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Factors that influence nursing and midwifery students' intentions to study abroad: A qualitative study using the theory of planned behaviour
Factors that influence nursing and midwifery students’ intentions to study abroad: A qualitative study using the theory of planned behaviour S. Kelleher, S. Fitzgerald, J. Hegarty PII: DOI: Reference:
S0260-6917(16)30077-6 doi: 10.1016/j.nedt.2016.05.019 YNEDT 3297
To appear in:
Nurse Education Today
Received date: Accepted date:
14 April 2016 19 May 2016
Please cite this article as: Kelleher, S., Fitzgerald, S., Hegarty, J., Factors that influence nursing and midwifery students’ intentions to study abroad: A qualitative study using the theory of planned behaviour, Nurse Education Today (2016), doi: 10.1016/j.nedt.2016.05.019
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ACCEPTED MANUSCRIPT FACTORS THAT INFLUENCE NURSING AND MIDWIFERY STUDENTS’ INTENTIONS TO STUDY ABROAD: A QUALITATIVE STUDY USING THE THEORY OF PLANNED BEHAVIOUR
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Kelleher, S., Fitzgerald, S. and Hegarty, J.
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Author 2: Dr. Serena Fitzgerald PhD, BSc, RGN College Lecturer School of Nursing and Midwifery University College Cork Ireland Tel: 00353 21 4901516 E: [email protected]
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Author 1: Mr. Seán Kelleher MSc. PGDCIC, PGDT&L, BSc. RGN College Lecturer - Erasmus coordinator School of Nursing and Midwifery University College Cork, Ireland Tel: 00353 21 4901477 E: [email protected]
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Word Count: 4,385
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Author 3: Prof. Josephine Hegarty PhD, MSc, BSc, RNT, RGN Director of Graduate Studies, Catherine McAuley School of Nursing & Midwifery, University College Cork, Ireland Tel: 00353 21 4901462 E: [email protected]
Background
Future nurses need to be broadly-educated, adaptable individuals who have significant experience in the world beyond the classroom. Study abroad is an ideal means of developing some of the skills and attitudes, that are not only valued within the nursing profession, but also have global applicability, such as flexibility, self-reliance, and sensitivity to other cultures (Reimer-Kirkham et al 2009, Edmonds 2010). While research that explores the impact of study abroad programmes on students has proliferated in disciplines such as business and fine arts, research in the discipline of health, particularly nursing, is relatively recent and still limited. However and notwithstanding the dearth of research on the
ACCEPTED MANUSCRIPT topic, there has long been a commonly held perception that international experiences for nursing students leads to improved health care delivery and more effective nursing (Meleis 1985, Lindquist
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1990). More recently study abroad has been associated with a range of benefits for nursing students
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such as personal and professional growth (Greatix-White 2007, Christofferson 2008, Edmonds 2010),
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increased self-efficacy, self-confidence and the ability to adapt to unfamiliar environments (Koskinen and Tossavainen 2004, Ruddock and Turner 2007,). However, despite the array of purported benefits allied with study abroad, very little is known about the factors that influence students’ decisions to
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participate in such programmes (Salisbury et al. 2008, Kent-Wilkinson et al. 2015, Brown et al.2016), emphasising the need for a better understanding of decision making processes and how various
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factors influence that process. Understanding more about how students plan and respond to multiple influences has been associated with numerous advantages such as: improving faculty and
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administrators efficiency in advising students regarding study abroad (Council on International
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Educational Exchange 2015) and assisting third level institutions in designing study abroad
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programmes and marketing them to students who are most likely to participate in the experience
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(Goel et al. 2010, Schnusenberg et al. 2012).
Aim and methods
The aim of this study is to identify the salient behavioural beliefs underlying nursing and midwifery students’ intentions to study abroad. Theoretical frameworks have been used to gain a deeper understanding of the motivating factors that influence students’ decisions to study abroad (Presley et al 2010, Schnusenberg et al. 2012, Zhuang et al. 2015). The Theory of Planned Behaviour (TPB) (Ajzen, 1985), is one such theory and suggests that the direct determinant of a particular behaviour is a person’s intention to engage in that behaviour. Intentions are assumed to capture the motivational factors that influence a behaviour namely: 1. the person’s attitude toward the behaviour; 2. normative pressure (subjective norms), and 3. the person’s perceived level of control
ACCEPTED MANUSCRIPT over the behaviour (perceived behavioural control). These three factors are in turn determined by a person’s salient behavioural beliefs (Ajzen 1985, 1991, Francis et al. 2004). The method used to
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elicit salient beliefs is termed elicitation research (Ajzen 1985, 1991).
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Participants and procedure
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A purposive sample (n=25) of undergraduate nursing and midwifery students was used to elicit student’s salient beliefs regarding study abroad. While there are no firmly established criteria for
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calculating sample size in qualitative research (Polit et al. 2001), Francis et al. (2004) suggest that a sample size of 25 is sufficient to reach saturation in elicitation studies. Ethical approval to conduct
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the study was granted by the University Research Ethics Committee and access to the student population was secured through the School specific ethics board.
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Data Collection
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Data were obtained individually and in a free response format (Fishbein and Ajzen 2010, Ajzen 2011)
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by means of an open ended questionnaire. The questionnaire contained seven open ended questions based on the belief categories of the TPB and related to: Behavioural outcomes (attitudes toward study abroad), and perceived advantages and
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disadvantages of participating in a short term study abroad programme at some point during the participants undergraduate programme.
Normative referents, (subjective norms) i.e. individuals or groups who participants thought would approve or disapprove of their participation in a study abroad programme.
Perceived behavioural control (control factors) i.e. factors or circumstances participants believed would make participation in a study abroad programme possible or impossible.
Any other issues or concerns relating to studying abroad.
Socio demographic Questions
ACCEPTED MANUSCRIPT Twelve socio-demographic items were generated from a review of the literature which aimed to identify facilitating factors for study abroad across the wider student population and included
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gender, age, ethnicity, academic year, academic discipline, relationship status, employment status,
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travel experience, second language proficiency, and parents’ level of education (Table 1).
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Data analysis
Manifest content analysis was employed to identify meaning units (Kondracki et al., 2002,
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Graneheim and Lundman 2004). Where necessary data were condensed to create condensed meaning units (Graneheim and Lundman 2004), and abstracted to create codes. Codes were
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categorised according to the overarching framework of the TPB (behavioural beliefs, normative beliefs, control beliefs) and in order of frequency (Table 2). Subsequently sub categories were
Findings
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developed to describe participants’ beliefs in relation to study abroad (Table 3).
An overview of student demographics can be seen in Table 1. Advantages of study abroad The main advantages of studying abroad for nursing and midwifery students related to the development of cultural sensitivity, and personal and professional development. The majority of participants (n=18) cited being able to observe practice in different social and cultural environments and experiencing a different culture as being particularly important. This was reflected in statements such as:
ACCEPTED MANUSCRIPT “Seeing how different cultures practice nursing – their general customs and how things are run – theories and views of nursing can aid in questioning your own practice so it can evolve” (P7).
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Others recognised the potential a study abroad experience may present for their own personal
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development (n=16), particularly in relation to areas such as learning a new language and expanding
through a different language would be great" (P17).
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their personal skills. For example one participant stated “the experience of working in a hospital
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Factors relating to professional development were also frequently cited as an advantage of a study abroad experience (n=20). Participants believed they would benefit from experiencing how nurses
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and midwives in other countries are educated, how they practice, and how their profession is perceived by the public.
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Disadvantages of study abroad
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The main perceived disadvantages of study abroad for nursing and midwifery students related to fears, insecurities, expense and time. Not being able to speak the language of the host country was
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perceived as being one of the main disadvantages (n=21), particularly when students lacked a certain proficiency in the language. Indeed the foreboding element of trying to communicate
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through a different language while in another country was captured by one respondent when she stated: “It would be a daunting experience to live [in another country] and study in another college all through a different language” (P 4). The financial cost of studying abroad was also identified (n=19) as a substantial drawback with some participants stating that they would not be able to afford to study abroad. Others were more specific regarding the perceived costs associated with study abroad and identified issues such as the cost of travel, the cost of living and the cost of accommodation, as being the main difficulties. People who approve of study abroad
ACCEPTED MANUSCRIPT The individuals or groups who participants believed would approve of study abroad were captured under three specific sub-categories: personal, academic and professional (Table 3). Family was the
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most frequently cited group (n=15) followed college lecturers and parents. Some participants
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offered qualifying statements as to why they believed their families would support a study abroad
my horizons both personally and professionally” (P25).
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experience such as: “My family would certainly approve of me studying abroad as it would broaden
The nursing community and future employers constituted the ‘professional’ subcategory with each
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being cited an equal number of times (n=6). A number of diverse terms were used by participants to
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infer the nursing community such as: “{The} Psychiatric Nurses Association” (P 22); “The Nursing and Midwifery Board of Ireland (P20)”; “ward staff (P3); and “nursing colleagues” (P 17).
