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Nursing student and faculty perceptions of reciprocity during international clinical learning experiences: A qualitative descriptive study
Nurse Education Today 84 (2020) 104242
Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/locate/nedt
Nursing student and faculty perceptions of reciprocity during international clinical learning experiences: A qualitative descriptive study
T
⁎
Natalie L. Gosse , Anna Katic-Duffy Centre for Nursing Studies, 100 Forest Road, St. Johns', NL A1A 1E5, Canada
A R T I C LE I N FO
A B S T R A C T
Keywords: Clinical education Intercultural collaboration International clinical placement International exchange experiences Nursing Student experiences
Background: Exposure of nursing students to global health care systems and cultures that are vastly different from which they are accustomed allow them to gain a unique perspective of our global village. A plethora of research has studied the lived experiences of visiting students during international clinical placements. Many studies have noted a multitude of benefits for visiting students. However, very little research examined the perspectives of host participants. Objectives: This study explores both visiting and host students and faculty's perceptions of reciprocity during international learning experiences. Design: A qualitative descriptive design was utilised. Setting: Intercultural collaboration between visiting and host participants occurred over a two week clinical learning experience in a regional hospital in Jamaica. Participants: Ten third year undergraduate Bachelor of Nursing students and two faculty from Canada engaged in clinical learning experiences with twelve fourth year host nursing students and three faculty from Jamaica. Method: Visiting students submitted reflective papers, participated in interviews, and a focus group two months later. Two separate focus groups were held to gather data from the hosting students and faculty. All data was analysed using thematic analysis for recurring themes. Results: The findings of this study show that both host and visiting students and faculty mutually gain benefits from intercultural exchange and collaboration. Reciprocity was noted in experiential knowledge acquisition, cultural awareness from educational and professional perspectives, and personal and professional transformative learning. Although notable differences from contrasting health care worlds were identified, the recognition of similarities and opportunities for transformative learning greatly outweighed the differences. Conclusion: There are reciprocal benefits to be gained in nursing education for visiting and host participants through the development of collaborative international partnerships. More research is required to further explore mutuality for students and faculty from different countries.
1. Introduction Nursing education has an opportunity to assist in the development of cultural humility and competence through facilitating international clinical learning experiences. Research suggests that not only do learning experiences gained from practice in another country engage students to self-reflect and develop an enhanced awareness of cultural differences, it has also been noted that these experiences provide students with opportunity for professional and personal transformative growth (Gower et al., 2017). Transformative learning develops through reflection of a life experience and assigning meaning of how the experience has impacted ones' worldviews. Reciprocity during international learning experiences reflects ⁎
mutual understandings, gains or benefits between all involved parties. In order to achieve reciprocal cultural understanding in its truest form, mutual respect is essential. Participants must consider each other as colearners and co-facilitators and encourage mutual knowledge sharing. A substantial amount of research has focused on the benefits of visiting nursing students during international placements, however very little research examines the reciprocal transcultural gains for the host students and faculty. 2. Literature review Nursing education supports the development of cultural competency and recognizes the importance of exposing nursing students to
Corresponding author. E-mail addresses: [email protected] (N.L. Gosse), anna.katic.duff[email protected] (A. Katic-Duffy).
https://doi.org/10.1016/j.nedt.2019.104242 Received 8 May 2019; Received in revised form 23 July 2019; Accepted 10 October 2019 0260-6917/ Crown Copyright © 2019 Published by Elsevier Ltd. All rights reserved.
Nurse Education Today 84 (2020) 104242
N.L. Gosse and A. Katic-Duffy
learning experience in Jamaica. The findings from this study will inform nurse educators of mutual perspectives from both guest and host students and faculty as well as highlight the importance of partnership to develop shared objectives.
diverse cultures. Integration of international clinical practicums into nursing curriculum has been shown in the literature to have multiple benefits. Student learning outcomes derived from international clinical placements suggest enhancements in knowledge regarding health care systems and educational practices, and recognition of nursing practice variances that are vastly different from their own (Browne et al., 2015; Gower et al., 2017). International clinical placements can also enhance the student nurse's future career, often providing an opportunity to further develop important professional attributes including leadership, communication, teamwork, critical thinking, cultural awareness and sensitivity (Browne et al., 2015; Gower et al., 2017; Harrison et al., 2016; Maginnis and Anderson, 2017; Ulvund and Mordal, 2017). Visiting student nurses participating in international clinical placements have also shown to have an easier time transitioning into the profession, readily able to incorporate varied points of view associated with other cultures and health care systems (Gower et al., 2017; Maginnis and Anderson, 2017). Improved cultural awareness advances respect towards all cultures thus allowing student nurses to incorporate values, customs and spiritual convictions in a way that recognizes the importance culture has on health (Browne and Fetherston, 2018; Gower et al., 2017; Ulvund and Mordal, 2017). Other research suggests that visiting students face challenges while working in a different country from which they are accustomed. It is not unusual for participants to feel vulnerable working in a resource limited environment which can often precipitate moral and ethical dilemmas (Gower et al., 2017; Harrison et al., 2016; Ulvund and Mordal, 2017). Ethical dilemmas can be attributed to lack of resources, hospital constraints, variance in clinical practice and inconsistencies related to nursing roles between the two settings which challenge students to realign their values and beliefs (Gower et al., 2017; Harrison et al., 2016). While some degree of cultural adjustment is expected, the role of faculty is multifaceted in alleviating culture shock, offering support and encouraging appropriate expression of feelings (Maginnis and Anderson, 2017). Comprehensive planning and preparation remains essential through ensuring students are adequately supported by academic staff and prepared for the changes in cultural norms. When visiting students are adequately prepared to understand cultural differences, they embrace the learning that comes with it and ultimately cope more effectively (Maginnis and Anderson, 2017). While there is an abundance of data related to the experience of visiting nursing students, limited literature speaks to the experience of host partners, however the importance of partnership and collaboration with international clinical placements was frequently reported. In resource depleted settings, a shared approach to learning optimizes the ability to deal with limited human and material resources. It is imperative to create an environment which facilitates a successful partnership incorporating trust, shared objectives, reverence, and responsibility (Bvumbwe, 2016). By openly sharing values and preconceptions, participants can respond respectfully to views and opinions from colleagues and fellow peers which inform greater cultural awareness. Paucity in current evidence on host partner perspectives of facilitating academic programs from other countries suggests a significant gap in the literature. A study by Underwood et al. (2016) focused on global host partner perspectives for international nursing student placements. Their findings support the development of equitable collaboration as host partners offer a unique role that honors local expertise and offers an understanding of contextual socioeconomic and cultural factors to successfully cultivate a meaningful partnership. Similar to findings in Bvumbwe's (2016) study, Underwood et al. (2016) study also acknowledges the important contribution and value of the host partner to develop a mutual approach to learning. The purpose of this study was to explore reciprocity from the perspectives of both visiting and host Bachelor of Nursing students and faculty gained through intercultural exchanges during a clinical
