- Email: [email protected]
Evaluation of an international and interprofessional collaboration forum
Nurse Education Today 46 (2016) 10–16
Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
Evaluation of an international and interprofessional collaboration forum Teresa Stone a,⁎, Susan Hua b, Sue Turale c a b c
Faculty of Health Sciences, Graduate School of Medicine, Yamaguchi University, Yamaguchi, Japan The School of Biomedical Sciences and Pharmacy, The University of Newcastle, NSW, Australia Department of Global Health and Nursing, Division of Nursing Science, Ewha Womans University, Seoul, Republic of Korea
a r t i c l e
i n f o
Article history: Received 14 February 2016 Received in revised form 14 June 2016 Accepted 29 June 2016 Available online xxxx Keywords: Japan Nursing Cultural exchange Undergraduate Leadership Health Internationalization Interprofessional
a b s t r a c t Background: International and interprofessional collaborations are increasingly becoming a core requirement for health professionals in our globalized world. Aim: The aim of this study was to evaluate the effectiveness of the Asia Pacific Alliance of Health Leaders (APAHL) Forum to enhance the development of international perspectives and leadership among students and faculty in the discipline of health. Methods: This pilot study used a student-designed questionnaire to evaluate the views of students and faculty members about the effectiveness of APAHL in meeting its goals. Quantitative data from the scaled items on the questionnaire were analyzed by aggregating the data. Qualitative data were analyzed using a qualitative descriptive approach. Results: Study participants comprised of 22 health science (nursing and laboratory science) students and 15 faculty members. Both faculty and students agreed that APAHL was effective in leadership development of students, as well as in advancing internationalization, interprofessional collaboration, and cultural awareness among students. A clear theme among the students was acknowledgement of the importance of communication, in particular being proficient in English. Difficulties in communication were an issue for both students and faculty members. Conclusion: This pilot study has shown the benefits of a student-focused international forum in developing crosscultural awareness, and will provide the groundwork for evaluating the effectiveness of cross-cultural and interprofessional leadership forums aimed particularly at students of health. © 2016 Elsevier Ltd. All rights reserved.
1. Introduction The Asia Pacific Alliance of Health Leaders (APAHL) Forum was designed to provide a platform for students and academics from different countries in the Asia Pacific Region to communicate and exchange ideas on global health issues. It was established ten years ago as a way for nurturing the professional development of students in the health disciplines to become international leaders of the future. The objectives of APAHL are (i) the promotion of mutual friendship and academic exchange and (ii) leadership development of new faculty members, undergraduate students, and graduate students of health (Stone, 2013). Undergraduate courses may not effectively prepare students for leadership roles (Heller et al., 2004), with leadership defined in a broad sense as relational skills with the goal of improving health care (Curtis et al., 2011). APAHL promotes international collaboration between students and between faculty members from Chiang Mai University (Thailand), Mahidol University (Thailand), Ewha Womans University (Korea), ⁎ Corresponding author. E-mail address: [email protected] (T. Stone).
http://dx.doi.org/10.1016/j.nedt.2016.06.023 0260-6917/© 2016 Elsevier Ltd. All rights reserved.
University of Newcastle (Australia), Yamaguchi University (Japan), and more recently University of New England (Australia). The APAHL Forum is held annually with a focus on different health topics to encourage interprofessional and international discussions. At each forum the hosting university is responsible for organizing an agenda that incorporates the theme of the forum, through activities such as academic panel discussions, group discussions, student presentations, and excursions to health centers (e.g. hospitals and community health centers). These activities allow students and faculty members to appreciate and learn from the experience of other countries in organizing health initiatives and strategies to address specific health issues. Through comparing and contrasting the different strategies among countries, participants are able to reflect on the advantages and disadvantages of their local health care system; also provided is a basis for formulating plans for future improvements. APAHL offers a forum for future health professionals to develop as leaders in addressing the following key factors: global health issues, internationalization, interprofessional collaboration, and communication. The aim of this study was to evaluate the effectiveness of the APAHL forum to enhance the development of international perspectives and leadership among students and faculty in the discipline of health.
T. Stone et al. / Nurse Education Today 46 (2016) 10–16
2. Background 2.1. Global Health Issues Health is not just the absence of disease but is determined by biological, psychological and social factors (World Health Organization (WHO), 2010). Each APAHL forum focuses on current global health issues that are important for future health leaders to think about, discuss and strategize to improve health care for the future. Previous APAHL forum topics have included (i) Leadership in the era of chronic disease, (ii) Gen Y′ers as health leaders: a challenge in aging society, (iii) Evidence-based practice for health promotion, (iv) Health leadership for a global society, and (v) Global health leadership for a multicultural society. A simplified example of the program is presented in Fig. 1. When addressing a global health issue, students are guided to think about multiple factors involved in health care, including biological, psychological, socioeconomic, cultural, political, technological and environmental factors. For example, biological factors are important for health professionals to understand when working in a multicultural environment where prevalence of disease may be more common in specific ethnic groups. APAHL uniquely creates an environment where academics and students from a range of health professional backgrounds and from a number of international countries are able to convene to exchange knowledge and ideas on a focused health theme. This interprofessional and internationalized learning process encourages the development of skills necessary for health leaders, with an understanding of the impact of health issues and health care on a global scale. 2.2. Internationalization Internationalization and cultural awareness are two of the key goals of APAHL. This is highlighted through forum discussions and presentations, cultural day activities, and site visits to hospital and community health care initiatives, as well as informal activities which encourage students to interact. Participants are enabled to compare and contrast differences between the host country's health care and that of their own, and work towards identifying strategies for improving the future of health care to meet the needs of the growing population. Future health leaders should have a good understanding of the association between ethnicity, culture and health (Williams, 1997), especially
11
with many countries becoming more multicultural with a diverse population. For example, Australian statistics show that 26% of the population was born overseas and 46% of the population has at least one parent not born in Australia (Williams, 1997). Race can be a predictor of lifestyle behaviors and readiness to access health services, due to the cultural influences on different ethnic groups (Williams, 1997). It is considered to be one of the determinants of the variations in health which assist health professionals to identify the risk factors. Understanding patients' social and cultural values is very important when it comes to providing holistic health care. The future of health care requires health professionals to be able to collaborate nationally and internationally with clinicians and researchers from other countries. Unlike Japan, many Western countries have a long history of immigration and their health professionals have good cross-cultural skills (Ono and Yamamoto, 2011). Japan and Korea are two of the few industrialized countries that do not have a substantial number of international migrants (Burgess, 2007). Experience in foreign countries can be useful for health professionals, and for teaching students about international standards and protocols in health (Ozawa et al., 2005). In Japan, a new system has been started for the reception of foreign nurses through the Economic Partnership Agreement (EPA) (Ono and Yamamoto, 2011). Such strategies are important for the Japanese Nursing Association (JNA) to work effectively with nursing associations and confederations of midwives from other countries, in order to exchange information, sponsor or participate in international conferences and workshops, and accept international trainees (Japanese Nursing Association, 2013). Correspondingly, the Australian government has set up a signature initiative known as the New Colombo Plan, which fosters the development of research and knowledge of the Indo-Pacific, by supporting Australian undergraduate students to study and undertake internships in the region. This initiative encourages close partnership between governments, universities and business. The goal of the internships and mentorships is to ensure Australian students are work-ready and have professional connections in the region (Department of Foreign Affairs and Trade, 2015). 2.3. Interprofessional Collaboration Interprofessional collaboration within the health care system is essential to ensure a streamlined approach to patient care, especially in the current global economy. Respect for the expertise of other health
Fig. 1. Simplified APAHL Program.
