to adjust to the new pedagogical approach, teaching methods and facilities at the host university. The lecturer had to balance the teaching in order to refer both to the local cultural perspective and circumstances as well as to the lecturer's own pedagogical approach. Being on exchange inspired the visiting lecturers to use different teaching methods. The experience was that the exchange contributed to a professional development in the form of a deeper and broader understanding of nursing. Participating lecturers noted the value of sharing experiences in teaching, which they considered beneficial to both institutions. The exchange gave the lecturers ideas about how they could improve their teaching, for example implementing team teaching, using reflection as a learning tool, using a skill lab and employing new forms of assessment. “We have been able to exchange ideas and compare approaches to teaching and learning, and we believe this has benefited both parties” (South Africa, 3).
Results Preparation and timing The respondents stated that both personal and professional preparation were essential prior to the exchange. Preparation includes gathering information about the content of one's teaching responsibilities and preliminary schedule. Furthermore, time should be allocated to plan teaching activities. If the preparation is inadequate, this creates a stressful situation for the lecturer. Preparation also includes synchronizing the period of the exchange with the lecturer's competence in the expected teaching subject at the host university. The lecturer's responsibilities at the home university also must be considered. It was stated that trying to be fully prepared before leaving could be stressful. Introduction to the education program, the university, the health care system and social structure, as well as cultural aspects contributes to an understanding of the context of the exchange activity. “A teaching plan was sent early on for timely preparation, which made it easy to prepare for the lesson” (Sweden, 7).“The program was explained clearly and the areas of exchange activities were mutually established” (Botswana, 10).
Planning and accomplishing the teaching could sometimes be a challenge due to the need to use unfamiliar equipment. For other lecturers a shortage of academic libraries and a lack of computers and the Internet were a challenge. “I have seen the need to use other didactic tools, adapting to the students in front of me, which has enhanced my teaching skills and my sensitivity to people with different backgrounds and ways of thinking” (Sweden, 4). The lecturers experienced that they had the possibility to share their knowledge with colleagues and students. New knowledge was acquired, which they brought home and used as examples from other contexts. They were also more prepared to inform exchange students. “It gave me the opportunity to share my expertise with the students from different countries, including two lecturers from the United States…” (South Africa, 1).“…giving examples from my own experiences (of being an exchange teacher) is a strength in teaching…” (Sweden, 10). Demanding but worthwhile
Two lecturers from the same institution being on exchange during the same period provides an opportunity to share, support and reflect on experiences during as well as after the exchange period. It was stated that when the same lecturer had been on exchange to the same institution several times it promoted closer links between the faculty and the participating lecturer. Shorter exchange periods were mentioned as negative. “That the same lecturer participates in the exchange continuously means that the contact with lecturers at the host university can deepen the relationships, which could contribute to confidence and friendship” (Sweden, 2). Practical support and personal engagement contribute to a successful time for the visiting lecturer, for example being met at the airport and being introduced to the accommodations and the institution were seen as important and made the exchange lecturer feel wanted and welcome. A lack of support led to negative feelings and could even override positive experiences. “Staff members have been extremely helpful in assisting us in coping with the challenges of language and other practical difficulties involved in living in a different culture” (South Africa, 3).
The task of carrying out an exchange was seen as demanding but worthwhile at the same time. The lecturers expressed that they felt dual expectations — duties to teach at the host university and simultaneously maintain their duties at the home university. Taking up the gauntlet of visiting another country, meeting new people and teaching at another institution was seen as an advantage and led to personal growth. Being left to rely on him/herself, in teaching sessions as well as during spare time, forced the lecturer to become independent and self-confident. The exchange period also provided time for reflection, to become aware of oneself, to be more openminded and to trust oneself, which led to increased self-confidence and self-esteem. “First I was very happy when I got the chance…after that followed worry…would I manage?” (Tanzania, 15).“…the challenges in the exchange have made me grow as a person…” (Sweden, 4). Taking part in an exchange was seen as an important part of their future career. “…It enhanced my career…added the teaching experience to my CV…” (South Africa, 1).