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People who would not approve of study abroad
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The individuals who participants believed would disapprove of study abroad were similarly captured
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under two specific sub-categories: personal and professional. For some participants Family (n=4) and friends (n=2) were identified as the groups who would most likely disapprove of a study abroad
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programme. Others identified Current employers (=5) as the group most likely to disapprove.
Factors that would make study abroad possible or impossible Control factors were sub-categorised under: finance, personal factors, and organisation. All participants (n=25) indicated that the most important factor when considering whether or not to participate in a study abroad programme related to the monetary cost of studying abroad with many suggesting that they would participate in a study abroad programme if there was greater financial support (n=10); for example one participant stated: “[If I] won the lottery or if the programme was fully subsidised” (P14). The main financial issues for respondents related to inadequate personal finance, the lack of financial aid and financial commitments at home such as mortgages and bills.
ACCEPTED MANUSCRIPT One participant stated: “paying rent on double accommodation” (P13) suggesting that paying for accommodation in both the host country and at home was a factor that would potentially deter
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participants from studying abroad.
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Being able to speak the language of the host country was identified by the many participants (n=18)
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as an important factor when considering to study abroad. Some participants indicated that they would go on a study abroad programme if they knew English was spoken in the host country. Others suggested that having some understanding of the language spoken in the host country was the most
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important factor.
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Family commitments at home, that ranged from having young children to having a pet to care for were also frequently cited factors among participants (n=8). Participants used short phrases to
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express their beliefs such as: “Family responsibilities” (P23); “Family circumstances” (P2). Other
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personal factors related to the fear of being alone and experiencing homesickness and the lack of
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confidence to participate a study abroad programme. How a study abroad programme was organised and the availability of support structures were the most frequently cited (n=8) organisational factors. In particular the issue of accommodation was
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highlighted as being important. One participant stated: “[I would like to have my] accommodation set up by host university/hospital pre-arrival “(P 1). Another participant suggested that the level of guidance and support from within the home college was a factor: “[I would like] support from [my] college with [the necessary] structures in place” (P6).
Discussion
ACCEPTED MANUSCRIPT This study has provided a detailed insight into nursing and midwifery students’ perceptions of study abroad and revealed numerous factors that may influence their intention to study abroad during
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their undergraduate education.
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In the main, nursing and midwifery students were positive about the prospect of studying abroad at
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some point during their undergraduate education, and exhibited comparable behavioural, normative and control beliefs regarding study abroad as have been identified in other student cohorts in earlier TPB studies (Gatfield and Chen 2006, Presley et al. 2010, Goel et al. 2010, Schnusenberg et al. 2012,
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Fitzsimmons et al. 2013, Zhuang et al. 2015). Notwithstanding the apparent similarities (Table 4) the
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findings of this study raise a number of issues that warrant further discussion, particularly when contextualised to nursing and midwifery students in Ireland.
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Cultural sensitivity
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An important finding was that nursing and midwifery students perceive the development of cultural
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sensitivity as being one of the main cross cultural benefits associated with studying abroad. This may seem unsurprising given the vast amount of literature that supports the value of international experiences for nursing students in the development and application of cultural competence into
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clinical practice (Koskinen and Tossavainen 2004, Ruddock and Turner 2007, Edmonds 2010). This study however is the first to use a theoretical framework in the form of the TPB to support this finding among nursing and midwifery students. Despite the array of apparent cross cultural-benefits associated with study abroad, the generalisability of such propositions has rarely been questioned, particularly within the context of Erasmus funded exchanges for nursing and midwifery students in Europe. Study abroad research suggests that the development of cross cultural skills such as cultural sensitivity, cultural competence, or intercultural development is dependent on a number of factors such as: the duration of the study abroad programme (Medina-Lopez-Portillo 2004, Engle and Engle
ACCEPTED MANUSCRIPT 2003): the students’ experience of studying in an unfamiliar environment, and the students exposure to stress and varying degrees of culture shock (Ruddock and Turner 2007). Indeed whether
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or not a nursing or midwifery student is exposed to patients from diverse cultures can be quite
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random and is dependent upon the location of the nursing programme and available clinical
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experiences (Carpenter and Garcia 2012). For example a student who decides to engage in an eight week study abroad experience in the UK may be exposed to similar health care structures and
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patient population as they experience in Ireland.
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A similar argument might be made for many other EU member states, where health care delivery is influenced predominantly by shared EU policies (Marmot et al. 2012). Salisbury (2011) suggests that decades of evidence that appear to support the claim that study abroad enhances intercultural
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competence are repeatedly limited by a series of methodological weaknesses including; small
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homogenous samples, an absence of longitudinal study design, no accounting for potential selection
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bias, and the lack of controls for potentially confounding demographic and college experience variables. As such more studies need to be conducted to support the belief that a study abroad experience actually delivers on expectations relating to cross cultural skills such as the development
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of cultural sensitivity and cultural competence. Professional development Participants identified a number of factors relating to study abroad that they believe would enhance their professional development such as experiencing other health care systems and learning new skills particular to their respective professions. However couched within professional development is the concept of professional identity. Professional identity is that which is constructed in relation to a reference group of professionals and a workspace (Caballero, 2009) and refers to the commonality of the nursing and midwifery professions (Ohlen and Segesten 1998). This was expressed by participants when they indicated that
ACCEPTED MANUSCRIPT they believed studying abroad would allow them to experience how nurses and midwives are educated in other countries and how the professions are perceived within a particular country.
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The notion that a student’s professional identity might be facilitated through the medium of study
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abroad is an important finding of this study particularly as student nurses and midwives often
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experience difficulty in coming to terms with how they, as a professional group, are perceived by the public and other health care professionals (Takase et al. 2002, Dawoud amd Maben 2008). A study by Dawoud and Maben (2008) that explored the perceived threats and challenges that face the
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nursing profession in the UK identified poor public perception of the profession as one of its main
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challenges. In addition the report found that inadequate nursing education, training, and professional development standards contributed to the negative public perception.
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The need to strengthen nursing and midwifery students’ professional identity has received
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considerable attention in the literature (Takase 2002, Azizi et al., 2013; Maranon and Pera 2015). Takase et al. (2002) caution that negative public images of nurses and the upward comparison with
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physicians and other health professionals may induce feelings of inferiority and powerlessness within nurses. More recent studies suggest that the low self-esteem of student nurses significantly
2013).
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correlate with student's attrition rate and depression (Azizi et al., 2013; Peterson-Graziose et al.,
The findings of this study suggest that study abroad may be useful in helping students ascertain and contextualise their professional reality. This however is speculative and future research is required to explore and gain greater insight into the effect of study abroad on the development of nursing and midwifery students’ professional identity.
Employability
ACCEPTED MANUSCRIPT An interesting point of note in relation to the advantages of study abroad as perceived by nursing and midwifery students is that the topic of employability. The absence of something that might have
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been expected, what Barker and Jago (2012) refer to as ‘negative facts’, can offer important insights
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into a field of study by uncovering some of the more subtle and complicated social and structural
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constraints that participants may have found difficult to express (Thorne 2016). The only reference that was made to employability related to participants’ normative beliefs where less than 25% of respondents believed that future employers would approve of them studying
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abroad. This is in contrast to evidence from international literature which suggests that one of the
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main benefits to studying abroad, particularly for business students, relates to employment opportunities (Presley et al 2010, Molony et al 2012, European Commission 2014) and revolves primarily around the expectation that students competitiveness and career prospects will be
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enhanced (Molony et al 2012. Zhuang et al. 2015). Indeed data from a TPB survey by Presley et al. (2010) suggest that the benefits of opening new career opportunities are one of the most favourable
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outcomes of studying abroad among undergraduate business students. It is unclear from the findings why nursing and midwifery students did not identify enhanced career
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opportunities as a possible advantage of study abroad. One rationale may be that nursing and midwifery students simply do not believe that a study abroad experience will enhance their employment prospects because they perceive it as being undervalued by their prospective employers. Such a perception is not unfounded. A QS Global Employer Survey (Molony et al. 2012) found that only 41% and 59% of employers in the UK and Ireland respectively actively seek or attribute value to an international study experience when recruiting. Kowarski (2010) argues that many employers do not value time spent abroad because students cannot articulate its value in a manner that is appealing to prospective employers. Indeed the importance of equipping students with an ability to articulate how a study abroad experience has benefitted them is demonstrated in a recent large scale study by the European commission (2014) which explored the impact of the
ACCEPTED MANUSCRIPT European Union's Erasmus student exchange programme. The study found that 92% of employers are looking for personality traits boosted by the programme such as tolerance, confidence, and
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problem-solving skills, when making a recruitment decision.
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As such academic institutions need to consider how it can promote reflection on study abroad so
learning experiences into employability outcomes.