3. Methods 3.1. Research design A qualitative descriptive framework was used to explore the perceptions of reciprocity gained by host nursing students and faculty during an international clinical learning experience. Visiting students' perceptions of the experience were also explored. Data was collected through a combination of individual interviews, analysis of reflective papers and semi structured focus groups which allowed for identification and description of recurrent themes. A combination of all data collection methods allowed the authors to gain an understanding of the perspectives and meaning of mutual collaborative experiences gained through engagement in the international clinical learning experience. 3.2. Setting Undergraduate nursing students and faculty from Canada participated in an observational clinical learning experience in a regional hospital in Jamaica for a two week period. The visiting students worked collaboratively with host nursing students from a partnering educational institution in a variety of clinical contexts. Students rotated through several hospital units to gain exposure to various medical/ surgical areas, pediatrics, obstetrics, and emergency settings. Other collaborative learning experiences included participation in a local community health fair, a simulation laboratory session, and a classroom setting. 3.3. Participants The target population for this study was Bachelor of Nursing students from Canada completing an international clinical learning experience, as well as hosting students and faculty from the participating educational institute in Jamaica. All ten Canadian students, as well as, twelve students and three faculty members from Jamaica agreed to participate in this study. All participating students and faculty received a letter of invitation that explained the study and also included a consent form to participate. 3.4. Procedure 3.4.1. Focus groups (Canada and Jamaica) One researcher conducted individual interviews with all Canadian students after the clinical placement was completed and final grades were assigned by a separate faculty member from the summer semester. A semi-structured focus group was held with the participating Canadian students two months after the international experience. Two separate focus groups were held for the participants from Jamaica, one for students and one for faculty. Twelve undergraduate nursing students from Jamaica were interviewed via a semi-structured focus group on the last day of the clinical experience. Three faculty members from the partnering educational institution in Jamaica chose to participate in the faculty focus group on the last day of the clinical experience. All focus groups were led by the two accompanying Canadian faculty. The focus groups lasted 25–60 min and were audio recorded. All groups were aware of the audio recording and advised not to include names when speaking to maintain confidentiality. The focus groups were semi-structured; however, participants were encouraged to speak openly and freely. The interviewers' intentions were to allow freedom 2
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N.L. Gosse and A. Katic-Duffy
standardized medical equipment such as oxygen and suction equipment, and the differing scope of practice afforded to health care providers such as registered nurses, assistant nurses and physicians. As time together increased, recognition of similarities emerged. Students from both countries agreed that although some practices varied, it was primarily due to the disparities in resources; however, practices that required limited use of physical resources drew upon the same body of knowledge.
to express experiences and opinions and then ask follow up questions to gain a deeper understanding. 3.5. Reflective analysis One researcher collected reflective papers submitted by the Canadian students. Reflective papers were analysed for common themes by both researchers. Findings and validation of these themes were confirmed by researchers during individual interviews as well as during the focus group two months post experience.
“It was a wonderful experience that we shared together... I realize that we really have no differences.... I see mostly similarities. The way that our assessment is done, it is just the same as they would do a head to toe assessment”. [Host Student]
3.6. Data analysis Both authors participated in the international clinical learning experience and were active in conducting all three focus groups, examining the transcripts, and identifying common themes emerging from the three separate focus groups. All interviews were audio recorded and transcribed verbatim. Text transcriptions and audio recordings were listened to repeatedly by the primary nurse researcher and were analysed utilizing the principles of thematic analysis until common themes were extracted. The second author examined the selfreflective papers submitted by the Canadian students for common themes. Both researchers discussed each other's interpretation of the data and reached a consensus that addressed the common themes surfacing from all groups of participants. Interpretations of findings were validated by the Canadian students during the focus group two months post experience.
Similarities between nursing practices only began to emerge after the differences in practice were explored between students. The stark variances in resources intrigued visiting students to explore with questions and make comparisons to their own knowledge. After working together for several days in a variety of practice settings, students began noticing more similarities between practices rather than differences between health care resources (see Table 1). In addition to mutual knowledge acquisition relating to nursing practice, continued intercultural dialogue between students and faculty also exposed many similarities and differences between academic expectations and standards: “At first I was intimidated because the students from Jamaica were able to recall memorized information. I thought they were all incredibly smart to remember all the details... then as time went on I realized that we have learned the same information but in different ways. I was able to help the Jamaican students learn and understand some nursing processes”. [Visiting student]
3.7. Ethical considerations Ethical approval was obtained from both the provincial Health Research Ethics Board in Canada and the ethics board in the partnering educational institution in Jamaica. All potential participants were assured that their participation was completely voluntary, and that they had the right to withdraw without prejudice. All students were assured that non participation would not affect their academic standing. Researchers did not give the clinical evaluations or assign grades to the participating Canadian students or have any involvement with evaluation of host students. Focus groups and interviews with the Canadian students occurred after final grades were received for the semester in which the clinical experience occurred. Focus groups with the Jamaica students occurred privately, without the presence of host faculty from the participating educational institution in Jamaica. Confidentiality was maintained with both focus groups of host students and faculty. Interview data and transcripts were de-identified. The researchers advised that identity of participating students or faculty would not be revealed and all measures would be taken to protect privacy and confidentiality.
Faculty also engaged in knowledge sharing and compared educational approaches to teaching/learning within clinical and classroom settings. Findings indicate that mutual gains in educational approaches were also noted for host faculty. “There was a day where I was quizzing some of my students and the Canadian faculty participated in it and asked some beautiful questions that brought out information and that pulled out more from me as a faculty. It inspired something else in my brain and that was beautiful as well”. [Host faculty] Host faculty also engaged in the teaching/learning process with the Canadian students in all learning settings. Mutual value of these intercultural teaching learning experiences was noted by both visiting students and host faculty: “She [Canadian student] was very intimidated and afraid of engaging in this experience however when it was over she felt empowered and enabled as a student nurse….it solidified her confidence in her knowledge base and ability to work under pressure with this alternate style of teaching with faculty from a different country”. [Host Faculty]
4. Results Four central themes emerged that reflected mutual benefits to both host and visiting students during international clinical learning experiences. Results are described under these themes with quotes to illustrate findings (see Table 1).