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Swedish lecturers experienced that using English when teaching was a challenge, but also an opportunity to improve their language skill. The language barrier was described as an obstacle to interaction, and could prevent visitors from taking part in activities like seminars and staff meetings. This is mentioned specifically by visitors coming to Sweden, where English is not the official language. “…being an exchange lecturer is a challenge when it comes to teaching in English, in a different cultural context, and being left to one's own resources…” (Sweden, 10).“Language barriers…as Swedish was a medium of communication outside the class, that limited social interaction” (South Africa, 8). Visiting another nursing school could lead to feelings of loneliness. For some participants the exchange visit was a sacrifice involving leaving their family, and feelings of homesickness were expressed. Feeling lonely was less obvious if the lecturers travelled together in a pair or if the visiting lecturer met and socialized with other guest lecturers. “It is good to be two teachers coming from the same college, as this can minimize loneliness” (Tanzania, 15). The visiting lecturers found that the allowance they received was not in harmony with living costs in Sweden, and they therefore could not travel or take excursions like they saw the Swedish lecturers do during their exchange periods.
I have gained an increased understanding of peoples' different lives and circumstances…” (Sweden, 10).
Expanded network An international exchange provided opportunities for new contacts, leading to professional relationships that lasted far beyond the visit. This new network included friendship with colleagues and staff members at the host university, other visiting lecturers, international students and people in society. Meeting and sharing professional knowledge also led to collaboration such as research and publications. Another spin-off effect was an exchange of nursing staff between a Swedish and an African hospital. Lecturers travelling in pairs relied on each other and experienced a closer friendship. On the other hand, lecturers travelling on their own seemed to be more involved in activities at the host university and thereby established new contacts with their host colleagues. “I have participated in writing a chapter in a book and in a research project…this has been a contribution to my professional development to a great extent…” (Sweden, 5).“…very rewarding, and friendships have been established across the sea. I have made friends…lecturers from the US, and kept contact since 2001” (South Africa, 9).
Discussion “…I experienced a culture shock in the shops when I realized how expensive food was. …very high prices for food” (South Africa, 9).
Broadening perspective Visiting another country entailed that the lecturers faced a different culture. They expressed that the exchange gave them opportunities to meet colleagues in their natural environment, which enhanced their understanding of cultural similarities and differences. The exchange increased the lecturers' understanding for a different society, causing them to reflect on their own as well as other cultures. “Meeting other teachers and students from different countries, learning about one's own culture, recognizing the differences and adapting your behaviour to appreciate and accommodate those differences” (Tanzania, 14).“…having respect for the differences, seeking comprehension for things you don't have knowledge about…accepting the fundamental elements in the culture…” (Sweden, 9). The lecturers noticed the different living conditions when they were on exchange. Available resources influenced both the education and the health care system. The African lecturers noticed the well equipped hospitals and high number of staff, as well as how the health care system is organized to take care of care for the elderly and mentally disabled. On the other hand, the Swedish lecturers stated that it is possible to provide care in spite of shortage of resources. Being on an exchange arose questions on global distributions of resources and lack of equity. “I have obtained that Human basic needs are equal irrespective of where coming from, therefore as we are talking about globalization there is a need to address health problems globally and also ensure the equal distribution of resources so that people can access health service and other basic needs …” (Tanzania, 14).“… in some way the world has become bigger and more concrete and