12
T. Stone et al. / Nurse Education Today 46 (2016) 10–16
professions and development of strategies for all to work together in a patient-centered approach is the future of health care. APAHL provides the opportunity for students of different health disciplines to work together on presentations and group activities to highlight the importance of interdisciplinary collaboration. This helps them to gain insight into the roles and responsibilities of different professions, learn about other countries' health problems, and observe what has been implemented to address specific global health issues. Together, these collaborative activities are designed to provoke the exchange of ideas that may be useful to them as future health leaders for application in their own counties. 2.4. Communication Effective communication is a major requirement for health leaders, determined not only by competency in a language, but also ability to impart information to individuals and groups. This includes patients, families, communities, other health professionals, academics and government. The official language of APAHL is English, which is necessary for international collaboration in order to foster mutual understanding and to communicate with people from overseas (Sakurai, 2001). English can be particularly problematic for students for whom it is not their first language. For example, Japanese students struggle because they are usually taught the English language at school by a Japanese teacher and have not been able to practice the language outside the classroom (Matsuki, 2007). This has limited the ability for students to travel and study overseas, and for health professionals and academics to work or collaborate with others from different countries. In 1997 Japan sent more students than any other country to study in America, however the numbers have dropped by almost 50% over the last 14 years (McNeill, 2011). APAHL provides the opportunity for students and staff to communicate and interact with delegates from other countries, which is beneficial to their professional growth as health leaders. The forum was established to guide the professional development of students in the health disciplines to become international leaders of the future. 3. Methods The aim of this study, which was led by participating students, was to evaluate the effectiveness of the APAHL forum among students and faculty in the discipline of health. As APAHL was started by Yamaguchi University, it was important to first focus on the perspective of the Japanese students and faculty members. This study provides the ground-work for evaluating the effectiveness of cross-cultural and interprofessional leadership forums aimed particularly at students of health. 3.1. Student Selection The process of selecting students to attend APAHL varied across the different universities. Yamaguchi University generally sends an initial expression of interest to students, and then short-lists candidates to participate in an interview conducted by faculty members. The selection criteria include competency in the English language, strong commitment to attend APAHL and the role they want to play within it, and what use they will make of the experience in their future careers. 3.2. Study Design This study was conducted using a qualitative and quantitative approach to evaluate the views of students and faculty at Yamaguchi University, with regards to the effectiveness of APAHL in meeting its goals to develop future health leaders through academic exchange with other countries. Current students and faculty members who attended or were involved with the arrangements for APAHL at
Yamaguchi University (n = 41) were contacted with an information letter and invited to participate. All participants were fully informed about the purpose of the study, and assured that it was completely voluntary, anonymous, and that the information provided was confidential. Those who chose to participate were asked to complete a consent form. The evaluation was conducted using a questionnaire which was designed based on the goals of APAHL (Table 1). The questionnaire items for students were focused on how the forum has shaped their outlook on their health professional careers and their development as health care leaders. The questionnaire items for faculty members were based more on mutual friendship, professional growth, and promoting academic exchange between colleagues from international universities. Questions were designed to provide responses either as ratings (strongly agree to strongly disagree) or comments. Comments to specific questions formed the basis of the qualitative data. We used an evaluationbased research methodology to evaluate whether a given program is achieving its stated goals. It is a process that critically examines a program, and involves collecting and analyzing information about a program's activities, characteristics, and outcomes. The purpose of this study approach was to make judgments about a program, to improve its effectiveness, and/or to inform programming decisions (Patton, 1987). 3.3. Ethical Considerations Ethical approval to conduct the study was obtained from the Ethical Committee of Yamaguchi University before the commencement of data collection. Participants were provided with written and verbal study information, signed a consent form, and were informed of their rights to study withdrawal, and protection of privacy and confidentiality. 3.4. Data Analysis Quantitative data from the scaled items on the questionnaire were analyzed by aggregating the data. Qualitative data were analyzed using a qualitative descriptive approach. An initial thematic analysis was conducted and findings were presented in an informative narrative as key patterns or themes, as suggested by Borbasi et al. (2008). The data were treated inductively with coding and theme development directed by the content of the data. First reoccurring words were identified and listed, and then concepts or ideas were highlighted to identify important features of the data that might be relevant to answering the
Table 1 Questionnaire items. Questionnaire items for students included: 1. Describe the experience of presenting to international students and colleagues at the APAHL forum. 2. Has APAHL helped you develop as a leader? 3. What benefits, if any, has APAHL had in regard to your professional growth and research development? 4. Has APAHL affected the way you think about your career, and possible employment in other countries? 5. What, if anything, has changed in your life as a result of APAHL? 6. What suggestions do you have to improve APAHL in the future? 7. Overall assessment of the APAHL forum you attended? Questionnaire items for faculty members: 1. What benefits do you think students and faculty members have gained from APAHL? 2. Has APAHL been effective in the promotion of mutual friendship? 3. Has APAHL been effective in promoting academic exchange? 4. Has APAHL been effective in the leadership development of students? 5. What benefits, if any, has APAHL had in to your professional growth, leadership, and research development? 6. Has APAHL been effective in advancing internationalization and cultural awareness? 7. What suggestions do you have to improve APAHL? 8. Overall assessment of APAHL?
T. Stone et al. / Nurse Education Today 46 (2016) 10–16
13
4.2. Student Evaluation
Table 2 Participants. Student (n = 22)
Faculty members (n = 15)
Nursing
Health science
Nursing
Health science
12 (54.5%)
10 (45.5%)
7 (46.7%)
8 (53.3%)
research question. From repeated concepts, themes were identified. Themes are repeated ideas in any text or narrative. This phase involved examining the words and concepts, and then collating this data to identify significant broader patterns of meaning. The related themes were then compared and related back to the purpose of APAHL and the research questions. Important in this process was the need to ask the how and why questions, rather than merely summarizing the data, and to ensure that the themes accurately represented the dataset and answered the research questions (Auckland, 2013). In this phase, themes were refined, split, combined, or discarded as required. Finally, the themes were woven together and co-occurrent relationships were examined and contextualized in relation to existing literature. 3.5. Credibility Credibility of a study is important to ensure that the findings are congruent with the reality (Merriam, 2001). In this study we used several strategies listed by Shenton (2004) to ensure credibility, including ensuring anonymity so that participants were able to express an honest opinion, giving participants the option of refusing participation without penalty, frequent debriefing sessions within the research team, and a reflective diary to record decisions made and to provide an audit trail. An audit trail allows independent researchers to judge whether a study is trustworthy and has been conducted systematically and rigorously (Carcary, 2011). A potential bias of this evaluation was that the University was invested in the APAHL program. Whilst “quantitative researchers attempt to disassociate themselves as much as possible from the research process, qualitative researchers have come to embrace their involvement and role within the research” (Golafshani, 2003, p.300). In order to establish that the research was credible we used Lincoln's (2002, p.11) criteria: we were deeply involved in the research process; ensured we had sufficient data; used peer debriefing to ensure sufficient distance from the phenomenon; kept an observable audit trail; and considered inferences and interpretations.