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Perceived Barriers to study abroad
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that students can articulate the benefits of the experience and develop the skills to translate these
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Language Barrier
The most frequently cited disadvantage to study abroad for nursing and midwifery students related to not being able to communicate effectively in the host country. Indeed the majority of
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respondents in the current study indicated that they would be more likely to participate in a study
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abroad programme if English was the main language in use. This is reflected in the wider literature
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which identifies language to be a critical factor in influencing interest in international study opportunities (Souto-Otero et al. 2013, Owen et al. 2013).
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Unlike other EU member states, achieving proficiency in a foreign language is not a feature of education systems in Ireland. The Eurostudent V survey (Harmon and Foubert 2013) identified that 63% of third level students in Ireland have no knowledge of a foreign language. In contrast, 88% of Finnish students and 78% of German students consider their first foreign language proficiency as being either good or very good respectively. Complicating this issue further is the fact that having a second language is not normally a pre-requisite for admission to nursing and midwifery programmes of study, unlike the majority of other third level health related programmes. This is of concern as language barriers and poor communication skills have been identified as not only a very serious threat to patient safety (Squires and Jacob 2016, van Rosse et al. 2016) but also one of the main challenges facing the nursing profession (Dawoud and Maben 2008, Squires and
ACCEPTED MANUSCRIPT Jacob 2016) ). This prompts the question why isn’t a second language a pre-requisite for entry to a profession that not only provides care to an ever increasing multi-denominational patient group, but
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offers extensive international employment opportunities?
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Consideration must be given to ways of addressing this issue such as the desirability of second
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language requirements when recruiting students to undergraduate programmes or the implementation of structures which would enable students to gain language competency as part of
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their programme. Cost barrier
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The financial cost associated with study abroad was identified as being a major disadvantage and is further reflected in participants’ control beliefs when they refer to financial commitments at home
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and the lack of financial aid as being barriers to study abroad. Perhaps unsurprisingly the cost of
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studying abroad is a recurring theme in the study abroad literature and the most commonly cited
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reason for non-mobility (Schnusenberg et al. 2012, Souto-Otero et al. 2013, Kent-Wilkinson et al. 2015). Research suggests that financial issues include travel costs, living costs in the host culture and loss of earnings at home (Van Der Meld 2003). These factors when combined with the perceived
2010).
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inability to work while on exchange may outweigh a student’s desire to study abroad (Eder et al.
The current study’s findings support this contention with nursing and midwifery students suggesting that they would be more inclined to consider a study abroad experience if they were able to earn money while abroad. It is unclear however why students have the perception that they cannot work while on a study abroad programme. While the practicalities associated with securing work while on a study abroad programme may be formidable for students, there are very few restrictions, particularly for EU students. For example, Erasmus + students, whether they are in receipt of an EU grant or not, are entitled to hold a part-time job as long as the student carries out the activities foreseen in the agreed mobility programme (European Commission 2016).
ACCEPTED MANUSCRIPT This suggests that students proposing to engage in a study abroad programme need to be adequately informed regarding not only the obligatory information, but also any practical
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supplementary information regarding the programme as early as possible allowing students to plan
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ahead. This could include establishing contacts in the host country in advance of commencing the
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programme to explore the possibility of securing part-time employment. Limitations
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This study has a number of limitations. The research sample was quite homogenous in so far the majority of participants were young, single, and female. This limitation however may be difficult to
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address considering the female-dominated nature of nursing and midwifery and gender bias inherent in nursing and midwifery education. Notwithstanding this, international literature reports
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that female students consistently outnumber males in relation to studying abroad irrespective of
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their programme of study (Desoff 2006, Stallman et al 2010).
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All participants were students in the same educational institution and all were exposed to the possibility of engaging in a study abroad programme while in 2nd year. The fact that participants did
responses.
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not consider partaking in a study abroad opportunity a year previously may have biased their
Conclusion and implications There is an abundance of anecdotal and empirical literature to suggest that students who have undertaken a study abroad experience often find it to be a defining moment in both their educational and personal growth. Despite the perceived value associated with international mobility for students, participation in study abroad programmes among health care professionals in particular is low. This is of concern as future health care professionals need to be equipped with the competencies and skills which enable them to work in a globalised health care environment. Such
ACCEPTED MANUSCRIPT competencies and skills, many would argue, are best developed through the experiential learning afforded through study abroad programmes.
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In order to gain a deeper understanding of the factors that influence nursing and midwifery
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student’s decision to study abroad a theory based elicitation study was conducted. The study’s
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findings support earlier works in identifying the main behavioural, normative and control factors that influence a student’s decision to study abroad. This study however is the first to recognise enhanced professional identity as a potential benefit of study abroad. It also isolates factors such as
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cultural sensitivity, employability, language and cost as important issues in need of further
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investigation, particularly as they relate to the development and promotion of study abroad programmes for undergraduate nursing and midwifery students.
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The findings of this study have implications for administrators, academics, and others involved in the
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development of third level study abroad programmes for nursing and midwifery students. It urges the development of new methods to promote the perceived benefits of study abroad, address the
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perceived barriers and ultimately increase student participation.
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Greatix-White, S. (2007) Uncovering study abroad: foreignness and its relevance to nurse education and cultural competence. Nurse Education Today, 28, 530–538.
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Harmon, D. and Foubert, O. (2013) EUROSTUDENT SURVEY V Report on the Social and Living Conditions of Higher Education Students in Ireland. http://database.eurostudent.eu/146#countries%5B%5D=12 Accessed January 12th 2016. Kent-Wilkinson, A., Dietrich Leurer, M., Luimes, J., Ferguson, L. and Murray, L. (2015) Studying abroad: Exploring factors influencing nursing students’ decisions to apply for clinical placements in international settings. Nurse Education Today 35 (8), 941-947 Kondracki, N.L., Wellman, N.S., Amundson, D.R., 2002. Content analysis: review of methods and their applications in nutrition education. Journal of Nutrition Education and Behaviour 34 (4), 224–230. Koskinen, L. and Tossavainen, K. (2004) Study abroad as a process of learning intercultural competence in nursing. International Journal of Nursing Practice 10, 111-120. Kowarski, I. (2010). Colleges Help Students to translate the benefits of study abroad. Chronicle of Higher Education 56(41), 21-22. Lindquist, G.J. (1990) Integration of international and transcultural content in nursing curricula: A process for change. Journal of Professional Nursing, 6, 272–279. Maranon, A.A., and Pera, M.P. (2015) Theory and practice in the construction of professional identity in nursing students: A qualitative study. Nurse Education Today 35, 859–863. Marmot, M., Allen, J., Bell, R., Bloomer, E. and Goldblatt, P. (2012) WHO Europeanreview of social health determinants of health and the health divide. Lancet 15, 380(9846), 1011-29.
ACCEPTED MANUSCRIPT Medina-Lopez-Portillo, A., (2004), Intercultural Learning Assessment: The Link between Program Duration and the Development of Intercultural Sensitivity, Frontiers: The Interdisciplinary Journal of Study Abroad, Volume 10, pp. 179-199
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Meleis, A. I. (1985) Theoretical nursing: Development and progress. Philadelphia: J. B. Lippincott, 483.
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Molony, J., Sowter, B., and Potts, D. (2012) QS global Employer Survey Report 2011. How employers Value and International Study Experience. QS Intelligence Unit. http://content.qs.com/qs/qs-globalemployer-survey-2011.pdf accessed Dec 12th 2012 Ohlen, J. and Segesten, K. (1998) The professional identity of the nurse: concept analysis and development. Journal of Advanced Nursing 28, (4) 720-727.
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Owen, C., Breheny, P., Ingram, R. et al (2013) Factors associated with pharmacy student interest in international study. American Journal of Pharmaceutical Education 77(3), 54 Peterson-Graziose, V., Bryer, J., Nikolaidou, M., (2013). Self-esteem and self-efficacy as predictors of attrition in associate degree nursing students. Journal of Nursing Education 52 (6), 351–354.
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Polit, D., Beck, C. and Hungler, B. (2001) Essentials of nursing research. Methods, appraisal, and utilization (5th ed). Philadelphia: Lippincott
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Presley, A. Damron-Martinez, D. and Zhang, L. (2010) A study of business student choice to study abroad : a test of the theory of planned behaviour. Journal of Teaching in International Business 4, 227-247
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Reimer -Kirkham, S., Van Hofwegen, L. and Pankratz, D. (2009) Keeping the Vision: Sustaining social Consciousness with nursing Students following International Learning Experiences. International Journal of Nursing Education Scholarship 6(1), 1-6. Ruddock, H.C. and Turner de, S. (2007) Developing cultural sensitivity: nursing students' experiences of a study abroad programme. Journal of Advanced Nursing 59 (4), 361-9.