The overall result showed that participating lecturers judged their international exchange to be a positive experience that resulted in personal as well as professional development. A positive outcome requires an open-minded approach by the participating lecturer as well as support from the organizations involved. Limited research was found on lecturers' experiences of international exchange. However, a number of studies have been conducted among students. Since similar results have been found among individuals who have participated in international exchange, the results will be discussed in relation to those experiences. All the authors are engaged in international work and also represent the same, Swedish university, which can be seen as a limitation. This fact might have influenced their objectivity. To avoid this, the analysis was presented and discussed with colleagues in South Africa, which can be seen as contributing to trustworthiness (Guba and Lincoln, 1989). Also the fact that English is not the mother tongue for any of the participants can be seen as a limitation. But to participate as exchange lecturer it is necessary to be fluent in English. The lecturers participating in this study described their experiences as leading to personal growth and increased self-confidence. This has also been confirmed in earlier studies (Button et al., 2005; Lee, 2004; Rantz et al., 2004; Sandgren et al., 1999). In this study, the lecturers described the exchange as demanding but worthwhile which is in line with an earlier study (Chauke and Mokoena, 2006). Being left to rely on oneself in teaching sessions as well as during spare time allowed time for reflection (Bower, 2004). Students reported the exchange as a stressful experience and a challenge, but overcoming challenges made them work on their own values and beliefs, which led to increased selfconfidence and self-awareness (Masano, 2009; Lee, 2004; Sandin et al., 2009). This is in line with our interpretation that lecturers described personal growth despite some hardship. A lecturer who has had the possibility to do something different from his/her daily activities and business has been given the chance for personal and professional renewal (Bower, 2004). On the other hand, there is also research reporting that participants in an exchange program had learned a great deal, but the academic outcome of the program was still not impressive (Inglis et al., 1998).
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Being an exchange lecturer led to new contacts with people from different countries and universities. Some of the lecturers in this study have maintained this contact after the exchange. Nurses around the world benefit from networking. Global nursing exchange programs have been described as a welcoming, unstructured environment that connects colleagues in deeper ways, with the collective wisdom demonstrated by the nursing exchange helping to stimulate dialogue, cultivating a new reality for all involved (Rantz et al., 2004). Meeting individuals from different countries is a powerful way to learn about different cultures and understand people's different ways of living (Button et al., 2005; Sandin et al., 2009). Greatrex-White (2008) found that close relationships developed with people of other nationalities, cultures and disciplines form a powerful base for support during the exchange. In this study, the lecturers stated that their time spent in another context led to a broader understanding of each other's living conditions and insights into different ways of organizing education, teaching and health care. In a study by Sandin et al. (2009) students experienced culture shock when undertaking fieldwork in Tanzania, but at the same time they gained understanding for a different society. The lecturers also experienced frustration when it became obvious how different economic conditions influenced people's health care, education and personal life. Hopefully, this eye-opener led to an engagement in issues of human rights and equity. The lecturers from Africa experienced the Swedish language as a hindrance in both social and academic aspects. Inability to speak the language of the host country may render one reliant upon the willingness of the hosts to translate and their ability to speak English, which might increase feelings of dependency, worthlessness and being the outsider (Greatrex-White, 2008). Furthermore, there were two other concerns that could affect the equality: The limited funding and the initiatives and decisions in the program. It is therefore important to address the issues of reciprocity and equality. This requires a process of communication and decision-making (Ogilvie et al., 2003), thereby allowing both universities to benefit from the program and learn from each other (Khalil, 2006). Being an exchange lecturer implied the need for a balance in adjusting to teaching methods at the host university and still maintain one's own teaching approaches and habits. African lecturers stated that they had adopted new and different pedagogical approaches such as critical thinking, reflection, team teaching, seminar work and group discussions. The teaching approach in Africa was experienced as hierarchic, as opposed to the individual autonomy found in Sweden (Sandin et al., 2009). Lecturers in this study described that the exchange resulted in their reflecting on their own attitudes and values, in which brought about new ways of teaching and interacting with students. African lecturers visiting Sweden stated that the interaction between students and lecturers in Sweden was on a more equal basis, but that despite this friendly tone the Swedish lecturers still kept their professional demeanor (Chauke and Mokoena, 2006). According to the Swedish Higher Education Act, internationalization is an essential part of higher education (SFS 