In the two month post-experience focus group, visiting students remained mindful of differences primarily in approach to patient care, roles and status of students in the health facility, and in the educational setting. Participants agreed that despite notable differences, similarities prevailed and benefits were gained through knowledge sharing in clinical, lab and classroom settings. The end result from all participants was that they learned to respect differences and value diversity.
1.) Mutual knowledge acquisition in recognition of differences and similarities Host and guest students frequently compared nursing knowledge and practices during collaboration. Initial discussions mostly focused on disparities between the two health care systems. Students also frequently discussed variances noted between nursing and health care practices including: infection control measures, asepsis procedures, limited availability of health care resources such as dressing supplies, nursing procedures, pain management practices, limited availability of
2.) Reciprocal awareness of cultural diversity All participating students reflected on enhancements in their cultural awareness after engaging in this clinical experience. Canadian students recognized cultural variations in how health situations were approached that greatly differed from their ways of thinking. Variations 3
Nurse Education Today 84 (2020) 104242
N.L. Gosse and A. Katic-Duffy
Table 1 Common themes and indicative quotes. Themes
Indicative quotes
Mutual knowledge acquisition in recognition of differences and similarities
“The main thing that was different was the resource situation. We had to do everything manually, in your culture [Canada], they are pre-packaged, pre-made…everything is a one-time use whereas we have to sterilize and go back again” [Host Student]. “…they [Jamaica students] can be pretty good critical thinkers. It taught one how to critically think in a situation with lack of resources. By the end of the rotation, my perception had completely changed. I learned so much. I feel determined to bring what I learned to clinical with me” [Visiting Student]. “We were doing a procedure where we had a Canadian student participating. I realized that everything she thought she was going to do for the patient, she informed her. She called the patient by name and she talked during the procedure. I find that their communication is very good”. [Host Student] “…your interactions and therapeutic touch with the patients is much more than our interaction. Close, very close” [Host Student] “I feel that we [Canada] do more to get to know the patient. There were clearly cultural differences in how we communicated with the patient”. [Visiting Student] “The hospital was so much different than ours, there was no air conditioning, there were strong odors in some units of the hospital, and patients were placed in large wards, sometimes up to 10 in a ward”. [Visiting Student] “….if we want to become a better form of ourselves we must start with learning about how we tick and react to circumstances”. [Visiting Student] “…I was aware the Canadians were coming however initially I was a bit skeptical because of the difference in culture…in countries, the different medical devices ….I was a bit skeptical thinking that they would look down and be scornful….but when they came I realized that they didn't really look down on us and then we were able to share information and knowledge…..They aided me in the sense where I fell short, they helped me. I learned a lot and it was great having them”. [Host Student] “The friendship has not ended with the visit, so I am looking forward to the continued relationship with the Canadians”. [Host Faculty] “What I realize is it is as if we have known you for years, we have built this relationship, we laugh, we talk, we share the same views and have similar views”. [Host Student]
Reciprocal awareness of cultural diversity
Transformation during the adjustment process
The value of partnerships and collaboration
and find our place in this exchange” [Visiting Student].
between communication and relational skills were also primarily attributed to cultural differences:
In addition to the physical surroundings, students also became challenged when exposure to clinical situations created moral and ethical dilemmas. Clinical situations that created ethical dilemmas but also created opportunities for personal transformations included bearing witness to pain and suffering. Visiting students struggled with not having readily available and advanced pharmacologic methods of pain control. Additionally, visiting students struggled with knowledge of health situations whereby due to lack of availability of resources, treatment options were limited and as a result patient health outcomes were less favorable. Visiting students struggled as they recognized the health outcome would be different in their familiar resource wealthy health care system. Visiting students continued to describe the process as an “emotional roller coaster” with highs and lows each clinical day. They spent evenings debriefing in attempts to assign meaning and perspectives to create newly formed worldviews:
“Culturally the birth was very different from what happens in Canada. In Jamaica it was very stoic which was different from what I had imagined. Physiologically giving birth is the same experience in Canada and Jamaica however it was very surprising to see the variation in the social and emotional experiences”. [Visiting student] Differences in communication styles were also attributed to cultural variations between both host and visiting students. A host student reported: “I noted differences in terms of personal space. Canadians are very close, in our culture we tend to seek to secure our personal space”. All participating students agreed that mutual collaboration during intercultural exchanges allowed for enhanced cultural competence. With repeated intercultural interactions in a variety of learning environments, both host and visiting students noted they had a better understanding of each other's cultural beliefs, values and practices by the end of the experience. The consensus from the Canadian students was unanimous and accurately reflected with this comment:
“To reflect and critically analyze myself…it is the most productive thing we can do to grow and learn from our experiences”. [Visiting Student] Findings indicate that exposure to these experiences reinforced long term learning and highlighted the transformative impact of the international clinical experience. During the post-experience focus group, visiting students remained changed personally and professionally:
“…going to Jamaica provided ample opportunity to understand the importance of culture and allow myself as a nurse to quickly adapt to a new environment which is in my opinion a priceless nursing experience”.
“This experience made me a better person, a better nurse....I learned to take the experiences gained in a resource limited setting and now for example, I am more cognizant of the supplies I use in clinical back here in Canada”. [Visiting Student]
3.) Transformation during the adjustment process Visiting students agreed that finding their place in the clinical experience was an adjustment. Emotions were compared to a ‘roller coaster’ with excitement during the initial days, while anxiety and cultural shock prevailed over the next several days. Reflective learning and transformative processes began only after the initial adjustment period. Experiences that required adjustment included the physical surroundings as well as exposure to clinical circumstances that challenged students to address personal assumptions and biases.