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Salisbury, M., Umbach, P. and Paulsen, M. and Pascarella, E. (2008) Going Global: Understanding the Choice Process of the Intent to Study Abroad. Research in Higher Education 50, 119-143 Salisbury, M. (2011) The effect of study abroad on intercultural competence among undergraduate college students. PhD (Doctor of Philosophy) thesis, University of Iowa. http://ir.uiowa.edu/cgi/viewcontent.cgi?article=2458&context=etd accessed Dec. 10th 2015. Schnusenberg, O., De Jong, P. and Goel, L. ( 2012) Predicting Study Abroad Intentions Based on the Theory of Planned Behavior. Journal of Innovative Education 10(3), 337–361 Souto-Otero, M., Huisman, J., Beerkens, M., de Wit, H. and Vujić, S. (2013) Barriers to international student mobility: evidence from the ERASMUS program. Educational Researcher 42 (2), 70-77. Squires, A. and Jacobs, E.A. (2016) Language and communication issues impact healthcare providers around the world (Editorial). International Journal of Nursing Studies 54, 5-6. Stallman, E., Woodruff, E., Kasravi, J., & Comp, D. (2010). The diversification of the student profile. In W. W. Hoffa & S. C. DePaul (Eds.), A history of U.S. study abroad: 1965-present (pp. 115–160). Lancaster, PA: Frontiers: The Interdisciplinary Journal of Study Abroad. Takase, M., Kershaw, E. and Burt, L. (2002) Does public image of nurses matter? Journal of Professional Nursing 18, (4) 196-205.
ACCEPTED MANUSCRIPT Thorne, S. (2016) The Dog that didn’t bark in the night time. Nursing Inquiry (editorial) http://onlinelibrary.wiley.com/doi/10.1111/nin.12136/epdf accessed Feb. 5th 2016. Van Der Meld, J. S. (2003) Asian Americans: factors influencing the decision to study abroad. Frontiers: the interdisciplinary journal of study abroad, IX, 71-110.
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Zhuang, W., King, K. and Carnes, L. (2015) Studying Abroad: Understanding the Relationships Among Beliefs. Perceived Value and Behavioural Intentions. Journal of Teaching in International Business 26, 32-35.
ACCEPTED MANUSCRIPT Table 1
Socio-demographic Characteristics
Variable
n
% 68% 28% 4%
18-24 25-34 35-44
17 7 1
Gender
Female Male
24 1
Nationality Ethnicity Programme (Year 3 students n=25)
Irish White General Nursing Midwifery Integrated Nursing Mental Health Nursing Intellectual Disability Nursing
100% 100% 11 6 4 3 1
Relationship status
Single In a relationship Married
Fluent in a second language
No Yes
Casual/Part time employment Frequency of holidays abroad
Yes No Once per year Once every few years >2 times per year
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44% 24% 16% 12% 4%
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96% 4%
16 5 4
64% 20% 16%
22 3
88% 12%
18 6 14 10 1
76% 24% 56% 40% 4%
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Age
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(n=10)
40
Experiencing how nurses and midwives are educated abroad Learning a new language
(n=6)
24
(n=6)
24
Learning new skills
(n=6)
24
Meeting new people
(n=5)
20
Gaining new life experiences
(n=4)
16
Experiencing different countries attitudes toward the nursing and midwifery profession Experiencing other health care systems Behavioural Beliefs (Dis-advantages) Language barrier
(n=4)
16
(n=21)
84
The cost of living abroad
(n=19)
76
travel expenses
(n=19)
76
Missing home and family/ Homesickness Feeling isolated /fear of being alone Missing out on learning new things in Ireland Fear of falling behind
(n=10)
40
(n=10)
40
(n=4)
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72
CR
(n=18)
Participation in a study abroad programme at some point during an undergraduate programme
US
%
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n
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Behavioural Beliefs (Advantages) Observing practice in different social and cultural environments Experiencing different cultures
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Frequency of salient beliefs
16
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Table 2
Control Beliefs (Enablers) Having adequate personal finance
n
%
(n=25)
100
Ability to speak the language
(n=18)
72
Financial aid
(n=10)
40
Good support and organisation
(n=8)
32
Travelling as part of a group /health and safety Getting time off work
(n=4)
16
(n=4)
16
Good accessibility to host country
(n=4)
16
Family support
(n=3)
12
Being able to work while abroad
(n=3)
12
Short period of time abroad
(n=3)
12
Friends support
(n=3)
12
Enthusiasm to study abroad
(n=3)
12
(n=25)
100
(n=18)
72
n
%
(n=15)
60
College lecturers
(n=10)
40
Lack of financial aid
(n=10)
40
Parents
(n=8)
32
36
(n=6)
24
Friends
(n=6)
24
Family commitments/responsibilities Financial commitments at home
(n=9)
Nursing community
(n=6)
24
Future employers
(n=6)
24
Feeling homesick
(n=4)
16
College Not having supportSalient beliefs (n=4) regarding 16 Table 3 adequateModal study abroad systems Nursing Students Takes up too much time. (n=3) 12 Normative Beliefs
(n=4)
16
Being alone
(n=4)
16
(n=3)
12
Lack of confidence
(n=3)
12
Normative Beliefs (n=5)
20
(n=4)
16
(n=2)
8
(n=5)
20
(n=5)
20
Behavioural Beliefs
Behavioural beliefs
(Advantages)
(Disadvantages)
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Normative Beliefs (Supportive) Family
Control Beliefs (Barriers) High costs associated with study abroad Language barrier
(Un-supportive)
Normative CurrentBeliefs employer (Supportive) Family
(Un-supportive)
Friends
Cultural sensitivity
Observing practice in different social and cultural
Fears and Insecurities
Language barrier
Personal
Personal
Family Parents
Family Friends
Control Beliefs
Control Beliefs
(Enablers)
(Barriers)
Finance
Finance
Having adequate personal finance Financial aid
High cost associated with study abroad Lack of financial aid
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US
CR
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ACCEPTED MANUSCRIPT Comparison of behavioural, normative and control beliefs across studies Gatfield and Chen (2006)
Presley et al (2010)
Experiencing a new culture
Improving language skills
Career opportunities
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Academic reputation
Gatfield and Chen (2006)
Presley et al (2010)
Parents
Other family members
Cost
Schnusenberg and De Jong (2012)
Fitzsimmons, Flanagan and Wang (2013)
Zhuang, et al. (2015)
Current Study
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Others who have studied abroad Social obligations
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Current employer
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Professors/coaches/ academic sponsors Future employers
Goel, De Jong and Schnusenberg (2010)
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Normative Beliefs
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Professional development
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Friends
Disruption of academic progress Better qualifications
Significant others
Current Study
Personal safety
Zhuang, et al. (2015)
Homesickness
Fitzsimmons, Flanagan and Wang (2013)
Fun experience
PBC
Schnusenberg and De Jong (2012)
Personal development
Goel, De Jong and Schnusenberg (2010)
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Behavioural Beliefs
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Table 4
Gatfield and Chen (2006)
Presley et al (2010)
Goel, De Jong and Schnusenberg (2010)
Schnusenberg and De Jong (2012)
Fitzsimmons, Flanagan and Wang (2013)
Financial Aid
Interesting classes
Major Classes
Language skills
Assistance in academic planning Assimilation assistance
Safety and Health issues
Disruption of home country activities Administrative support
Zhuang, et al. (2015)
Current Study
Length of Time
Contact with home
Enthusiasm to study abroad
23
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ACCEPTED MANUSCRIPT Highlights
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The use of a cognitive model to explore students’ perceptions of study abroad Study abroad can assist in the development of students’ professional identity Cultural sensitivity and employability require further investigation Language and cost issues need further investigation
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S0260-6917(16)30077-6 doi: 10.1016/j.nedt.2016.05.019 YNEDT 3297
To appear in:
Nurse Education Today
Received date: Accepted date:
14 April 2016 19 May 2016
Please cite this article as: Kelleher, S., Fitzgerald, S., Hegarty, J., Factors that influence nursing and midwifery students’ intentions to study abroad: A qualitative study using the theory of planned behaviour, Nurse Education Today (2016), doi: 10.1016/j.nedt.2016.05.019
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT FACTORS THAT INFLUENCE NURSING AND MIDWIFERY STUDENTS’ INTENTIONS TO STUDY ABROAD: A QUALITATIVE STUDY USING THE THEORY OF PLANNED BEHAVIOUR
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Kelleher, S., Fitzgerald, S. and Hegarty, J.