Evaluation of the APAHL criteria from the perspective of students is detailed in Table 3. Overall, all students agreed or strongly agreed with the statement that APAHL has led to their friendship with people in other countries. Approximately 90% of students (n = 20) agreed with the statement that APAHL has had a positive impact on their relationship with teachers and professors. All students agreed or strongly agreed with the statement that APAHL has had a positive impact on them in connection with their future careers. ■ I am developed so much from APAHL. I have many friends, many experience, many knowledge. I love this forum. I love APAHL. And I love everybody. Thank you for giving a good opportunity to me.
When asked about their experience of presenting in front of international students and faculty at the APAHL forum, the majority of the students commented that they were nervous and had difficulty presenting in English. In particular, they struggled with pronunciation and where to pause during their speech; however, students described the experience as being “valuable” or “wonderful”. They mentioned that they learnt a lot from watching other students present, and were pleased to feel that “everyone listened to our presentations seriously”. They compared themselves unfavorably with other students who did not need to read their script. ■ The other country's presentation was excellent because the other country's students presented without notes. ■ A group discussion and the presentation were very great. I mean, I learn how to work with group/searching the information/practicing English. ■ I want to know about foreign countries more and I must study English more and more! ■ I thought it would be hard to connect with people from other countries if I couldn't speak English but I learnt that the right attitude and making an effort to understand was very important. I felt close to people from other countries. ■ I was glad that other students listened warmly to my poor English.
4.1. Study Participants
Comments on whether APAHL had assisted them to develop as a leader were divided. Students who were given roles in coordinating activities or guiding other students commented positively to this question, whereas those who were not given such roles commented more about growing in confidence and courage. In addition, all students found APAHL to be beneficial with regards to professional growth and research development, especially learning about health care and developments in other countries. They emphasized that they had learnt about the importance of international and interprofessional collaboration.
Details of the study participants are summarized in Table 2. Of the 41 invited participants, only one faculty member did not consent to being part of the research and three people did not return a completed questionnaire; therefore, the final participation rate was 92.5%. Of the study participants, 40.5% were faculty members and 59.5% were students. Other demographic data were not collected because of the small sample size and issues of confidentiality.
■ I was impressed by faculty members and students from another country. I would like to be a researcher who can research with people from foreign countries. ■ As I'm a leader in the group discussion. I learnt how to manage my team to complete the presentation. I learn how to work with foreigner friends. ■ Increased my knowledge regarding other countries/cultures.
4. Results
Table 3 APAHL criteria – student evaluation.
APAHL has led you to have friendships with people in other countries. (n = 22) APAHL has had a positive impact on your relationship with your teachers and professors. (n = 22) APAHL has positively affected the way you think about your career, and possible employment in other countries. (n = 21)
1
2
3
4
Strongly disagree
Disagree
Agree
Strongly agree
0 0 0
0 2 (9.1%) 0
4 (18.2%) 6 (27.3%) 10 (47.6%)
18 (81.8%) 14 (63.6%) 11 (52.4%)
14
T. Stone et al. / Nurse Education Today 46 (2016) 10–16
■ I grew as a leader when I judged and brought the group together in Japanese team or multinational team in APAHL.
Interestingly, comments on whether anything has changed in their life as a result of APAHL focused more on “the importance of English” and effective communication skills, in order to foster international cooperation and collaboration in their future careers. Communication was again the focus when asked about suggestions to improve APAHL in the future. The students struggled with the English language and felt that they needed more time to prepare their presentations with teaching staff prior to APAHL. They mentioned that their perspective on the future of health care has broadened and the experience has given them an interest in potentially working abroad. ■ Because this is the first time for me to [deliver an] international presentation. It's made me proud and confident. ■ By working on projects together, I could truly communicate with students who're from different countries. ■ I think I can now talk with foreign people if I go abroad.
4.3. Faculty Evaluation Evaluation of the APAHL criteria from the perspective of faculty members is detailed in Table 4. Approximately 80% of the faculty participants (n = 12) strongly agreed that APAHL has been effective in promoting mutual friendship. Interestingly, only 67% of the faculty members (n = 10) agreed or strongly agreed that APAHL has been effective in promoting academic exchange, with 33% of the faculty participants (n = 5) disagreeing. The majority of faculty staff agreed or strongly agreed that APAHL has been effective in the leadership development of students, and in advancing internationalization and cultural awareness. The faculty staff members were involved mainly in organizing the overall logistics, in particular overseeing administration in sending students overseas to attend APAHL. They saw this as their duty as a member of the University, but also as a way to interact with the students. About benefits gained by students and faculty members from APAHL, academics commented that the experience increased their cross-cultural knowledge of other countries, and their understanding of the health care situation and initiatives of others in addressing the global health issue of the forum. Meeting academics from other countries enabled them to compare education standards and the style of teaching. They commented that the process of planning APAHL was educational for them, but did note that the workload was not shared by everyone at the University. When asked about the benefits of APAHL to professional growth, leadership, and research development, faculty participants felt that the current agenda was more beneficial for the students. However, one participant mentioned positively that APAHL was instrumental in enabling the University to attain a collaborative research grant with other APAHL universities, in order to exchange research students for an extended period to foster research collaborations and growth.
Table 5 Overall assessment of the APAHL Forum you attended?.
Student (n = 22) Teacher (n = 15)
1 Poor
2
3
4 Excellent
0 0
0 1 (6.7%)
6 (27.3%) 8 (53.3%)
16 (72.7%) 6 (40.0%)
Suggestions to improve APAHL were focused on developing strategies so that more students could enjoy the benefits of the forum, and that the workload should be more equally shared. Similar to the comments from the students, the faculty staff felt that their proficiency in English needed to be improved to gain the maximum experience from participating in APAHL. Interestingly two faculty members also spoke about the need to further develop their interpersonal skills: ■ Need to improve English skill and inter-personal skills ■ We cannot say the whole faculty is heading for internationalization or fostering human resources for next generation. ■ I think in the future we will see one or more of these students lead their own country. ■ It was effective in my professional growth and research development. ■ I learned about research from other universities from other countries. Learning how to express opinions and comments at the presentation and conference was so helpful.
4.4. Overall Assessment of APAHL by Faculty and Students Overall, the majority of students (n = 16) reported that that their experience of the APAHL forum was excellent (Table 5). Similarly, the majority of the faculty participants reported the forum to be good or excellent (Table 5). More specifically, the students chose cultural exchange as the most positive aspect of APAHL (n = 16, 69.6%), with the presentation as the second most valuable (n = 5, 21.7%) (Table 6). In contrast, the opinions from the faculty members were more evenly spread about what was the most positive aspect of APAHL, with international collaboration (n = 6, 37.5%) and cultural exchange (n = 5, 31.3%) chosen most frequently (Table 6). Overall comments from students were positive. In particular, they valued the opportunity to work with students from other countries in similar and different health disciplines, and recognized that there was no way they could have experienced this without a forum such as APAHL. Limitations in English were again highlighted as an issue for the students and an area in which they needed to improve for their future careers. Some faculty members highlighted the lack of commitment for internationalization by others of the faculty as an area for improvement. They again highlighted the fact that only a small number of students were able to benefit from the APAHL forum. 5. Discussion International and interprofessional collaboration is increasingly becoming a core requirement for health professionals at both the local and global level. At the local level, these interactions are necessary to
Table 4 APAHL criteria – faculty evaluation.