4.) The value of partnerships and collaboration There is considerable value in academic partnerships between host and visiting nursing education programs. Participants agreed that a valuable friendship and mutual understanding had developed after a short two-week clinical learning experience. The development of a mutual partnership not only enhanced participant's knowledge of nursing, but also aided in understanding the impact of culture on health beliefs and practices. Faculty also expressed knowledge and mutual
“Everyone was on sensory overload and it took a while to fully adapt 4
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Underwood et al., 2016). Underwood et al. state that it is imperative for attending faculty have an awareness of local socio-economic, cultural, and political factors that challenge the host community as it is a vital part of preparing students to work sensitively with the community members. Findings from this study support that reciprocity between host and visiting participants as mutual collaborative partners must be respected. Collaboration must entail that visiting partners respectfully work with and fully appreciate the culture in order to enhance the learning experience. One way to promote this is to develop a close partnership and appreciate the knowledge provided from the host partner. Host partners can offer perspectives from a cultural lens to aid in understanding and acceptance of differences in cultural practices. An appreciative approach honors the expertise of the local leaders and values them as co-faculty (Underwood et al., 2016). Participation in the unique experience of an international health experience also broadened the cultural lens of host students. Intercultural dialogue and collaboration provided understanding of health care systems that vary greatly in resource availability. Host students noted a process of cultural adjustment towards the visiting students however it was not to the same degree because adjustment to a different health care setting was not required. Host students in this study were asked about challenges of having visiting students assigned to them in the clinical setting. Challenges included timing of the placement as it was close to their examination period and extra demands placed on the student's time. Frequent discussions and explanations of practice or answering questions from visiting students interfered with their ability to complete nursing responsibilities in a timely manner. However, host students reported that the benefits of having the visiting students outweighed the challenges.
respect for experiencing and learning alternative teaching styles as well as having a broader sense of how cultural variations influence academic settings. Host students also felt empowered and valued as co-teachers: “We brainstormed about the care plans together and the following day, she [visiting student] was taking the history, it was like she was more with it.” [Host student] In addition to working collaboratively at the bedside, close personal friendships developed. “….having the Canadian students around me helped me to see the brighter side of life….they were perky and confident, optimistic and motivating”. Another host student agreed and stated: “Instead of coming to clinical area every morning feeling weighed down, I actually looked forward to the interaction because it made the work feel lighter”. Supporting and positive comments from host participants indicate there is value and benefit for all parties if mutually agreed upon objectives are developed. 5. Discussion 5.1. Implications for visiting partners The findings of this study were consistent with previously published studies that found a multitude of benefits of international placements for visiting students. Visiting students in this study reported gains in knowledge acquisition, improved cultural competency as well as personal and professional transformation. As the adjustment process occurred, enhanced thinking processes began to surface for the visiting students. Consistent with the findings of Browne et al. (2015) and Gower et al. (2017), regular debriefing sessions focused on the differences in health care resources and allocations, however visiting students in this study were also able to process the health disparities and assign a positive outcome by recognizing that health care quality was not only about healthcare constraints and that critical thinking and creativity can overcome some shortfalls in resources. One primary role of attending faculty is to facilitate student personal, professional growth and support the transformative learning process (Gower et al., 2017; Maginnis and Anderson, 2017). Faculty must validate students' feelings and emotions, and engage the students to reflect, analyze and make sense of their clinical experiences. Allowing students the time to debrief, and self-reflect is critical to process the experiences of learning from different cultures and health care systems.
5.3. Implications for future practice The findings from this study provide insight into the host partners views of having partners from a more developed country practice within their healthcare system. It was determined that a global perspective of nursing and health care was gained by all participants in this study. These findings could impact how international placements are organized in the future to provide mutual learning opportunities for both the visiting as well as host partners. Reorganization of objectives for an international experience to include collaborative goals will lead to stronger partnerships while mutual cultural understanding is gained. 6. Conclusion In an effort to create global citizens and provide development of reciprocal cultural competency, offering opportunities for both visiting and host students and faculty members to gain unique perspectives through lived experiences during a collaborative international clinical learning experience is required in nursing education. Mutual benefits and learning occurred for visiting as well as host partners in this study. Collaboration between the partners promoted mutual cultural sensitivity, cultivated respect for diversity, enhanced awareness of health disparities and different health care systems, promoted critical thinking regarding complex health issues in resource limited settings, and supported the delivery of culturally competent care. The value of international partnerships therefore cannot be underestimated. To better understand the reciprocal learning and mutuality that occurs amongst visiting and host nursing students and faculty, more opportunities for intercultural exchanges and dialogues must be offered within nursing education.
5.2. Implications for host partners Limited research has studied the perspectives of the hosting partners in international clinical experiences. The findings from this study correlate with Bvumbwe (2016) and Underwood et al. (2016) studies that highlight the unique role host partners have in expanding the avenues for reciprocity during international clinical experiences. Reciprocity for host partners was gained through collaborative knowledge sharing of cultural, health and education practices. The host partners played an important role because development of a reciprocal relationship was garnered through open dialogue and acknowledgment of each other's contribution to mutual learning. Underwood et al. (2016) study supports that a successful international partnership is gained through “cultural bridging, collaboration, capacity building, and mutual goal setting” (p.354). Studies of host partner perspectives also acknowledge the value of collaboration between visiting and host faculty through the building of a successful partnership for future collaboration (Bvumbwe, 2016;
Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not for profit sectors. 5
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Ethical approval
placements for nursing students: A cross-section exploration of the structure, aims and objectives of placements. Education Today, 66, 1–7. doi:10.1016./j.nedt.2018. 03.023. Browne, C.A., Fetherston, C.M., Medigovich, K., 2015. International clinical placements for Australian undergraduate nursing students: a systematic thematic synthesis of the literature. Nurse Educ. Today 35, 1028–1036. https://doi.org/10.1016/j.nedt.2015. 05.012. Bvumbwe, T., 2016. Enhancing nursing education via academic- clinical partnership: an integrative review. International Journal of Nursing Sciences 3 (3), 314–322. https:// doi.org/10.1016/j.ijnss.2016.07.002. Gower, S., Duggan, R., Dantas, J., Boldy, D., 2017. Something has shifted: nursing students’ global perspective following international clinical placements. J. Adv. Nurs. 73, 2395–2406. https://doi.org/10.1111/jan.13320. Harrison, J.D., Logar, T., Le, P., Glass, M., 2016. What are the ethical issues facing globalhealth trainees working overseas? A multi-professional qualitative study. Healthcare 43 (4), 1–9. https://doi.org/10.3390/healthcare4030043. Maginnis, C., Anderson, J., 2017. A discussion of nursing students’ experiences of culture shock during an international clinical placement and the clinical facilitators’ role. Contemp. Nurse 53 (3), 348–354. https://doi.org/10.1111/jan.13320. Ulvund, I., Mordal, E., 2017. The impact of short term clinical placement in a developing country on nursing students: a qualitative descriptive study. Nurse Educ. Today 55, 96–100. https://doi.org/10.1016/j.nedt.2017.05.013. Underwood, M., Gleeson, J., Konnert, C., Wong, K., Valerio, B., 2016. Global host partner perspectives: utilizing a conceptual model to strengthen collaboration with host partners for international nursing student placements. Public Health Nurs. 33 (4), 351–359.