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Author 2: Dr. Serena Fitzgerald PhD, BSc, RGN College Lecturer School of Nursing and Midwifery University College Cork Ireland Tel: 00353 21 4901516 E: [email protected]
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Author 1: Mr. Seán Kelleher MSc. PGDCIC, PGDT&L, BSc. RGN College Lecturer - Erasmus coordinator School of Nursing and Midwifery University College Cork, Ireland Tel: 00353 21 4901477 E: [email protected]
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Word Count: 4,385
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Author 3: Prof. Josephine Hegarty PhD, MSc, BSc, RNT, RGN Director of Graduate Studies, Catherine McAuley School of Nursing & Midwifery, University College Cork, Ireland Tel: 00353 21 4901462 E: [email protected]
Background
Future nurses need to be broadly-educated, adaptable individuals who have significant experience in the world beyond the classroom. Study abroad is an ideal means of developing some of the skills and attitudes, that are not only valued within the nursing profession, but also have global applicability, such as flexibility, self-reliance, and sensitivity to other cultures (Reimer-Kirkham et al 2009, Edmonds 2010). While research that explores the impact of study abroad programmes on students has proliferated in disciplines such as business and fine arts, research in the discipline of health, particularly nursing, is relatively recent and still limited. However and notwithstanding the dearth of research on the
ACCEPTED MANUSCRIPT topic, there has long been a commonly held perception that international experiences for nursing students leads to improved health care delivery and more effective nursing (Meleis 1985, Lindquist
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1990). More recently study abroad has been associated with a range of benefits for nursing students
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such as personal and professional growth (Greatix-White 2007, Christofferson 2008, Edmonds 2010),
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increased self-efficacy, self-confidence and the ability to adapt to unfamiliar environments (Koskinen and Tossavainen 2004, Ruddock and Turner 2007,). However, despite the array of purported benefits allied with study abroad, very little is known about the factors that influence students’ decisions to
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participate in such programmes (Salisbury et al. 2008, Kent-Wilkinson et al. 2015, Brown et al.2016), emphasising the need for a better understanding of decision making processes and how various
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factors influence that process. Understanding more about how students plan and respond to multiple influences has been associated with numerous advantages such as: improving faculty and
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administrators efficiency in advising students regarding study abroad (Council on International
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Educational Exchange 2015) and assisting third level institutions in designing study abroad
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programmes and marketing them to students who are most likely to participate in the experience
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(Goel et al. 2010, Schnusenberg et al. 2012).
Aim and methods
The aim of this study is to identify the salient behavioural beliefs underlying nursing and midwifery students’ intentions to study abroad. Theoretical frameworks have been used to gain a deeper understanding of the motivating factors that influence students’ decisions to study abroad (Presley et al 2010, Schnusenberg et al. 2012, Zhuang et al. 2015). The Theory of Planned Behaviour (TPB) (Ajzen, 1985), is one such theory and suggests that the direct determinant of a particular behaviour is a person’s intention to engage in that behaviour. Intentions are assumed to capture the motivational factors that influence a behaviour namely: 1. the person’s attitude toward the behaviour; 2. normative pressure (subjective norms), and 3. the person’s perceived level of control
ACCEPTED MANUSCRIPT over the behaviour (perceived behavioural control). These three factors are in turn determined by a person’s salient behavioural beliefs (Ajzen 1985, 1991, Francis et al. 2004). The method used to
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elicit salient beliefs is termed elicitation research (Ajzen 1985, 1991).
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Participants and procedure
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A purposive sample (n=25) of undergraduate nursing and midwifery students was used to elicit student’s salient beliefs regarding study abroad. While there are no firmly established criteria for
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calculating sample size in qualitative research (Polit et al. 2001), Francis et al. (2004) suggest that a sample size of 25 is sufficient to reach saturation in elicitation studies. Ethical approval to conduct
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the study was granted by the University Research Ethics Committee and access to the student population was secured through the School specific ethics board.
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Data Collection
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Data were obtained individually and in a free response format (Fishbein and Ajzen 2010, Ajzen 2011)
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by means of an open ended questionnaire. The questionnaire contained seven open ended questions based on the belief categories of the TPB and related to: Behavioural outcomes (attitudes toward study abroad), and perceived advantages and
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disadvantages of participating in a short term study abroad programme at some point during the participants undergraduate programme.
Normative referents, (subjective norms) i.e. individuals or groups who participants thought would approve or disapprove of their participation in a study abroad programme.
Perceived behavioural control (control factors) i.e. factors or circumstances participants believed would make participation in a study abroad programme possible or impossible.
Any other issues or concerns relating to studying abroad.
Socio demographic Questions
ACCEPTED MANUSCRIPT Twelve socio-demographic items were generated from a review of the literature which aimed to identify facilitating factors for study abroad across the wider student population and included
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gender, age, ethnicity, academic year, academic discipline, relationship status, employment status,
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travel experience, second language proficiency, and parents’ level of education (Table 1).
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Data analysis
Manifest content analysis was employed to identify meaning units (Kondracki et al., 2002,
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Graneheim and Lundman 2004). Where necessary data were condensed to create condensed meaning units (Graneheim and Lundman 2004), and abstracted to create codes. Codes were
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categorised according to the overarching framework of the TPB (behavioural beliefs, normative beliefs, control beliefs) and in order of frequency (Table 2). Subsequently sub categories were
Findings
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developed to describe participants’ beliefs in relation to study abroad (Table 3).
An overview of student demographics can be seen in Table 1. Advantages of study abroad The main advantages of studying abroad for nursing and midwifery students related to the development of cultural sensitivity, and personal and professional development. The majority of participants (n=18) cited being able to observe practice in different social and cultural environments and experiencing a different culture as being particularly important. This was reflected in statements such as:
ACCEPTED MANUSCRIPT “Seeing how different cultures practice nursing – their general customs and how things are run – theories and views of nursing can aid in questioning your own practice so it can evolve” (P7).
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Others recognised the potential a study abroad experience may present for their own personal
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development (n=16), particularly in relation to areas such as learning a new language and expanding
through a different language would be great" (P17).
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their personal skills. For example one participant stated “the experience of working in a hospital
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Factors relating to professional development were also frequently cited as an advantage of a study abroad experience (n=20). Participants believed they would benefit from experiencing how nurses
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and midwives in other countries are educated, how they practice, and how their profession is perceived by the public.
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Disadvantages of study abroad
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The main perceived disadvantages of study abroad for nursing and midwifery students related to fears, insecurities, expense and time. Not being able to speak the language of the host country was
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perceived as being one of the main disadvantages (n=21), particularly when students lacked a certain proficiency in the language. Indeed the foreboding element of trying to communicate
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through a different language while in another country was captured by one respondent when she stated: “It would be a daunting experience to live [in another country] and study in another college all through a different language” (P 4). The financial cost of studying abroad was also identified (n=19) as a substantial drawback with some participants stating that they would not be able to afford to study abroad. Others were more specific regarding the perceived costs associated with study abroad and identified issues such as the cost of travel, the cost of living and the cost of accommodation, as being the main difficulties. People who approve of study abroad
ACCEPTED MANUSCRIPT The individuals or groups who participants believed would approve of study abroad were captured under three specific sub-categories: personal, academic and professional (Table 3). Family was the
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most frequently cited group (n=15) followed college lecturers and parents. Some participants
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offered qualifying statements as to why they believed their families would support a study abroad
my horizons both personally and professionally” (P25).
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experience such as: “My family would certainly approve of me studying abroad as it would broaden
The nursing community and future employers constituted the ‘professional’ subcategory with each
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being cited an equal number of times (n=6). A number of diverse terms were used by participants to
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infer the nursing community such as: “{The} Psychiatric Nurses Association” (P 22); “The Nursing and Midwifery Board of Ireland (P20)”; “ward staff (P3); and “nursing colleagues” (P 17).
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People who would not approve of study abroad
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The individuals who participants believed would disapprove of study abroad were similarly captured
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under two specific sub-categories: personal and professional. For some participants Family (n=4) and friends (n=2) were identified as the groups who would most likely disapprove of a study abroad
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programme. Others identified Current employers (=5) as the group most likely to disapprove.
Factors that would make study abroad possible or impossible Control factors were sub-categorised under: finance, personal factors, and organisation. All participants (n=25) indicated that the most important factor when considering whether or not to participate in a study abroad programme related to the monetary cost of studying abroad with many suggesting that they would participate in a study abroad programme if there was greater financial support (n=10); for example one participant stated: “[If I] won the lottery or if the programme was fully subsidised” (P14). The main financial issues for respondents related to inadequate personal finance, the lack of financial aid and financial commitments at home such as mortgages and bills.
ACCEPTED MANUSCRIPT One participant stated: “paying rent on double accommodation” (P13) suggesting that paying for accommodation in both the host country and at home was a factor that would potentially deter
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participants from studying abroad.
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Being able to speak the language of the host country was identified by the many participants (n=18)
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as an important factor when considering to study abroad. Some participants indicated that they would go on a study abroad programme if they knew English was spoken in the host country. Others suggested that having some understanding of the language spoken in the host country was the most
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important factor.
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Family commitments at home, that ranged from having young children to having a pet to care for were also frequently cited factors among participants (n=8). Participants used short phrases to
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express their beliefs such as: “Family responsibilities” (P23); “Family circumstances” (P2). Other
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personal factors related to the fear of being alone and experiencing homesickness and the lack of
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confidence to participate a study abroad programme. How a study abroad programme was organised and the availability of support structures were the most frequently cited (n=8) organisational factors. In particular the issue of accommodation was
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highlighted as being important. One participant stated: “[I would like to have my] accommodation set up by host university/hospital pre-arrival “(P 1). Another participant suggested that the level of guidance and support from within the home college was a factor: “[I would like] support from [my] college with [the necessary] structures in place” (P6).