APAHL has been effective in the promotion of mutual friendship? (n = 15) APAHL has been effective in promoting academic exchange? (n = 15) APAHL has been effective in the leadership development of students? (n = 15) APAHL has been effective in advancing internationalization and cultural awareness? (n = 15)
1
2
3
4
Strongly disagree
Disagree
Agree
Strongly agree
0 0 1 (6.7%) 0
1 (6.7%) 5 (33.3%) 0 0
2 (13.3%) 6 (40.0%) 3 (20.0%) 5 (33.3%)
12 (80.0%) 4 (26.7%) 11 (73.3%) 10 (66.7%)
T. Stone et al. / Nurse Education Today 46 (2016) 10–16
15
Table 6 What was the most positive aspect of APAHL?.
Student (n = 23) Teacher (n = 16) a
International collaboration
Presentation
Cultural exchange
Sightseeing
Other
1 (4.3%) 6 (37.5%)
5 (21.7%) 3 (18.8%)
16 (69.6%) 5 (31.3%)
0 1 (6.3%)
1 (4.3%)a 1 (6.3%)a
Percentages may not total 100 due to rounding.
provide optimal patient care. However at a global level, they are necessary to address changes in global health issues and trends, and to implement policy or strategies. It is important for health students to have opportunities to develop as future health leaders. The objectives of APAHL are to foster the growth of students in the core values of leaders, which include understanding and addressing global health issues, internationalization, interprofessional collaboration, and effective communication. Based on the perspective of the Japanese contingency, the results of this study suggest that APAHL is meeting the aims of the program. In particular, both faculty and students agreed that APAHL is effective in leadership development of students, as well as in advancing internationalization, interprofessional collaboration, and cultural awareness among students. A clear theme among the students was acknowledgement of the importance of communication, in particular being proficient in English. Comments from students on whether APAHL had assisted them to develop as a leader were divided, and were based more on the roles they were allocated during the forum. It is important for students to understand that health professionals need to be individual health leaders in order for change to occur, especially in the face of significant global health issues and the economy. Improvements could be made to the program to better emphasize this point through faculty presentations or group activities. Another common theme was on developing strategies so that more students could enjoy the benefits of the forum. Participant numbers are limited at each forum for financial reasons of the hosting university, but the objectives of APAHL in developing health leaders could be adopted by each university to a larger cohort of students after each forum. Responses from faculty participants suggest that they thought the current APAHL program was more beneficial for students. Promotion of academic exchange was divided among faculty staff, as they saw their roles more in terms of their duty as a member of the university to organize the overall logistics and administration of APAHL. Faculty participants did comment positively about having an increased understanding of other cultures, health care systems, and teaching styles. It appears that for academic exchange to occur within the current program, individuals have to be more proactive in forming academic and research discussions, and forging potential collaboration between set activities in the agenda. With faculty participants congregating at APAHL, each with expertise in a number of research disciplines, it is important to take advantage of such a forum to discuss and exchange research ideas. This would be a significant opportunity, as a number of countries have research grants based on joint international collaboration and exchanges. Potential improvements include allocating more time in the agenda for academic discussions and presentations to generate new research proposals, and to deliberate logistics to attain project outcomes after the forum. The findings of this study suggest that there is a need for further development of the APAHL forum to maximize its benefits to both students and faculty. It would be interesting to evaluate the forum from the perspective of other universities participating in APAHL, to gain a complete understanding of the effectiveness of the forum to all stakeholders, especially to identify similar and unique themes. In addition, future studies designed to evaluate the impact of student participation in APAHL on their clinical practice and health care perspectives post-graduation, would provide important information about the long-standing benefits of such a program.
5.1. Limitations of the Study The study design does have limitations. This pilot study was conducted with APAHL students and faculty members only at Yamaguchi University to evaluate the program from the perspective of the Japanese stakeholders. Because the total number of staff and students participating from each university per year was relatively small, this does lead to an overall small sample size for the study, and thus results are not generalizable. Similarly, the undergraduate students conducting the study were committed to the program and this has influenced the style of questions. 6. Conclusion This pilot study has shown the benefits of APAHL, an international forum focused on health students and staff, in developing future health leaders. Participants are encouraged to develop their understanding of how to address global health issues on an international and interprofessional scale. This study provides the ground-work for evaluating the effectiveness of cross-cultural and interprofessional leadership forums. Acknowledgements The authors thank Mai Tamekiyo and Sakura Ogawa who collated the data for analysis and Wai Yan Law and Kate Jennar for their assistance in the literature review. References Auckland, U.o., 2013. About thematic analysis. from http://www.psych.auckland.ac.nz/ uoa/about-thematic-analysis. Borbasi, S., Jackson, D., Langford, R.W., 2008. Navigating the maze of nursing research (Vol. 2nd). Elsevier, Sydney. Burgess, C., 2007. Multicultural Japan? Discourse and the ‘Myth’ of homogeneity. 2013, from http://japanfocus.org/-Chris-Burgess/2389. Carcary, M., 2011. The research audit trial – enhancing trustworthiness in qualitative inquiry. Electron. J. Bus. Res. Methods 9 (1), 1–87. Curtis, E.A., de Vries, J., Sheerin, F.K., 2011. Developing leadership in nursing: exploring core factors. Br. J. Nurs. 20 (5), 306–309. Department of Foreign Affairs and Trade New Colombo Plan, 2015. Available from dfat. gov.au/new-colombo-plan. Golafshani, N., 2003. Understanding reliability and validity in qualitative research. Qual. Rep. 8 (4), 597–607. Heller, B.R., et al., 2004. Educating nurses for leadership roles. J. Contin. Educ. Nurs. 35 (5), 203–210 (quiz 232-3). Japanese Nursing Association, 2013. International activities. Available from http://www. nurse.or.jp/jna/english/activities/international.html. Lincoln, Y.S., 2002. On the nature of qualitative evidence. Paper Presented at the Annual Meeting of the Association for the Study of Higher Education, California. Matsuki, N., 2007. Let's eliminate English from entrance examination, and improve English of Japanese people. JAPIC NEWS, pp. 2–3. McNeill, D., 2011. Global economy exposes Japan's shortage of English-speaking graduates. 2013, from http://chronicle.com/article/Global-Economy-Exposes-Japans/ 129596/?sid=at&utm_source=at&utm_medium=en. Merriam, S.B., 2001. Qualitative Research and Case Study Applications in Education. Jossey-Bass, San Francisco. Ono, S., Yamamoto, Y., 2011. The examination of literature about cross cultural ability of nursing people. Kawasaki Med. Welf. Soc. 20 (2), 507–512. Ozawa, A., Fujioka, Y., Yuki, M., Tashiro, M., 2005. Samoan culture and nursing: An observation and experience of Japanese nursing students. Bulletin/Nagano Coll. Nurs. 7, 21–30. Patton, M.Q., 1987. How to use qualitative methods in evaluation (No. 4). Sage. Sakurai, R., 2001. A example of international exchange with Korea: student exchange with college of nursing in Seoul National University. Oita Univ. Nurs. Health Sci. 2 (2), 61–64.
16
T. Stone et al. / Nurse Education Today 46 (2016) 10–16
Shenton, A.K., 2004. Strategies for ensuring trustworthiness in qualitative research projects. Educ. Inf. 22, 63–75. Stone, T.E., 2013. Memorandum of Understanding for the Asia Pacific for Health Leaders (APAHL). Williams, D.R., 1997. Race and health: basic questions, emerging directions. Ann. Epidemiol. 7 (5), 322–333.
World Health Organization, 2010. Global Status Report on Noncommunicable Diseases. WHO, Geneva (176 pp., Available from:http://www.who.int/nmh/publications/ncd_ report2010/en/).
Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/nedt
Evaluation of an international and interprofessional collaboration forum Teresa Stone a,⁎, Susan Hua b, Sue Turale c a b c
Faculty of Health Sciences, Graduate School of Medicine, Yamaguchi University, Yamaguchi, Japan The School of Biomedical Sciences and Pharmacy, The University of Newcastle, NSW, Australia Department of Global Health and Nursing, Division of Nursing Science, Ewha Womans University, Seoul, Republic of Korea
a r t i c l e
i n f o
Article history: Received 14 February 2016 Received in revised form 14 June 2016 Accepted 29 June 2016 Available online xxxx Keywords: Japan Nursing Cultural exchange Undergraduate Leadership Health Internationalization Interprofessional
a b s t r a c t Background: International and interprofessional collaborations are increasingly becoming a core requirement for health professionals in our globalized world. Aim: The aim of this study was to evaluate the effectiveness of the Asia Pacific Alliance of Health Leaders (APAHL) Forum to enhance the development of international perspectives and leadership among students and faculty in the discipline of health. Methods: This pilot study used a student-designed questionnaire to evaluate the views of students and faculty members about the effectiveness of APAHL in meeting its goals. Quantitative data from the scaled items on the questionnaire were analyzed by aggregating the data. Qualitative data were analyzed using a qualitative descriptive approach. Results: Study participants comprised of 22 health science (nursing and laboratory science) students and 15 faculty members. Both faculty and students agreed that APAHL was effective in leadership development of students, as well as in advancing internationalization, interprofessional collaboration, and cultural awareness among students. A clear theme among the students was acknowledgement of the importance of communication, in particular being proficient in English. Difficulties in communication were an issue for both students and faculty members. Conclusion: This pilot study has shown the benefits of a student-focused international forum in developing crosscultural awareness, and will provide the groundwork for evaluating the effectiveness of cross-cultural and interprofessional leadership forums aimed particularly at students of health. © 2016 Elsevier Ltd. All rights reserved.
1. Introduction The Asia Pacific Alliance of Health Leaders (APAHL) Forum was designed to provide a platform for students and academics from different countries in the Asia Pacific Region to communicate and exchange ideas on global health issues. It was established ten years ago as a way for nurturing the professional development of students in the health disciplines to become international leaders of the future. The objectives of APAHL are (i) the promotion of mutual friendship and academic exchange and (ii) leadership development of new faculty members, undergraduate students, and graduate students of health (Stone, 2013). Undergraduate courses may not effectively prepare students for leadership roles (Heller et al., 2004), with leadership defined in a broad sense as relational skills with the goal of improving health care (Curtis et al., 2011). APAHL promotes international collaboration between students and between faculty members from Chiang Mai University (Thailand), Mahidol University (Thailand), Ewha Womans University (Korea), ⁎ Corresponding author. E-mail address: [email protected] (T. Stone).
http://dx.doi.org/10.1016/j.nedt.2016.06.023 0260-6917/© 2016 Elsevier Ltd. All rights reserved.
University of Newcastle (Australia), Yamaguchi University (Japan), and more recently University of New England (Australia). The APAHL Forum is held annually with a focus on different health topics to encourage interprofessional and international discussions. At each forum the hosting university is responsible for organizing an agenda that incorporates the theme of the forum, through activities such as academic panel discussions, group discussions, student presentations, and excursions to health centers (e.g. hospitals and community health centers). These activities allow students and faculty members to appreciate and learn from the experience of other countries in organizing health initiatives and strategies to address specific health issues. Through comparing and contrasting the different strategies among countries, participants are able to reflect on the advantages and disadvantages of their local health care system; also provided is a basis for formulating plans for future improvements. APAHL offers a forum for future health professionals to develop as leaders in addressing the following key factors: global health issues, internationalization, interprofessional collaboration, and communication. The aim of this study was to evaluate the effectiveness of the APAHL forum to enhance the development of international perspectives and leadership among students and faculty in the discipline of health.
T. Stone et al. / Nurse Education Today 46 (2016) 10–16
2. Background 2.1. Global Health Issues Health is not just the absence of disease but is determined by biological, psychological and social factors (World Health Organization (WHO), 2010). Each APAHL forum focuses on current global health issues that are important for future health leaders to think about, discuss and strategize to improve health care for the future. Previous APAHL forum topics have included (i) Leadership in the era of chronic disease, (ii) Gen Y′ers as health leaders: a challenge in aging society, (iii) Evidence-based practice for health promotion, (iv) Health leadership for a global society, and (v) Global health leadership for a multicultural society. A simplified example of the program is presented in Fig. 1. When addressing a global health issue, students are guided to think about multiple factors involved in health care, including biological, psychological, socioeconomic, cultural, political, technological and environmental factors. For example, biological factors are important for health professionals to understand when working in a multicultural environment where prevalence of disease may be more common in specific ethnic groups. APAHL uniquely creates an environment where academics and students from a range of health professional backgrounds and from a number of international countries are able to convene to exchange knowledge and ideas on a focused health theme. This interprofessional and internationalized learning process encourages the development of skills necessary for health leaders, with an understanding of the impact of health issues and health care on a global scale. 2.2. Internationalization Internationalization and cultural awareness are two of the key goals of APAHL. This is highlighted through forum discussions and presentations, cultural day activities, and site visits to hospital and community health care initiatives, as well as informal activities which encourage students to interact. Participants are enabled to compare and contrast differences between the host country's health care and that of their own, and work towards identifying strategies for improving the future of health care to meet the needs of the growing population. Future health leaders should have a good understanding of the association between ethnicity, culture and health (Williams, 1997), especially
11
with many countries becoming more multicultural with a diverse population. For example, Australian statistics show that 26% of the population was born overseas and 46% of the population has at least one parent not born in Australia (Williams, 1997). Race can be a predictor of lifestyle behaviors and readiness to access health services, due to the cultural influences on different ethnic groups (Williams, 1997). It is considered to be one of the determinants of the variations in health which assist health professionals to identify the risk factors. Understanding patients' social and cultural values is very important when it comes to providing holistic health care. The future of health care requires health professionals to be able to collaborate nationally and internationally with clinicians and researchers from other countries. Unlike Japan, many Western countries have a long history of immigration and their health professionals have good cross-cultural skills (Ono and Yamamoto, 2011). Japan and Korea are two of the few industrialized countries that do not have a substantial number of international migrants (Burgess, 2007). Experience in foreign countries can be useful for health professionals, and for teaching students about international standards and protocols in health (Ozawa et al., 2005). In Japan, a new system has been started for the reception of foreign nurses through the Economic Partnership Agreement (EPA) (Ono and Yamamoto, 2011). Such strategies are important for the Japanese Nursing Association (JNA) to work effectively with nursing associations and confederations of midwives from other countries, in order to exchange information, sponsor or participate in international conferences and workshops, and accept international trainees (Japanese Nursing Association, 2013). Correspondingly, the Australian government has set up a signature initiative known as the New Colombo Plan, which fosters the development of research and knowledge of the Indo-Pacific, by supporting Australian undergraduate students to study and undertake internships in the region. This initiative encourages close partnership between governments, universities and business. The goal of the internships and mentorships is to ensure Australian students are work-ready and have professional connections in the region (Department of Foreign Affairs and Trade, 2015). 2.3. Interprofessional Collaboration Interprofessional collaboration within the health care system is essential to ensure a streamlined approach to patient care, especially in the current global economy. Respect for the expertise of other health
Fig. 1. Simplified APAHL Program.