Ethical approval was obtained from both the provincial Health Research Ethics Board in Canada and the ethics board in the partnering educational institution in Jamaica. Declaration of competing interest There are no conflicts of interest to disclose. Acknowledgements The authors thank Patricia Grainger for her guidance, support and expert advice throughout all phases of this study. We also acknowledge the contributions of research assistant, Julia MacDonald for transcribing the data. The authors also wish to thank the students from Canada and Jamaica as well as faculty for their eager involvement and participation in this study. References Browne, C. A., & Fetherston, C. M. (2018). How do we facilitate international clinical
6
Contents lists available at ScienceDirect
Nurse Education Today journal homepage: www.elsevier.com/locate/nedt
Nursing student and faculty perceptions of reciprocity during international clinical learning experiences: A qualitative descriptive study
T
⁎
Natalie L. Gosse , Anna Katic-Duffy Centre for Nursing Studies, 100 Forest Road, St. Johns', NL A1A 1E5, Canada
A R T I C LE I N FO
A B S T R A C T
Keywords: Clinical education Intercultural collaboration International clinical placement International exchange experiences Nursing Student experiences
Background: Exposure of nursing students to global health care systems and cultures that are vastly different from which they are accustomed allow them to gain a unique perspective of our global village. A plethora of research has studied the lived experiences of visiting students during international clinical placements. Many studies have noted a multitude of benefits for visiting students. However, very little research examined the perspectives of host participants. Objectives: This study explores both visiting and host students and faculty's perceptions of reciprocity during international learning experiences. Design: A qualitative descriptive design was utilised. Setting: Intercultural collaboration between visiting and host participants occurred over a two week clinical learning experience in a regional hospital in Jamaica. Participants: Ten third year undergraduate Bachelor of Nursing students and two faculty from Canada engaged in clinical learning experiences with twelve fourth year host nursing students and three faculty from Jamaica. Method: Visiting students submitted reflective papers, participated in interviews, and a focus group two months later. Two separate focus groups were held to gather data from the hosting students and faculty. All data was analysed using thematic analysis for recurring themes. Results: The findings of this study show that both host and visiting students and faculty mutually gain benefits from intercultural exchange and collaboration. Reciprocity was noted in experiential knowledge acquisition, cultural awareness from educational and professional perspectives, and personal and professional transformative learning. Although notable differences from contrasting health care worlds were identified, the recognition of similarities and opportunities for transformative learning greatly outweighed the differences. Conclusion: There are reciprocal benefits to be gained in nursing education for visiting and host participants through the development of collaborative international partnerships. More research is required to further explore mutuality for students and faculty from different countries.
1. Introduction Nursing education has an opportunity to assist in the development of cultural humility and competence through facilitating international clinical learning experiences. Research suggests that not only do learning experiences gained from practice in another country engage students to self-reflect and develop an enhanced awareness of cultural differences, it has also been noted that these experiences provide students with opportunity for professional and personal transformative growth (Gower et al., 2017). Transformative learning develops through reflection of a life experience and assigning meaning of how the experience has impacted ones' worldviews. Reciprocity during international learning experiences reflects ⁎
mutual understandings, gains or benefits between all involved parties. In order to achieve reciprocal cultural understanding in its truest form, mutual respect is essential. Participants must consider each other as colearners and co-facilitators and encourage mutual knowledge sharing. A substantial amount of research has focused on the benefits of visiting nursing students during international placements, however very little research examines the reciprocal transcultural gains for the host students and faculty. 2. Literature review Nursing education supports the development of cultural competency and recognizes the importance of exposing nursing students to
Corresponding author. E-mail addresses: [email protected] (N.L. Gosse), anna.katic.duff[email protected] (A. Katic-Duffy).
https://doi.org/10.1016/j.nedt.2019.104242 Received 8 May 2019; Received in revised form 23 July 2019; Accepted 10 October 2019 0260-6917/ Crown Copyright © 2019 Published by Elsevier Ltd. All rights reserved.
Nurse Education Today 84 (2020) 104242
N.L. Gosse and A. Katic-Duffy
learning experience in Jamaica. The findings from this study will inform nurse educators of mutual perspectives from both guest and host students and faculty as well as highlight the importance of partnership to develop shared objectives.