Discussion
ACCEPTED MANUSCRIPT This study has provided a detailed insight into nursing and midwifery students’ perceptions of study abroad and revealed numerous factors that may influence their intention to study abroad during
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their undergraduate education.
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In the main, nursing and midwifery students were positive about the prospect of studying abroad at
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some point during their undergraduate education, and exhibited comparable behavioural, normative and control beliefs regarding study abroad as have been identified in other student cohorts in earlier TPB studies (Gatfield and Chen 2006, Presley et al. 2010, Goel et al. 2010, Schnusenberg et al. 2012,
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Fitzsimmons et al. 2013, Zhuang et al. 2015). Notwithstanding the apparent similarities (Table 4) the
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findings of this study raise a number of issues that warrant further discussion, particularly when contextualised to nursing and midwifery students in Ireland.
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Cultural sensitivity
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An important finding was that nursing and midwifery students perceive the development of cultural
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sensitivity as being one of the main cross cultural benefits associated with studying abroad. This may seem unsurprising given the vast amount of literature that supports the value of international experiences for nursing students in the development and application of cultural competence into
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clinical practice (Koskinen and Tossavainen 2004, Ruddock and Turner 2007, Edmonds 2010). This study however is the first to use a theoretical framework in the form of the TPB to support this finding among nursing and midwifery students. Despite the array of apparent cross cultural-benefits associated with study abroad, the generalisability of such propositions has rarely been questioned, particularly within the context of Erasmus funded exchanges for nursing and midwifery students in Europe. Study abroad research suggests that the development of cross cultural skills such as cultural sensitivity, cultural competence, or intercultural development is dependent on a number of factors such as: the duration of the study abroad programme (Medina-Lopez-Portillo 2004, Engle and Engle
ACCEPTED MANUSCRIPT 2003): the students’ experience of studying in an unfamiliar environment, and the students exposure to stress and varying degrees of culture shock (Ruddock and Turner 2007). Indeed whether
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or not a nursing or midwifery student is exposed to patients from diverse cultures can be quite
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random and is dependent upon the location of the nursing programme and available clinical
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experiences (Carpenter and Garcia 2012). For example a student who decides to engage in an eight week study abroad experience in the UK may be exposed to similar health care structures and
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patient population as they experience in Ireland.
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A similar argument might be made for many other EU member states, where health care delivery is influenced predominantly by shared EU policies (Marmot et al. 2012). Salisbury (2011) suggests that decades of evidence that appear to support the claim that study abroad enhances intercultural
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competence are repeatedly limited by a series of methodological weaknesses including; small
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homogenous samples, an absence of longitudinal study design, no accounting for potential selection
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bias, and the lack of controls for potentially confounding demographic and college experience variables. As such more studies need to be conducted to support the belief that a study abroad experience actually delivers on expectations relating to cross cultural skills such as the development
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of cultural sensitivity and cultural competence. Professional development Participants identified a number of factors relating to study abroad that they believe would enhance their professional development such as experiencing other health care systems and learning new skills particular to their respective professions. However couched within professional development is the concept of professional identity. Professional identity is that which is constructed in relation to a reference group of professionals and a workspace (Caballero, 2009) and refers to the commonality of the nursing and midwifery professions (Ohlen and Segesten 1998). This was expressed by participants when they indicated that
ACCEPTED MANUSCRIPT they believed studying abroad would allow them to experience how nurses and midwives are educated in other countries and how the professions are perceived within a particular country.
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The notion that a student’s professional identity might be facilitated through the medium of study
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abroad is an important finding of this study particularly as student nurses and midwives often
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experience difficulty in coming to terms with how they, as a professional group, are perceived by the public and other health care professionals (Takase et al. 2002, Dawoud amd Maben 2008). A study by Dawoud and Maben (2008) that explored the perceived threats and challenges that face the
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nursing profession in the UK identified poor public perception of the profession as one of its main
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challenges. In addition the report found that inadequate nursing education, training, and professional development standards contributed to the negative public perception.
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The need to strengthen nursing and midwifery students’ professional identity has received
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considerable attention in the literature (Takase 2002, Azizi et al., 2013; Maranon and Pera 2015). Takase et al. (2002) caution that negative public images of nurses and the upward comparison with
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physicians and other health professionals may induce feelings of inferiority and powerlessness within nurses. More recent studies suggest that the low self-esteem of student nurses significantly
2013).
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correlate with student's attrition rate and depression (Azizi et al., 2013; Peterson-Graziose et al.,
The findings of this study suggest that study abroad may be useful in helping students ascertain and contextualise their professional reality. This however is speculative and future research is required to explore and gain greater insight into the effect of study abroad on the development of nursing and midwifery students’ professional identity.
Employability
ACCEPTED MANUSCRIPT An interesting point of note in relation to the advantages of study abroad as perceived by nursing and midwifery students is that the topic of employability. The absence of something that might have
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been expected, what Barker and Jago (2012) refer to as ‘negative facts’, can offer important insights
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into a field of study by uncovering some of the more subtle and complicated social and structural
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constraints that participants may have found difficult to express (Thorne 2016). The only reference that was made to employability related to participants’ normative beliefs where less than 25% of respondents believed that future employers would approve of them studying
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abroad. This is in contrast to evidence from international literature which suggests that one of the
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main benefits to studying abroad, particularly for business students, relates to employment opportunities (Presley et al 2010, Molony et al 2012, European Commission 2014) and revolves primarily around the expectation that students competitiveness and career prospects will be
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enhanced (Molony et al 2012. Zhuang et al. 2015). Indeed data from a TPB survey by Presley et al. (2010) suggest that the benefits of opening new career opportunities are one of the most favourable
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outcomes of studying abroad among undergraduate business students. It is unclear from the findings why nursing and midwifery students did not identify enhanced career
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opportunities as a possible advantage of study abroad. One rationale may be that nursing and midwifery students simply do not believe that a study abroad experience will enhance their employment prospects because they perceive it as being undervalued by their prospective employers. Such a perception is not unfounded. A QS Global Employer Survey (Molony et al. 2012) found that only 41% and 59% of employers in the UK and Ireland respectively actively seek or attribute value to an international study experience when recruiting. Kowarski (2010) argues that many employers do not value time spent abroad because students cannot articulate its value in a manner that is appealing to prospective employers. Indeed the importance of equipping students with an ability to articulate how a study abroad experience has benefitted them is demonstrated in a recent large scale study by the European commission (2014) which explored the impact of the
ACCEPTED MANUSCRIPT European Union's Erasmus student exchange programme. The study found that 92% of employers are looking for personality traits boosted by the programme such as tolerance, confidence, and
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problem-solving skills, when making a recruitment decision.
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As such academic institutions need to consider how it can promote reflection on study abroad so
learning experiences into employability outcomes.
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Perceived Barriers to study abroad
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that students can articulate the benefits of the experience and develop the skills to translate these
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Language Barrier
The most frequently cited disadvantage to study abroad for nursing and midwifery students related to not being able to communicate effectively in the host country. Indeed the majority of
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respondents in the current study indicated that they would be more likely to participate in a study
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abroad programme if English was the main language in use. This is reflected in the wider literature
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which identifies language to be a critical factor in influencing interest in international study opportunities (Souto-Otero et al. 2013, Owen et al. 2013).
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Unlike other EU member states, achieving proficiency in a foreign language is not a feature of education systems in Ireland. The Eurostudent V survey (Harmon and Foubert 2013) identified that 63% of third level students in Ireland have no knowledge of a foreign language. In contrast, 88% of Finnish students and 78% of German students consider their first foreign language proficiency as being either good or very good respectively. Complicating this issue further is the fact that having a second language is not normally a pre-requisite for admission to nursing and midwifery programmes of study, unlike the majority of other third level health related programmes. This is of concern as language barriers and poor communication skills have been identified as not only a very serious threat to patient safety (Squires and Jacob 2016, van Rosse et al. 2016) but also one of the main challenges facing the nursing profession (Dawoud and Maben 2008, Squires and
ACCEPTED MANUSCRIPT Jacob 2016) ). This prompts the question why isn’t a second language a pre-requisite for entry to a profession that not only provides care to an ever increasing multi-denominational patient group, but
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offers extensive international employment opportunities?
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Consideration must be given to ways of addressing this issue such as the desirability of second
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language requirements when recruiting students to undergraduate programmes or the implementation of structures which would enable students to gain language competency as part of
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their programme. Cost barrier
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The financial cost associated with study abroad was identified as being a major disadvantage and is further reflected in participants’ control beliefs when they refer to financial commitments at home
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and the lack of financial aid as being barriers to study abroad. Perhaps unsurprisingly the cost of
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studying abroad is a recurring theme in the study abroad literature and the most commonly cited
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reason for non-mobility (Schnusenberg et al. 2012, Souto-Otero et al. 2013, Kent-Wilkinson et al. 2015). Research suggests that financial issues include travel costs, living costs in the host culture and loss of earnings at home (Van Der Meld 2003). These factors when combined with the perceived
2010).