12
T. Stone et al. / Nurse Education Today 46 (2016) 10–16
professions and development of strategies for all to work together in a patient-centered approach is the future of health care. APAHL provides the opportunity for students of different health disciplines to work together on presentations and group activities to highlight the importance of interdisciplinary collaboration. This helps them to gain insight into the roles and responsibilities of different professions, learn about other countries' health problems, and observe what has been implemented to address specific global health issues. Together, these collaborative activities are designed to provoke the exchange of ideas that may be useful to them as future health leaders for application in their own counties. 2.4. Communication Effective communication is a major requirement for health leaders, determined not only by competency in a language, but also ability to impart information to individuals and groups. This includes patients, families, communities, other health professionals, academics and government. The official language of APAHL is English, which is necessary for international collaboration in order to foster mutual understanding and to communicate with people from overseas (Sakurai, 2001). English can be particularly problematic for students for whom it is not their first language. For example, Japanese students struggle because they are usually taught the English language at school by a Japanese teacher and have not been able to practice the language outside the classroom (Matsuki, 2007). This has limited the ability for students to travel and study overseas, and for health professionals and academics to work or collaborate with others from different countries. In 1997 Japan sent more students than any other country to study in America, however the numbers have dropped by almost 50% over the last 14 years (McNeill, 2011). APAHL provides the opportunity for students and staff to communicate and interact with delegates from other countries, which is beneficial to their professional growth as health leaders. The forum was established to guide the professional development of students in the health disciplines to become international leaders of the future. 3. Methods The aim of this study, which was led by participating students, was to evaluate the effectiveness of the APAHL forum among students and faculty in the discipline of health. As APAHL was started by Yamaguchi University, it was important to first focus on the perspective of the Japanese students and faculty members. This study provides the ground-work for evaluating the effectiveness of cross-cultural and interprofessional leadership forums aimed particularly at students of health. 3.1. Student Selection The process of selecting students to attend APAHL varied across the different universities. Yamaguchi University generally sends an initial expression of interest to students, and then short-lists candidates to participate in an interview conducted by faculty members. The selection criteria include competency in the English language, strong commitment to attend APAHL and the role they want to play within it, and what use they will make of the experience in their future careers. 3.2. Study Design This study was conducted using a qualitative and quantitative approach to evaluate the views of students and faculty at Yamaguchi University, with regards to the effectiveness of APAHL in meeting its goals to develop future health leaders through academic exchange with other countries. Current students and faculty members who attended or were involved with the arrangements for APAHL at
Yamaguchi University (n = 41) were contacted with an information letter and invited to participate. All participants were fully informed about the purpose of the study, and assured that it was completely voluntary, anonymous, and that the information provided was confidential. Those who chose to participate were asked to complete a consent form. The evaluation was conducted using a questionnaire which was designed based on the goals of APAHL (Table 1). The questionnaire items for students were focused on how the forum has shaped their outlook on their health professional careers and their development as health care leaders. The questionnaire items for faculty members were based more on mutual friendship, professional growth, and promoting academic exchange between colleagues from international universities. Questions were designed to provide responses either as ratings (strongly agree to strongly disagree) or comments. Comments to specific questions formed the basis of the qualitative data. We used an evaluationbased research methodology to evaluate whether a given program is achieving its stated goals. It is a process that critically examines a program, and involves collecting and analyzing information about a program's activities, characteristics, and outcomes. The purpose of this study approach was to make judgments about a program, to improve its effectiveness, and/or to inform programming decisions (Patton, 1987). 3.3. Ethical Considerations Ethical approval to conduct the study was obtained from the Ethical Committee of Yamaguchi University before the commencement of data collection. Participants were provided with written and verbal study information, signed a consent form, and were informed of their rights to study withdrawal, and protection of privacy and confidentiality. 3.4. Data Analysis Quantitative data from the scaled items on the questionnaire were analyzed by aggregating the data. Qualitative data were analyzed using a qualitative descriptive approach. An initial thematic analysis was conducted and findings were presented in an informative narrative as key patterns or themes, as suggested by Borbasi et al. (2008). The data were treated inductively with coding and theme development directed by the content of the data. First reoccurring words were identified and listed, and then concepts or ideas were highlighted to identify important features of the data that might be relevant to answering the
Table 1 Questionnaire items. Questionnaire items for students included: 1. Describe the experience of presenting to international students and colleagues at the APAHL forum. 2. Has APAHL helped you develop as a leader? 3. What benefits, if any, has APAHL had in regard to your professional growth and research development? 4. Has APAHL affected the way you think about your career, and possible employment in other countries? 5. What, if anything, has changed in your life as a result of APAHL? 6. What suggestions do you have to improve APAHL in the future? 7. Overall assessment of the APAHL forum you attended? Questionnaire items for faculty members: 1. What benefits do you think students and faculty members have gained from APAHL? 2. Has APAHL been effective in the promotion of mutual friendship? 3. Has APAHL been effective in promoting academic exchange? 4. Has APAHL been effective in the leadership development of students? 5. What benefits, if any, has APAHL had in to your professional growth, leadership, and research development? 6. Has APAHL been effective in advancing internationalization and cultural awareness? 7. What suggestions do you have to improve APAHL? 8. Overall assessment of APAHL?
T. Stone et al. / Nurse Education Today 46 (2016) 10–16
13
4.2. Student Evaluation
Table 2 Participants. Student (n = 22)
Faculty members (n = 15)
Nursing
Health science
Nursing
Health science
12 (54.5%)
10 (45.5%)
7 (46.7%)
8 (53.3%)
research question. From repeated concepts, themes were identified. Themes are repeated ideas in any text or narrative. This phase involved examining the words and concepts, and then collating this data to identify significant broader patterns of meaning. The related themes were then compared and related back to the purpose of APAHL and the research questions. Important in this process was the need to ask the how and why questions, rather than merely summarizing the data, and to ensure that the themes accurately represented the dataset and answered the research questions (Auckland, 2013). In this phase, themes were refined, split, combined, or discarded as required. Finally, the themes were woven together and co-occurrent relationships were examined and contextualized in relation to existing literature. 3.5. Credibility Credibility of a study is important to ensure that the findings are congruent with the reality (Merriam, 2001). In this study we used several strategies listed by Shenton (2004) to ensure credibility, including ensuring anonymity so that participants were able to express an honest opinion, giving participants the option of refusing participation without penalty, frequent debriefing sessions within the research team, and a reflective diary to record decisions made and to provide an audit trail. An audit trail allows independent researchers to judge whether a study is trustworthy and has been conducted systematically and rigorously (Carcary, 2011). A potential bias of this evaluation was that the University was invested in the APAHL program. Whilst “quantitative researchers attempt to disassociate themselves as much as possible from the research process, qualitative researchers have come to embrace their involvement and role within the research” (Golafshani, 2003, p.300). In order to establish that the research was credible we used Lincoln's (2002, p.11) criteria: we were deeply involved in the research process; ensured we had sufficient data; used peer debriefing to ensure sufficient distance from the phenomenon; kept an observable audit trail; and considered inferences and interpretations.