diverse cultures. Integration of international clinical practicums into nursing curriculum has been shown in the literature to have multiple benefits. Student learning outcomes derived from international clinical placements suggest enhancements in knowledge regarding health care systems and educational practices, and recognition of nursing practice variances that are vastly different from their own (Browne et al., 2015; Gower et al., 2017). International clinical placements can also enhance the student nurse's future career, often providing an opportunity to further develop important professional attributes including leadership, communication, teamwork, critical thinking, cultural awareness and sensitivity (Browne et al., 2015; Gower et al., 2017; Harrison et al., 2016; Maginnis and Anderson, 2017; Ulvund and Mordal, 2017). Visiting student nurses participating in international clinical placements have also shown to have an easier time transitioning into the profession, readily able to incorporate varied points of view associated with other cultures and health care systems (Gower et al., 2017; Maginnis and Anderson, 2017). Improved cultural awareness advances respect towards all cultures thus allowing student nurses to incorporate values, customs and spiritual convictions in a way that recognizes the importance culture has on health (Browne and Fetherston, 2018; Gower et al., 2017; Ulvund and Mordal, 2017). Other research suggests that visiting students face challenges while working in a different country from which they are accustomed. It is not unusual for participants to feel vulnerable working in a resource limited environment which can often precipitate moral and ethical dilemmas (Gower et al., 2017; Harrison et al., 2016; Ulvund and Mordal, 2017). Ethical dilemmas can be attributed to lack of resources, hospital constraints, variance in clinical practice and inconsistencies related to nursing roles between the two settings which challenge students to realign their values and beliefs (Gower et al., 2017; Harrison et al., 2016). While some degree of cultural adjustment is expected, the role of faculty is multifaceted in alleviating culture shock, offering support and encouraging appropriate expression of feelings (Maginnis and Anderson, 2017). Comprehensive planning and preparation remains essential through ensuring students are adequately supported by academic staff and prepared for the changes in cultural norms. When visiting students are adequately prepared to understand cultural differences, they embrace the learning that comes with it and ultimately cope more effectively (Maginnis and Anderson, 2017). While there is an abundance of data related to the experience of visiting nursing students, limited literature speaks to the experience of host partners, however the importance of partnership and collaboration with international clinical placements was frequently reported. In resource depleted settings, a shared approach to learning optimizes the ability to deal with limited human and material resources. It is imperative to create an environment which facilitates a successful partnership incorporating trust, shared objectives, reverence, and responsibility (Bvumbwe, 2016). By openly sharing values and preconceptions, participants can respond respectfully to views and opinions from colleagues and fellow peers which inform greater cultural awareness. Paucity in current evidence on host partner perspectives of facilitating academic programs from other countries suggests a significant gap in the literature. A study by Underwood et al. (2016) focused on global host partner perspectives for international nursing student placements. Their findings support the development of equitable collaboration as host partners offer a unique role that honors local expertise and offers an understanding of contextual socioeconomic and cultural factors to successfully cultivate a meaningful partnership. Similar to findings in Bvumbwe's (2016) study, Underwood et al. (2016) study also acknowledges the important contribution and value of the host partner to develop a mutual approach to learning. The purpose of this study was to explore reciprocity from the perspectives of both visiting and host Bachelor of Nursing students and faculty gained through intercultural exchanges during a clinical
3. Methods 3.1. Research design A qualitative descriptive framework was used to explore the perceptions of reciprocity gained by host nursing students and faculty during an international clinical learning experience. Visiting students' perceptions of the experience were also explored. Data was collected through a combination of individual interviews, analysis of reflective papers and semi structured focus groups which allowed for identification and description of recurrent themes. A combination of all data collection methods allowed the authors to gain an understanding of the perspectives and meaning of mutual collaborative experiences gained through engagement in the international clinical learning experience. 3.2. Setting Undergraduate nursing students and faculty from Canada participated in an observational clinical learning experience in a regional hospital in Jamaica for a two week period. The visiting students worked collaboratively with host nursing students from a partnering educational institution in a variety of clinical contexts. Students rotated through several hospital units to gain exposure to various medical/ surgical areas, pediatrics, obstetrics, and emergency settings. Other collaborative learning experiences included participation in a local community health fair, a simulation laboratory session, and a classroom setting. 3.3. Participants The target population for this study was Bachelor of Nursing students from Canada completing an international clinical learning experience, as well as hosting students and faculty from the participating educational institute in Jamaica. All ten Canadian students, as well as, twelve students and three faculty members from Jamaica agreed to participate in this study. All participating students and faculty received a letter of invitation that explained the study and also included a consent form to participate. 3.4. Procedure 3.4.1. Focus groups (Canada and Jamaica) One researcher conducted individual interviews with all Canadian students after the clinical placement was completed and final grades were assigned by a separate faculty member from the summer semester. A semi-structured focus group was held with the participating Canadian students two months after the international experience. Two separate focus groups were held for the participants from Jamaica, one for students and one for faculty. Twelve undergraduate nursing students from Jamaica were interviewed via a semi-structured focus group on the last day of the clinical experience. Three faculty members from the partnering educational institution in Jamaica chose to participate in the faculty focus group on the last day of the clinical experience. All focus groups were led by the two accompanying Canadian faculty. The focus groups lasted 25–60 min and were audio recorded. All groups were aware of the audio recording and advised not to include names when speaking to maintain confidentiality. The focus groups were semi-structured; however, participants were encouraged to speak openly and freely. The interviewers' intentions were to allow freedom 2
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standardized medical equipment such as oxygen and suction equipment, and the differing scope of practice afforded to health care providers such as registered nurses, assistant nurses and physicians. As time together increased, recognition of similarities emerged. Students from both countries agreed that although some practices varied, it was primarily due to the disparities in resources; however, practices that required limited use of physical resources drew upon the same body of knowledge.
to express experiences and opinions and then ask follow up questions to gain a deeper understanding. 3.5. Reflective analysis One researcher collected reflective papers submitted by the Canadian students. Reflective papers were analysed for common themes by both researchers. Findings and validation of these themes were confirmed by researchers during individual interviews as well as during the focus group two months post experience.
“It was a wonderful experience that we shared together... I realize that we really have no differences.... I see mostly similarities. The way that our assessment is done, it is just the same as they would do a head to toe assessment”. [Host Student]
3.6. Data analysis Both authors participated in the international clinical learning experience and were active in conducting all three focus groups, examining the transcripts, and identifying common themes emerging from the three separate focus groups. All interviews were audio recorded and transcribed verbatim. Text transcriptions and audio recordings were listened to repeatedly by the primary nurse researcher and were analysed utilizing the principles of thematic analysis until common themes were extracted. The second author examined the selfreflective papers submitted by the Canadian students for common themes. Both researchers discussed each other's interpretation of the data and reached a consensus that addressed the common themes surfacing from all groups of participants. Interpretations of findings were validated by the Canadian students during the focus group two months post experience.
Similarities between nursing practices only began to emerge after the differences in practice were explored between students. The stark variances in resources intrigued visiting students to explore with questions and make comparisons to their own knowledge. After working together for several days in a variety of practice settings, students began noticing more similarities between practices rather than differences between health care resources (see Table 1). In addition to mutual knowledge acquisition relating to nursing practice, continued intercultural dialogue between students and faculty also exposed many similarities and differences between academic expectations and standards: “At first I was intimidated because the students from Jamaica were able to recall memorized information. I thought they were all incredibly smart to remember all the details... then as time went on I realized that we have learned the same information but in different ways. I was able to help the Jamaican students learn and understand some nursing processes”. [Visiting student]
3.7. Ethical considerations Ethical approval was obtained from both the provincial Health Research Ethics Board in Canada and the ethics board in the partnering educational institution in Jamaica. All potential participants were assured that their participation was completely voluntary, and that they had the right to withdraw without prejudice. All students were assured that non participation would not affect their academic standing. Researchers did not give the clinical evaluations or assign grades to the participating Canadian students or have any involvement with evaluation of host students. Focus groups and interviews with the Canadian students occurred after final grades were received for the semester in which the clinical experience occurred. Focus groups with the Jamaica students occurred privately, without the presence of host faculty from the participating educational institution in Jamaica. Confidentiality was maintained with both focus groups of host students and faculty. Interview data and transcripts were de-identified. The researchers advised that identity of participating students or faculty would not be revealed and all measures would be taken to protect privacy and confidentiality.