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inability to work while on exchange may outweigh a student’s desire to study abroad (Eder et al.
The current study’s findings support this contention with nursing and midwifery students suggesting that they would be more inclined to consider a study abroad experience if they were able to earn money while abroad. It is unclear however why students have the perception that they cannot work while on a study abroad programme. While the practicalities associated with securing work while on a study abroad programme may be formidable for students, there are very few restrictions, particularly for EU students. For example, Erasmus + students, whether they are in receipt of an EU grant or not, are entitled to hold a part-time job as long as the student carries out the activities foreseen in the agreed mobility programme (European Commission 2016).
ACCEPTED MANUSCRIPT This suggests that students proposing to engage in a study abroad programme need to be adequately informed regarding not only the obligatory information, but also any practical
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supplementary information regarding the programme as early as possible allowing students to plan
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ahead. This could include establishing contacts in the host country in advance of commencing the
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programme to explore the possibility of securing part-time employment. Limitations
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This study has a number of limitations. The research sample was quite homogenous in so far the majority of participants were young, single, and female. This limitation however may be difficult to
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address considering the female-dominated nature of nursing and midwifery and gender bias inherent in nursing and midwifery education. Notwithstanding this, international literature reports
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that female students consistently outnumber males in relation to studying abroad irrespective of
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their programme of study (Desoff 2006, Stallman et al 2010).
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All participants were students in the same educational institution and all were exposed to the possibility of engaging in a study abroad programme while in 2nd year. The fact that participants did
responses.
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not consider partaking in a study abroad opportunity a year previously may have biased their
Conclusion and implications There is an abundance of anecdotal and empirical literature to suggest that students who have undertaken a study abroad experience often find it to be a defining moment in both their educational and personal growth. Despite the perceived value associated with international mobility for students, participation in study abroad programmes among health care professionals in particular is low. This is of concern as future health care professionals need to be equipped with the competencies and skills which enable them to work in a globalised health care environment. Such
ACCEPTED MANUSCRIPT competencies and skills, many would argue, are best developed through the experiential learning afforded through study abroad programmes.
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In order to gain a deeper understanding of the factors that influence nursing and midwifery
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student’s decision to study abroad a theory based elicitation study was conducted. The study’s
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findings support earlier works in identifying the main behavioural, normative and control factors that influence a student’s decision to study abroad. This study however is the first to recognise enhanced professional identity as a potential benefit of study abroad. It also isolates factors such as
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cultural sensitivity, employability, language and cost as important issues in need of further
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investigation, particularly as they relate to the development and promotion of study abroad programmes for undergraduate nursing and midwifery students.
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The findings of this study have implications for administrators, academics, and others involved in the
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development of third level study abroad programmes for nursing and midwifery students. It urges the development of new methods to promote the perceived benefits of study abroad, address the
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perceived barriers and ultimately increase student participation.
References
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Ajzen, I. (2011) Constructing a theory of planned behavior questionnaire. http://people.umass.edu/aizen/pdf/tpb.measurement.pdf accessed July 6th 2014
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Azizi, M., Khamseh, F., Rahimi, A., Barati, M., (2013). The relationship between self-esteem and depression in nursing students of a selected medical university in Tehran. Iranian Journal of Psychiatric Nursing 1(1), 28–34. Barker, S. and Jago, M. (2012) Being positive about negative facts. Philosophy and Phenomenological Research 85(1): 117–38.
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Brown, M. Appiah Boateng, E. and Evans, C. (2016) Should I stay or should I go? A systematic review of factors that influence healthcare students’ decisions around study abroad programmes. Nurse Education Today 39, 63-71.
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Carpenter, L.J. and Garcia, L.A. (2012) Assessing outcomes of a study abroad course for nursing students. Nursing Education Perspectives 33(2), 85-89.
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Caballero, K. (2009). Construcción y desarrollo de la identidad profesional del profesorado universitario (The construction and development of professional identity among university teachers). (Doctoral Dissertation), Universidad de Granada. http://0hera.ugr.es.adrastea.ugr.es/tesisugr/17922471.pdf accessed Jan 10th 2016. Christofferson, J.E. (2008) Leading a Study-abroad Group of Nursing Students in Nicaragua: A Firsttimer's Account. Nursing Forum 43(4), 238-246.
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Dawoud, D. and Maben, J. (2008) Nurses in Society: Starting the Debate . National Nursing Research Unit. Kinds College London. https://www.kcl.ac.uk/nursing/research/nnru/publications/Reports/Nursesinsocietywrittenevidence .pdf accessed Feb. 3rd 2016. Desoff, A. (2006). Who’s not going abroad? International Educator, 15(2), 20–27. Eder, J., Smith, W.W. and Pitts, R. E. (2010) Exploring Factors Influencing Student Study Abroad Destination Choice. Journal of Teaching in Travel and Tourism 10: 232-250. Edmonds, M. (2010) The Lived Experience of Nursing Students Who Study Abroad: A Qualitative Inquiry. Journal of Studies in International Education, 14(5), 545-568. Elo S., Kyngäs H. (2008). The qualitative content analysis process. Journal of Advanced Nursing, 62, 107-115. Engle and Engle (2003). Study abroad levels: Towards a classification of program types. Frontiers: The Interdisciplinary Journal of Study Abroad, 9: 1-20. European Commission (2014) Erasmus Impact Study confirms EU student exchange scheme boosts employability and job mobility http://europa.eu/rapid/press-release_IP-14-1025_en.htm accessed 24th Sept 2014.
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European commission (2016) Annex 1: Specific rules and information relating to mobility activities, strategic partnerships and capacity building in higher education. Erasmus + Programme Guide version 2 http://ec.europa.eu/programmes/erasmus-plus/documents/erasmus-plus-programmeguide_en.pdf accessed Jan 2016.
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Fishbein, M. and Ajzen, I. (2010) Predicting and Changing Behavior. The reasoned Action Approach. Sussex: Psychology Press Fitzsimmons, S.R., Flanagan, D.J., and Wang, X. (2013) Business students’ choice of short-term or long-term study abroad opportunities. Journal of teaching in International Business 24 (2), 125-137.
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Francis, J., Eccles, M., Johnson, M., Walker, A., Grimshaw, J., Foy, R., Kaner, E., Smith, L. and Bonetti, D. (2004) Constructing questionnaires based on the Theory of Planned Behaviour. A manual for Health Service Reserarchers. Quality of Life and Management of Living resources http://pages.bangor.ac.uk/~pes004/exercise_psych/downloads/tpb_manual.pdf accessed May 2014.
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Gatfield, T. and Chen, C. (2006) Measuring Student Choice Criteria Using the Theory of Planned Behaviour: The case of Taiwan, Australia, UK, and USA. Journal of Marketing for Higher Education 16(1), 77-95.
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Goel,L., DeJong, P. and Schnusenberg, O. (2010) Toward a comprehensive framework of study abroad intentions and behaviors. Journal of teaching in international business 21 (4), p. 248-265
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Graneheim, UH. and Lundman, B. (2004). Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Education Today, 24, pp. 105-112.
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Greatix-White, S. (2007) Uncovering study abroad: foreignness and its relevance to nurse education and cultural competence. Nurse Education Today, 28, 530–538.
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Harmon, D. and Foubert, O. (2013) EUROSTUDENT SURVEY V Report on the Social and Living Conditions of Higher Education Students in Ireland. http://database.eurostudent.eu/146#countries%5B%5D=12 Accessed January 12th 2016. Kent-Wilkinson, A., Dietrich Leurer, M., Luimes, J., Ferguson, L. and Murray, L. (2015) Studying abroad: Exploring factors influencing nursing students’ decisions to apply for clinical placements in international settings. Nurse Education Today 35 (8), 941-947 Kondracki, N.L., Wellman, N.S., Amundson, D.R., 2002. Content analysis: review of methods and their applications in nutrition education. Journal of Nutrition Education and Behaviour 34 (4), 224–230. Koskinen, L. and Tossavainen, K. (2004) Study abroad as a process of learning intercultural competence in nursing. International Journal of Nursing Practice 10, 111-120. Kowarski, I. (2010). Colleges Help Students to translate the benefits of study abroad. Chronicle of Higher Education 56(41), 21-22. Lindquist, G.J. (1990) Integration of international and transcultural content in nursing curricula: A process for change. Journal of Professional Nursing, 6, 272–279. Maranon, A.A., and Pera, M.P. (2015) Theory and practice in the construction of professional identity in nursing students: A qualitative study. Nurse Education Today 35, 859–863. Marmot, M., Allen, J., Bell, R., Bloomer, E. and Goldblatt, P. (2012) WHO Europeanreview of social health determinants of health and the health divide. Lancet 15, 380(9846), 1011-29.
ACCEPTED MANUSCRIPT Medina-Lopez-Portillo, A., (2004), Intercultural Learning Assessment: The Link between Program Duration and the Development of Intercultural Sensitivity, Frontiers: The Interdisciplinary Journal of Study Abroad, Volume 10, pp. 179-199
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Meleis, A. I. (1985) Theoretical nursing: Development and progress. Philadelphia: J. B. Lippincott, 483.