1992:1934) and is judged by Swedish university lecturers to be a marker of quality (Widäng, 1993). Internationalization has also been found to open opportunities for empowerment in lecturers in South Africa (Cornes and Mokoena, 2004). An international perspective can be partly achieved through allowing visiting lecturers or by taking advantage of lecturers who have been on exchange. Faculty and students who remain at home but attend presentations by visiting lecturers could also benefit (Ogilvie et al., 2003). A positive exchange experience requires an open mind, engagement and time. University schedules, climate and personal responsibilities will affect the outcome. In order to ensure a successful exchange, the home university has to plan and organize the exchange period in collaboration with the participating lecturers as well as with the participating institution. It is equally important that the lecturer receive
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personal and professional support (Lee, 2004; Sandin et al., 2009). An obstacle to a successful exchange involves expectations from the home university that have to be taken into consideration when choosing a suitable period for the exchange. Being met at the airport as well as being involved in different activities and receiving support during the exchange is important for a fruitful exchange. This was also confirmed by Lee (2004). For lecturers who have international experience of their own, this is a natural way to meet a colleague — but could be a challenge for the faculty. Involving visitors in activities during evenings and weekends should be as natural as involving them in academic activities. African lecturers did not find the funding provided by the L–P Programme sufficient, and felt frustrated when facing the high living costs in Sweden. They found it difficult to participate in activities such as travelling and sightseeing. As mentioned earlier, the aim of the L–P Programme is to strengthen the collaboration between higher education institutions and to provide an opportunity to broaden the experience and understanding of each other's cultures and values. This study provides evidence that the lecturers gained a broader understanding of cultures and values and were provided an opportunity to reflect on their own professional role. The long term consequences are not evaluated in this study but it was evident that participating in an exchange lead to professional development for the lecturer. If the involved institutions are taking advantage of the gained experiences it might lead to improved teaching methods as well as curriculum development. Conclusion The overall result showed that participating lecturers judged their international exchange to be a positive experience that resulted in personal as well as professional development and form a base for future development. However, since the L–P projects are limited in time there is a risk that they might “fade out” when their financial support ends. On the other hand, this could be a trigger for seeking and disseminating future international collaboration. A positive outcome requires an openminded approach by participating lecturers as well as support from the organizations involved. Acknowledgement Thanks to all who contributed with their narratives. References Bower, K.A., 2004. Retreats as a foundation for change. The global nursing exchange as a retreat. Nursing Administration Quarterly 28 (1), 3–5. Burn, B.B., 1980. Study abroad and international exchanges. Philadelphia: Annuals of American Academy of Political & Social Sciences 449, 129–140. Button, L., Green, B., Tengnah, C., Johansson, I., Baker, C., 2005. The impact of international placements on nurses' personal and professional lives: literature review (2005). Journal of Advanced Nursing 50 (3), 315–324. Callister, L.C., Cox, A.H., 2006. Opening our hearts and minds: the meaning of international clinical nursing electives in the personal and professional lives of nurses. Nursing & Health Sciences 8 (2), 95–102. Chauke, M., Mokoena, J.D., 2006. The experiences of African nurse educators regarding their participation in an overseas exchange program. Africa Journal of Nursing and Midwifery 8 (2), 54–60. Cornes, D., Mokoena, J.D., 2004. Capacity building: the enhancement of leadership and scholarship skills for nurse educators in South Africa. Nursing Update 28 (3), 32–33. Duffy, M.E., 2005. We can learn so much from our colleagues in other countries. International Nursing Review 52, 4–11. Forest, J.J.F., 2002. Globalisation, universities and professors. Cambridge Review of International Affairs 15 (3), 435–450. Greatrex-White, S., 2008. Uncovering study abroad: foreignness and its relevance to nurse education and cultural competence. Nurse Education Today 28 (5), 530–538. Green, B., Johansson, I., Rossner, M., Tengnah, C., Scott, J., 2008. Studying abroad: a multiple case study of nursing students' international experiences. Nurse Education Today 28, 982–993. Guba, E., Lincoln, Y., 1989. Fourth Generation Evaluation. Sage, Newbury Park. Holloway, I., Wheeler, S., 2010. Qualitative Research in Nurses. Blackwell Oxford.
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