Faculty also engaged in knowledge sharing and compared educational approaches to teaching/learning within clinical and classroom settings. Findings indicate that mutual gains in educational approaches were also noted for host faculty. “There was a day where I was quizzing some of my students and the Canadian faculty participated in it and asked some beautiful questions that brought out information and that pulled out more from me as a faculty. It inspired something else in my brain and that was beautiful as well”. [Host faculty] Host faculty also engaged in the teaching/learning process with the Canadian students in all learning settings. Mutual value of these intercultural teaching learning experiences was noted by both visiting students and host faculty: “She [Canadian student] was very intimidated and afraid of engaging in this experience however when it was over she felt empowered and enabled as a student nurse….it solidified her confidence in her knowledge base and ability to work under pressure with this alternate style of teaching with faculty from a different country”. [Host Faculty]
4. Results Four central themes emerged that reflected mutual benefits to both host and visiting students during international clinical learning experiences. Results are described under these themes with quotes to illustrate findings (see Table 1).
In the two month post-experience focus group, visiting students remained mindful of differences primarily in approach to patient care, roles and status of students in the health facility, and in the educational setting. Participants agreed that despite notable differences, similarities prevailed and benefits were gained through knowledge sharing in clinical, lab and classroom settings. The end result from all participants was that they learned to respect differences and value diversity.
1.) Mutual knowledge acquisition in recognition of differences and similarities Host and guest students frequently compared nursing knowledge and practices during collaboration. Initial discussions mostly focused on disparities between the two health care systems. Students also frequently discussed variances noted between nursing and health care practices including: infection control measures, asepsis procedures, limited availability of health care resources such as dressing supplies, nursing procedures, pain management practices, limited availability of
2.) Reciprocal awareness of cultural diversity All participating students reflected on enhancements in their cultural awareness after engaging in this clinical experience. Canadian students recognized cultural variations in how health situations were approached that greatly differed from their ways of thinking. Variations 3
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Table 1 Common themes and indicative quotes. Themes
Indicative quotes
Mutual knowledge acquisition in recognition of differences and similarities
“The main thing that was different was the resource situation. We had to do everything manually, in your culture [Canada], they are pre-packaged, pre-made…everything is a one-time use whereas we have to sterilize and go back again” [Host Student]. “…they [Jamaica students] can be pretty good critical thinkers. It taught one how to critically think in a situation with lack of resources. By the end of the rotation, my perception had completely changed. I learned so much. I feel determined to bring what I learned to clinical with me” [Visiting Student]. “We were doing a procedure where we had a Canadian student participating. I realized that everything she thought she was going to do for the patient, she informed her. She called the patient by name and she talked during the procedure. I find that their communication is very good”. [Host Student] “…your interactions and therapeutic touch with the patients is much more than our interaction. Close, very close” [Host Student] “I feel that we [Canada] do more to get to know the patient. There were clearly cultural differences in how we communicated with the patient”. [Visiting Student] “The hospital was so much different than ours, there was no air conditioning, there were strong odors in some units of the hospital, and patients were placed in large wards, sometimes up to 10 in a ward”. [Visiting Student] “….if we want to become a better form of ourselves we must start with learning about how we tick and react to circumstances”. [Visiting Student] “…I was aware the Canadians were coming however initially I was a bit skeptical because of the difference in culture…in countries, the different medical devices ….I was a bit skeptical thinking that they would look down and be scornful….but when they came I realized that they didn't really look down on us and then we were able to share information and knowledge…..They aided me in the sense where I fell short, they helped me. I learned a lot and it was great having them”. [Host Student] “The friendship has not ended with the visit, so I am looking forward to the continued relationship with the Canadians”. [Host Faculty] “What I realize is it is as if we have known you for years, we have built this relationship, we laugh, we talk, we share the same views and have similar views”. [Host Student]
Reciprocal awareness of cultural diversity
Transformation during the adjustment process
The value of partnerships and collaboration
and find our place in this exchange” [Visiting Student].
between communication and relational skills were also primarily attributed to cultural differences:
In addition to the physical surroundings, students also became challenged when exposure to clinical situations created moral and ethical dilemmas. Clinical situations that created ethical dilemmas but also created opportunities for personal transformations included bearing witness to pain and suffering. Visiting students struggled with not having readily available and advanced pharmacologic methods of pain control. Additionally, visiting students struggled with knowledge of health situations whereby due to lack of availability of resources, treatment options were limited and as a result patient health outcomes were less favorable. Visiting students struggled as they recognized the health outcome would be different in their familiar resource wealthy health care system. Visiting students continued to describe the process as an “emotional roller coaster” with highs and lows each clinical day. They spent evenings debriefing in attempts to assign meaning and perspectives to create newly formed worldviews:
“Culturally the birth was very different from what happens in Canada. In Jamaica it was very stoic which was different from what I had imagined. Physiologically giving birth is the same experience in Canada and Jamaica however it was very surprising to see the variation in the social and emotional experiences”. [Visiting student] Differences in communication styles were also attributed to cultural variations between both host and visiting students. A host student reported: “I noted differences in terms of personal space. Canadians are very close, in our culture we tend to seek to secure our personal space”. All participating students agreed that mutual collaboration during intercultural exchanges allowed for enhanced cultural competence. With repeated intercultural interactions in a variety of learning environments, both host and visiting students noted they had a better understanding of each other's cultural beliefs, values and practices by the end of the experience. The consensus from the Canadian students was unanimous and accurately reflected with this comment:
“To reflect and critically analyze myself…it is the most productive thing we can do to grow and learn from our experiences”. [Visiting Student] Findings indicate that exposure to these experiences reinforced long term learning and highlighted the transformative impact of the international clinical experience. During the post-experience focus group, visiting students remained changed personally and professionally:
“…going to Jamaica provided ample opportunity to understand the importance of culture and allow myself as a nurse to quickly adapt to a new environment which is in my opinion a priceless nursing experience”.