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Molony, J., Sowter, B., and Potts, D. (2012) QS global Employer Survey Report 2011. How employers Value and International Study Experience. QS Intelligence Unit. http://content.qs.com/qs/qs-globalemployer-survey-2011.pdf accessed Dec 12th 2012 Ohlen, J. and Segesten, K. (1998) The professional identity of the nurse: concept analysis and development. Journal of Advanced Nursing 28, (4) 720-727.
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Owen, C., Breheny, P., Ingram, R. et al (2013) Factors associated with pharmacy student interest in international study. American Journal of Pharmaceutical Education 77(3), 54 Peterson-Graziose, V., Bryer, J., Nikolaidou, M., (2013). Self-esteem and self-efficacy as predictors of attrition in associate degree nursing students. Journal of Nursing Education 52 (6), 351–354.
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Polit, D., Beck, C. and Hungler, B. (2001) Essentials of nursing research. Methods, appraisal, and utilization (5th ed). Philadelphia: Lippincott
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Presley, A. Damron-Martinez, D. and Zhang, L. (2010) A study of business student choice to study abroad : a test of the theory of planned behaviour. Journal of Teaching in International Business 4, 227-247
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Reimer -Kirkham, S., Van Hofwegen, L. and Pankratz, D. (2009) Keeping the Vision: Sustaining social Consciousness with nursing Students following International Learning Experiences. International Journal of Nursing Education Scholarship 6(1), 1-6. Ruddock, H.C. and Turner de, S. (2007) Developing cultural sensitivity: nursing students' experiences of a study abroad programme. Journal of Advanced Nursing 59 (4), 361-9.
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Salisbury, M., Umbach, P. and Paulsen, M. and Pascarella, E. (2008) Going Global: Understanding the Choice Process of the Intent to Study Abroad. Research in Higher Education 50, 119-143 Salisbury, M. (2011) The effect of study abroad on intercultural competence among undergraduate college students. PhD (Doctor of Philosophy) thesis, University of Iowa. http://ir.uiowa.edu/cgi/viewcontent.cgi?article=2458&context=etd accessed Dec. 10th 2015. Schnusenberg, O., De Jong, P. and Goel, L. ( 2012) Predicting Study Abroad Intentions Based on the Theory of Planned Behavior. Journal of Innovative Education 10(3), 337–361 Souto-Otero, M., Huisman, J., Beerkens, M., de Wit, H. and Vujić, S. (2013) Barriers to international student mobility: evidence from the ERASMUS program. Educational Researcher 42 (2), 70-77. Squires, A. and Jacobs, E.A. (2016) Language and communication issues impact healthcare providers around the world (Editorial). International Journal of Nursing Studies 54, 5-6. Stallman, E., Woodruff, E., Kasravi, J., & Comp, D. (2010). The diversification of the student profile. In W. W. Hoffa & S. C. DePaul (Eds.), A history of U.S. study abroad: 1965-present (pp. 115–160). Lancaster, PA: Frontiers: The Interdisciplinary Journal of Study Abroad. Takase, M., Kershaw, E. and Burt, L. (2002) Does public image of nurses matter? Journal of Professional Nursing 18, (4) 196-205.
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Zhuang, W., King, K. and Carnes, L. (2015) Studying Abroad: Understanding the Relationships Among Beliefs. Perceived Value and Behavioural Intentions. Journal of Teaching in International Business 26, 32-35.
ACCEPTED MANUSCRIPT Table 1
Socio-demographic Characteristics
Variable
n
% 68% 28% 4%
18-24 25-34 35-44
17 7 1
Gender
Female Male
24 1
Nationality Ethnicity Programme (Year 3 students n=25)
Irish White General Nursing Midwifery Integrated Nursing Mental Health Nursing Intellectual Disability Nursing
100% 100% 11 6 4 3 1
Relationship status
Single In a relationship Married
Fluent in a second language
No Yes
Casual/Part time employment Frequency of holidays abroad
Yes No Once per year Once every few years >2 times per year
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44% 24% 16% 12% 4%
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96% 4%
16 5 4
64% 20% 16%
22 3
88% 12%
18 6 14 10 1
76% 24% 56% 40% 4%
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Age
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(n=10)
40
Experiencing how nurses and midwives are educated abroad Learning a new language
(n=6)
24
(n=6)
24
Learning new skills
(n=6)
24
Meeting new people
(n=5)
20
Gaining new life experiences
(n=4)
16
Experiencing different countries attitudes toward the nursing and midwifery profession Experiencing other health care systems Behavioural Beliefs (Dis-advantages) Language barrier
(n=4)
16
(n=21)
84
The cost of living abroad
(n=19)
76
travel expenses
(n=19)
76
Missing home and family/ Homesickness Feeling isolated /fear of being alone Missing out on learning new things in Ireland Fear of falling behind
(n=10)
40
(n=10)
40
(n=4)
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72
CR
(n=18)
Participation in a study abroad programme at some point during an undergraduate programme
US
%
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n
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Behavioural Beliefs (Advantages) Observing practice in different social and cultural environments Experiencing different cultures
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Frequency of salient beliefs
16
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Table 2
Control Beliefs (Enablers) Having adequate personal finance
n
%
(n=25)
100
Ability to speak the language
(n=18)
72
Financial aid
(n=10)
40
Good support and organisation
(n=8)
32
Travelling as part of a group /health and safety Getting time off work
(n=4)
16
(n=4)
16
Good accessibility to host country
(n=4)
16
Family support
(n=3)
12
Being able to work while abroad
(n=3)
12
Short period of time abroad
(n=3)
12
Friends support
(n=3)
12
Enthusiasm to study abroad
(n=3)
12
(n=25)
100
(n=18)
72
n
%
(n=15)
60
College lecturers
(n=10)
40
Lack of financial aid
(n=10)
40
Parents
(n=8)
32
36
(n=6)
24
Friends
(n=6)
24
Family commitments/responsibilities Financial commitments at home
(n=9)
Nursing community
(n=6)
24
Future employers
(n=6)
24
Feeling homesick
(n=4)
16
College Not having supportSalient beliefs (n=4) regarding 16 Table 3 adequateModal study abroad systems Nursing Students Takes up too much time. (n=3) 12 Normative Beliefs
(n=4)
16
Being alone
(n=4)
16
(n=3)
12
Lack of confidence
(n=3)
12
Normative Beliefs (n=5)
20
(n=4)
16
(n=2)
8
(n=5)
20
(n=5)
20
Behavioural Beliefs
Behavioural beliefs
(Advantages)
(Disadvantages)
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Normative Beliefs (Supportive) Family
Control Beliefs (Barriers) High costs associated with study abroad Language barrier
(Un-supportive)
Normative CurrentBeliefs employer (Supportive) Family
(Un-supportive)
Friends
Cultural sensitivity
Observing practice in different social and cultural
Fears and Insecurities
Language barrier
Personal
Personal
Family Parents
Family Friends
Control Beliefs
Control Beliefs
(Enablers)
(Barriers)
Finance
Finance
Having adequate personal finance Financial aid
High cost associated with study abroad Lack of financial aid
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MA N
US
CR
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ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT Comparison of behavioural, normative and control beliefs across studies Gatfield and Chen (2006)
Presley et al (2010)
Experiencing a new culture
Improving language skills
Career opportunities
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Academic reputation
Gatfield and Chen (2006)
Presley et al (2010)
Parents
Other family members
Cost
Schnusenberg and De Jong (2012)
Fitzsimmons, Flanagan and Wang (2013)
Zhuang, et al. (2015)
Current Study
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Others who have studied abroad Social obligations
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Current employer
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Professors/coaches/ academic sponsors Future employers
Goel, De Jong and Schnusenberg (2010)
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Normative Beliefs
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Professional development
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Friends
Disruption of academic progress Better qualifications
Significant others
Current Study
Personal safety
Zhuang, et al. (2015)
Homesickness
Fitzsimmons, Flanagan and Wang (2013)
Fun experience
PBC
Schnusenberg and De Jong (2012)
Personal development
Goel, De Jong and Schnusenberg (2010)
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Behavioural Beliefs
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Table 4
Gatfield and Chen (2006)
Presley et al (2010)
Goel, De Jong and Schnusenberg (2010)
Schnusenberg and De Jong (2012)
Fitzsimmons, Flanagan and Wang (2013)
Financial Aid
Interesting classes
Major Classes
Language skills
Assistance in academic planning Assimilation assistance
Safety and Health issues
Disruption of home country activities Administrative support
Zhuang, et al. (2015)
Current Study
Length of Time
Contact with home
Enthusiasm to study abroad
23
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ACCEPTED MANUSCRIPT Highlights
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The use of a cognitive model to explore students’ perceptions of study abroad Study abroad can assist in the development of students’ professional identity Cultural sensitivity and employability require further investigation Language and cost issues need further investigation
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