Evaluation of the APAHL criteria from the perspective of students is detailed in Table 3. Overall, all students agreed or strongly agreed with the statement that APAHL has led to their friendship with people in other countries. Approximately 90% of students (n = 20) agreed with the statement that APAHL has had a positive impact on their relationship with teachers and professors. All students agreed or strongly agreed with the statement that APAHL has had a positive impact on them in connection with their future careers. ■ I am developed so much from APAHL. I have many friends, many experience, many knowledge. I love this forum. I love APAHL. And I love everybody. Thank you for giving a good opportunity to me.
When asked about their experience of presenting in front of international students and faculty at the APAHL forum, the majority of the students commented that they were nervous and had difficulty presenting in English. In particular, they struggled with pronunciation and where to pause during their speech; however, students described the experience as being “valuable” or “wonderful”. They mentioned that they learnt a lot from watching other students present, and were pleased to feel that “everyone listened to our presentations seriously”. They compared themselves unfavorably with other students who did not need to read their script. ■ The other country's presentation was excellent because the other country's students presented without notes. ■ A group discussion and the presentation were very great. I mean, I learn how to work with group/searching the information/practicing English. ■ I want to know about foreign countries more and I must study English more and more! ■ I thought it would be hard to connect with people from other countries if I couldn't speak English but I learnt that the right attitude and making an effort to understand was very important. I felt close to people from other countries. ■ I was glad that other students listened warmly to my poor English.
4.1. Study Participants
Comments on whether APAHL had assisted them to develop as a leader were divided. Students who were given roles in coordinating activities or guiding other students commented positively to this question, whereas those who were not given such roles commented more about growing in confidence and courage. In addition, all students found APAHL to be beneficial with regards to professional growth and research development, especially learning about health care and developments in other countries. They emphasized that they had learnt about the importance of international and interprofessional collaboration.
Details of the study participants are summarized in Table 2. Of the 41 invited participants, only one faculty member did not consent to being part of the research and three people did not return a completed questionnaire; therefore, the final participation rate was 92.5%. Of the study participants, 40.5% were faculty members and 59.5% were students. Other demographic data were not collected because of the small sample size and issues of confidentiality.
■ I was impressed by faculty members and students from another country. I would like to be a researcher who can research with people from foreign countries. ■ As I'm a leader in the group discussion. I learnt how to manage my team to complete the presentation. I learn how to work with foreigner friends. ■ Increased my knowledge regarding other countries/cultures.
4. Results
Table 3 APAHL criteria – student evaluation.
APAHL has led you to have friendships with people in other countries. (n = 22) APAHL has had a positive impact on your relationship with your teachers and professors. (n = 22) APAHL has positively affected the way you think about your career, and possible employment in other countries. (n = 21)
1
2
3
4
Strongly disagree
Disagree
Agree
Strongly agree
0 0 0
0 2 (9.1%) 0
4 (18.2%) 6 (27.3%) 10 (47.6%)
18 (81.8%) 14 (63.6%) 11 (52.4%)
14
T. Stone et al. / Nurse Education Today 46 (2016) 10–16
■ I grew as a leader when I judged and brought the group together in Japanese team or multinational team in APAHL.
Interestingly, comments on whether anything has changed in their life as a result of APAHL focused more on “the importance of English” and effective communication skills, in order to foster international cooperation and collaboration in their future careers. Communication was again the focus when asked about suggestions to improve APAHL in the future. The students struggled with the English language and felt that they needed more time to prepare their presentations with teaching staff prior to APAHL. They mentioned that their perspective on the future of health care has broadened and the experience has given them an interest in potentially working abroad. ■ Because this is the first time for me to [deliver an] international presentation. It's made me proud and confident. ■ By working on projects together, I could truly communicate with students who're from different countries. ■ I think I can now talk with foreign people if I go abroad.
4.3. Faculty Evaluation Evaluation of the APAHL criteria from the perspective of faculty members is detailed in Table 4. Approximately 80% of the faculty participants (n = 12) strongly agreed that APAHL has been effective in promoting mutual friendship. Interestingly, only 67% of the faculty members (n = 10) agreed or strongly agreed that APAHL has been effective in promoting academic exchange, with 33% of the faculty participants (n = 5) disagreeing. The majority of faculty staff agreed or strongly agreed that APAHL has been effective in the leadership development of students, and in advancing internationalization and cultural awareness. The faculty staff members were involved mainly in organizing the overall logistics, in particular overseeing administration in sending students overseas to attend APAHL. They saw this as their duty as a member of the University, but also as a way to interact with the students. About benefits gained by students and faculty members from APAHL, academics commented that the experience increased their cross-cultural knowledge of other countries, and their understanding of the health care situation and initiatives of others in addressing the global health issue of the forum. Meeting academics from other countries enabled them to compare education standards and the style of teaching. They commented that the process of planning APAHL was educational for them, but did note that the workload was not shared by everyone at the University. When asked about the benefits of APAHL to professional growth, leadership, and research development, faculty participants felt that the current agenda was more beneficial for the students. However, one participant mentioned positively that APAHL was instrumental in enabling the University to attain a collaborative research grant with other APAHL universities, in order to exchange research students for an extended period to foster research collaborations and growth.
Table 5 Overall assessment of the APAHL Forum you attended?.
Student (n = 22) Teacher (n = 15)
1 Poor
2
3
4 Excellent
0 0
0 1 (6.7%)
6 (27.3%) 8 (53.3%)
16 (72.7%) 6 (40.0%)
Suggestions to improve APAHL were focused on developing strategies so that more students could enjoy the benefits of the forum, and that the workload should be more equally shared. Similar to the comments from the students, the faculty staff felt that their proficiency in English needed to be improved to gain the maximum experience from participating in APAHL. Interestingly two faculty members also spoke about the need to further develop their interpersonal skills: ■ Need to improve English skill and inter-personal skills ■ We cannot say the whole faculty is heading for internationalization or fostering human resources for next generation. ■ I think in the future we will see one or more of these students lead their own country. ■ It was effective in my professional growth and research development. ■ I learned about research from other universities from other countries. Learning how to express opinions and comments at the presentation and conference was so helpful.
4.4. Overall Assessment of APAHL by Faculty and Students Overall, the majority of students (n = 16) reported that that their experience of the APAHL forum was excellent (Table 5). Similarly, the majority of the faculty participants reported the forum to be good or excellent (Table 5). More specifically, the students chose cultural exchange as the most positive aspect of APAHL (n = 16, 69.6%), with the presentation as the second most valuable (n = 5, 21.7%) (Table 6). In contrast, the opinions from the faculty members were more evenly spread about what was the most positive aspect of APAHL, with international collaboration (n = 6, 37.5%) and cultural exchange (n = 5, 31.3%) chosen most frequently (Table 6). Overall comments from students were positive. In particular, they valued the opportunity to work with students from other countries in similar and different health disciplines, and recognized that there was no way they could have experienced this without a forum such as APAHL. Limitations in English were again highlighted as an issue for the students and an area in which they needed to improve for their future careers. Some faculty members highlighted the lack of commitment for internationalization by others of the faculty as an area for improvement. They again highlighted the fact that only a small number of students were able to benefit from the APAHL forum. 5. Discussion International and interprofessional collaboration is increasingly becoming a core requirement for health professionals at both the local and global level. At the local level, these interactions are necessary to
Table 4 APAHL criteria – faculty evaluation.