“This experience made me a better person, a better nurse....I learned to take the experiences gained in a resource limited setting and now for example, I am more cognizant of the supplies I use in clinical back here in Canada”. [Visiting Student]
3.) Transformation during the adjustment process Visiting students agreed that finding their place in the clinical experience was an adjustment. Emotions were compared to a ‘roller coaster’ with excitement during the initial days, while anxiety and cultural shock prevailed over the next several days. Reflective learning and transformative processes began only after the initial adjustment period. Experiences that required adjustment included the physical surroundings as well as exposure to clinical circumstances that challenged students to address personal assumptions and biases.
4.) The value of partnerships and collaboration There is considerable value in academic partnerships between host and visiting nursing education programs. Participants agreed that a valuable friendship and mutual understanding had developed after a short two-week clinical learning experience. The development of a mutual partnership not only enhanced participant's knowledge of nursing, but also aided in understanding the impact of culture on health beliefs and practices. Faculty also expressed knowledge and mutual
“Everyone was on sensory overload and it took a while to fully adapt 4
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Underwood et al., 2016). Underwood et al. state that it is imperative for attending faculty have an awareness of local socio-economic, cultural, and political factors that challenge the host community as it is a vital part of preparing students to work sensitively with the community members. Findings from this study support that reciprocity between host and visiting participants as mutual collaborative partners must be respected. Collaboration must entail that visiting partners respectfully work with and fully appreciate the culture in order to enhance the learning experience. One way to promote this is to develop a close partnership and appreciate the knowledge provided from the host partner. Host partners can offer perspectives from a cultural lens to aid in understanding and acceptance of differences in cultural practices. An appreciative approach honors the expertise of the local leaders and values them as co-faculty (Underwood et al., 2016). Participation in the unique experience of an international health experience also broadened the cultural lens of host students. Intercultural dialogue and collaboration provided understanding of health care systems that vary greatly in resource availability. Host students noted a process of cultural adjustment towards the visiting students however it was not to the same degree because adjustment to a different health care setting was not required. Host students in this study were asked about challenges of having visiting students assigned to them in the clinical setting. Challenges included timing of the placement as it was close to their examination period and extra demands placed on the student's time. Frequent discussions and explanations of practice or answering questions from visiting students interfered with their ability to complete nursing responsibilities in a timely manner. However, host students reported that the benefits of having the visiting students outweighed the challenges.
respect for experiencing and learning alternative teaching styles as well as having a broader sense of how cultural variations influence academic settings. Host students also felt empowered and valued as co-teachers: “We brainstormed about the care plans together and the following day, she [visiting student] was taking the history, it was like she was more with it.” [Host student] In addition to working collaboratively at the bedside, close personal friendships developed. “….having the Canadian students around me helped me to see the brighter side of life….they were perky and confident, optimistic and motivating”. Another host student agreed and stated: “Instead of coming to clinical area every morning feeling weighed down, I actually looked forward to the interaction because it made the work feel lighter”. Supporting and positive comments from host participants indicate there is value and benefit for all parties if mutually agreed upon objectives are developed. 5. Discussion 5.1. Implications for visiting partners The findings of this study were consistent with previously published studies that found a multitude of benefits of international placements for visiting students. Visiting students in this study reported gains in knowledge acquisition, improved cultural competency as well as personal and professional transformation. As the adjustment process occurred, enhanced thinking processes began to surface for the visiting students. Consistent with the findings of Browne et al. (2015) and Gower et al. (2017), regular debriefing sessions focused on the differences in health care resources and allocations, however visiting students in this study were also able to process the health disparities and assign a positive outcome by recognizing that health care quality was not only about healthcare constraints and that critical thinking and creativity can overcome some shortfalls in resources. One primary role of attending faculty is to facilitate student personal, professional growth and support the transformative learning process (Gower et al., 2017; Maginnis and Anderson, 2017). Faculty must validate students' feelings and emotions, and engage the students to reflect, analyze and make sense of their clinical experiences. Allowing students the time to debrief, and self-reflect is critical to process the experiences of learning from different cultures and health care systems.
5.3. Implications for future practice The findings from this study provide insight into the host partners views of having partners from a more developed country practice within their healthcare system. It was determined that a global perspective of nursing and health care was gained by all participants in this study. These findings could impact how international placements are organized in the future to provide mutual learning opportunities for both the visiting as well as host partners. Reorganization of objectives for an international experience to include collaborative goals will lead to stronger partnerships while mutual cultural understanding is gained. 6. Conclusion In an effort to create global citizens and provide development of reciprocal cultural competency, offering opportunities for both visiting and host students and faculty members to gain unique perspectives through lived experiences during a collaborative international clinical learning experience is required in nursing education. Mutual benefits and learning occurred for visiting as well as host partners in this study. Collaboration between the partners promoted mutual cultural sensitivity, cultivated respect for diversity, enhanced awareness of health disparities and different health care systems, promoted critical thinking regarding complex health issues in resource limited settings, and supported the delivery of culturally competent care. The value of international partnerships therefore cannot be underestimated. To better understand the reciprocal learning and mutuality that occurs amongst visiting and host nursing students and faculty, more opportunities for intercultural exchanges and dialogues must be offered within nursing education.
5.2. Implications for host partners Limited research has studied the perspectives of the hosting partners in international clinical experiences. The findings from this study correlate with Bvumbwe (2016) and Underwood et al. (2016) studies that highlight the unique role host partners have in expanding the avenues for reciprocity during international clinical experiences. Reciprocity for host partners was gained through collaborative knowledge sharing of cultural, health and education practices. The host partners played an important role because development of a reciprocal relationship was garnered through open dialogue and acknowledgment of each other's contribution to mutual learning. Underwood et al. (2016) study supports that a successful international partnership is gained through “cultural bridging, collaboration, capacity building, and mutual goal setting” (p.354). Studies of host partner perspectives also acknowledge the value of collaboration between visiting and host faculty through the building of a successful partnership for future collaboration (Bvumbwe, 2016;
Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not for profit sectors. 5
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Ethical approval
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Ethical approval was obtained from both the provincial Health Research Ethics Board in Canada and the ethics board in the partnering educational institution in Jamaica. Declaration of competing interest There are no conflicts of interest to disclose. Acknowledgements The authors thank Patricia Grainger for her guidance, support and expert advice throughout all phases of this study. We also acknowledge the contributions of research assistant, Julia MacDonald for transcribing the data. The authors also wish to thank the students from Canada and Jamaica as well as faculty for their eager involvement and participation in this study. References Browne, C. A., & Fetherston, C. M. (2018). How do we facilitate international clinical
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