APAHL has been effective in the promotion of mutual friendship? (n = 15) APAHL has been effective in promoting academic exchange? (n = 15) APAHL has been effective in the leadership development of students? (n = 15) APAHL has been effective in advancing internationalization and cultural awareness? (n = 15)
1
2
3
4
Strongly disagree
Disagree
Agree
Strongly agree
0 0 1 (6.7%) 0
1 (6.7%) 5 (33.3%) 0 0
2 (13.3%) 6 (40.0%) 3 (20.0%) 5 (33.3%)
12 (80.0%) 4 (26.7%) 11 (73.3%) 10 (66.7%)
T. Stone et al. / Nurse Education Today 46 (2016) 10–16
15
Table 6 What was the most positive aspect of APAHL?.
Student (n = 23) Teacher (n = 16) a
International collaboration
Presentation
Cultural exchange
Sightseeing
Other
1 (4.3%) 6 (37.5%)
5 (21.7%) 3 (18.8%)
16 (69.6%) 5 (31.3%)
0 1 (6.3%)
1 (4.3%)a 1 (6.3%)a
Percentages may not total 100 due to rounding.
provide optimal patient care. However at a global level, they are necessary to address changes in global health issues and trends, and to implement policy or strategies. It is important for health students to have opportunities to develop as future health leaders. The objectives of APAHL are to foster the growth of students in the core values of leaders, which include understanding and addressing global health issues, internationalization, interprofessional collaboration, and effective communication. Based on the perspective of the Japanese contingency, the results of this study suggest that APAHL is meeting the aims of the program. In particular, both faculty and students agreed that APAHL is effective in leadership development of students, as well as in advancing internationalization, interprofessional collaboration, and cultural awareness among students. A clear theme among the students was acknowledgement of the importance of communication, in particular being proficient in English. Comments from students on whether APAHL had assisted them to develop as a leader were divided, and were based more on the roles they were allocated during the forum. It is important for students to understand that health professionals need to be individual health leaders in order for change to occur, especially in the face of significant global health issues and the economy. Improvements could be made to the program to better emphasize this point through faculty presentations or group activities. Another common theme was on developing strategies so that more students could enjoy the benefits of the forum. Participant numbers are limited at each forum for financial reasons of the hosting university, but the objectives of APAHL in developing health leaders could be adopted by each university to a larger cohort of students after each forum. Responses from faculty participants suggest that they thought the current APAHL program was more beneficial for students. Promotion of academic exchange was divided among faculty staff, as they saw their roles more in terms of their duty as a member of the university to organize the overall logistics and administration of APAHL. Faculty participants did comment positively about having an increased understanding of other cultures, health care systems, and teaching styles. It appears that for academic exchange to occur within the current program, individuals have to be more proactive in forming academic and research discussions, and forging potential collaboration between set activities in the agenda. With faculty participants congregating at APAHL, each with expertise in a number of research disciplines, it is important to take advantage of such a forum to discuss and exchange research ideas. This would be a significant opportunity, as a number of countries have research grants based on joint international collaboration and exchanges. Potential improvements include allocating more time in the agenda for academic discussions and presentations to generate new research proposals, and to deliberate logistics to attain project outcomes after the forum. The findings of this study suggest that there is a need for further development of the APAHL forum to maximize its benefits to both students and faculty. It would be interesting to evaluate the forum from the perspective of other universities participating in APAHL, to gain a complete understanding of the effectiveness of the forum to all stakeholders, especially to identify similar and unique themes. In addition, future studies designed to evaluate the impact of student participation in APAHL on their clinical practice and health care perspectives post-graduation, would provide important information about the long-standing benefits of such a program.
5.1. Limitations of the Study The study design does have limitations. This pilot study was conducted with APAHL students and faculty members only at Yamaguchi University to evaluate the program from the perspective of the Japanese stakeholders. Because the total number of staff and students participating from each university per year was relatively small, this does lead to an overall small sample size for the study, and thus results are not generalizable. Similarly, the undergraduate students conducting the study were committed to the program and this has influenced the style of questions. 6. Conclusion This pilot study has shown the benefits of APAHL, an international forum focused on health students and staff, in developing future health leaders. Participants are encouraged to develop their understanding of how to address global health issues on an international and interprofessional scale. This study provides the ground-work for evaluating the effectiveness of cross-cultural and interprofessional leadership forums. Acknowledgements The authors thank Mai Tamekiyo and Sakura Ogawa who collated the data for analysis and Wai Yan Law and Kate Jennar for their assistance in the literature review. References Auckland, U.o., 2013. About thematic analysis. from http://www.psych.auckland.ac.nz/ uoa/about-thematic-analysis. Borbasi, S., Jackson, D., Langford, R.W., 2008. Navigating the maze of nursing research (Vol. 2nd). Elsevier, Sydney. Burgess, C., 2007. Multicultural Japan? Discourse and the ‘Myth’ of homogeneity. 2013, from http://japanfocus.org/-Chris-Burgess/2389. Carcary, M., 2011. The research audit trial – enhancing trustworthiness in qualitative inquiry. Electron. J. Bus. Res. Methods 9 (1), 1–87. Curtis, E.A., de Vries, J., Sheerin, F.K., 2011. Developing leadership in nursing: exploring core factors. Br. J. Nurs. 20 (5), 306–309. Department of Foreign Affairs and Trade New Colombo Plan, 2015. Available from dfat. gov.au/new-colombo-plan. Golafshani, N., 2003. Understanding reliability and validity in qualitative research. Qual. Rep. 8 (4), 597–607. Heller, B.R., et al., 2004. Educating nurses for leadership roles. J. Contin. Educ. Nurs. 35 (5), 203–210 (quiz 232-3). Japanese Nursing Association, 2013. International activities. Available from http://www. nurse.or.jp/jna/english/activities/international.html. Lincoln, Y.S., 2002. On the nature of qualitative evidence. Paper Presented at the Annual Meeting of the Association for the Study of Higher Education, California. Matsuki, N., 2007. Let's eliminate English from entrance examination, and improve English of Japanese people. JAPIC NEWS, pp. 2–3. McNeill, D., 2011. Global economy exposes Japan's shortage of English-speaking graduates. 2013, from http://chronicle.com/article/Global-Economy-Exposes-Japans/ 129596/?sid=at&utm_source=at&utm_medium=en. Merriam, S.B., 2001. Qualitative Research and Case Study Applications in Education. Jossey-Bass, San Francisco. Ono, S., Yamamoto, Y., 2011. The examination of literature about cross cultural ability of nursing people. Kawasaki Med. Welf. Soc. 20 (2), 507–512. Ozawa, A., Fujioka, Y., Yuki, M., Tashiro, M., 2005. Samoan culture and nursing: An observation and experience of Japanese nursing students. Bulletin/Nagano Coll. Nurs. 7, 21–30. Patton, M.Q., 1987. How to use qualitative methods in evaluation (No. 4). Sage. Sakurai, R., 2001. A example of international exchange with Korea: student exchange with college of nursing in Seoul National University. Oita Univ. Nurs. Health Sci. 2 (2), 61–64.
16
T. Stone et al. / Nurse Education Today 46 (2016) 10–16
Shenton, A.K., 2004. Strategies for ensuring trustworthiness in qualitative research projects. Educ. Inf. 22, 63–75. Stone, T.E., 2013. Memorandum of Understanding for the Asia Pacific for Health Leaders (APAHL). Williams, D.R., 1997. Race and health: basic questions, emerging directions. Ann. Epidemiol. 7 (5), 322–333.
World Health Organization, 2010. Global Status Report on Noncommunicable Diseases. WHO, Geneva (176 pp., Available from:http://www.who.int/nmh/publications/ncd_ report2010/en/).