Studying abroad: A multiple case study of nursing students’ international experiences

Nurse Education Today (2008) 28, 981–992

Nurse Education Today www.elsevier.com/nedt

Studying abroad: A multiple case study of nursing students’ international experiences Barbara F. Green a,1, Inez Johansson b, Megan Rosser Cassam Tengnah c, Jeremy Segrott d

c,*

,

a

Tusculum, Hopton Lane, Alfrick, Worcester, United Kingdom }nko }ping, Sweden School of Health Sciences, University of Jo c School of Health Science, University of Wales, Singleton Park, Swansea SA2 8PP, United Kingdom d Cardiff Institute of Society, Health and Ethics, Cardiff University, 53 Park Place, Cardiff CF10 3AT, United Kingdom b

Accepted 18 June 2008

KEYWORDS

Summary This paper examines the experiences of nursing students undertaking an international placement during their pre-registration education. The study took place in two schools – one in the United Kingdom, and one in Sweden. The move of nursing education into higher education enabled students to participate in international exchange programmes. Previous research demonstrates that students participating in such programmes may gain enhanced cultural awareness and experience personal and professional growth. The study comprised a multiple case study, utilising semi-structured individual and group interviews and documentary analysis. Eighteen students from the UK and 14 from Sweden participated. Participants described an increase in confidence, self-reliance and professional knowledge and skills resulting from their international placement. There was an awareness of how healthcare roles differ between countries and a change in attitudes to others from different backgrounds and cultures. The differences between the two cases were marginal. Whilst there was support from both home and host universities this varied between the international placement providers. The international placements were beneficial; however, there is a need for change in the preparation, support and monitoring of students, greater engagement with the partner institutions, and more effective mentoring of staff. c 2008 Elsevier Ltd. All rights reserved.

International exchange; Nursing students; Case study



* Corresponding author. Tel.: +44 1792 602115. E-mail addresses: [email protected] (B.F. Green), [email protected] (M. Rosser). 1 Tel.: +44 1886 833083.



0260-6917/$ - see front matter c 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2008.06.003

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Introduction Following the move of nursing education into higher education in Europe and elsewhere in the world opportunities were opened for staff and student international exchanges. A 12-year collaboration between two nursing schools (one in the UK and one in Sweden) has enabled student nurses to undertake a placement in international partner institutions as part of their educational programmes. The decision to undertake this research arose from limited information on assessing the benefits of an international placement from the United Kingdom and Swedish student perspective, the need for evidence to inform policy and practice, and a desire to add to the body of knowledge in this field of study.

Background The desire for co-operation in the field of education by European member states is embedded in the Treaty on European Union (European Commission, 1995). Article 26 of this treaty features actions aimed at contributing to quality education through co-operation. These include the development of a European dimension in education, promoting student mobility, and striving for recognition of study abroad. These actions are realised through the Socrates-Erasmus programme which aims to increase access to learning opportunities within the EU, promoting a sense of shared European identity. It provided the main resources and framework for enabling study abroad to be incorporated into educational programmes in the two collaborating institutions in this study. The Swedish institution was also able to extend the opportunity for travel for their students to countries outside Europe. Nursing shares common beliefs and values that go beyond the boundaries of individual countries. Whilst the roles and tasks performed in different countries may differ there is a constant in the idea of promoting health and contributing to the care of patients and their relatives. Different approaches to care can be enlightening and lead to exploring alternative ways of delivering healthcare. A belief in this strengthened and underpinned the commitment from the two collaborating institutions to provide opportunities for nursing students to learn about nursing in a wider context. This would satisfy the aim of enhancing the development of student nurses’ cognitive skills, personal growth and an appreciation of different forms of healthcare delivery in a rich learning environment.

B.F. Green et al. A literature review was undertaken to gain insights from others into the benefits of international placements (Button et al., 2005). It identified professional and personal development and greater understanding of healthcare provision in other countries amongst nursing students undertaking international placements. Also reported was a better understanding of cultural differences and the need to acknowledge this in the delivery of healthcare. In Passport to Mobility, Learning Differently, Learning Abroad, the European Commission’s Directorate-general for Education and Culture (2001) states that personal mobility is a factor in the Union’s goal of becoming a knowledge society. Large numbers of European students have participated in education and language programmes, and there is a continuing commitment from the EU to improve language preparation to support mobility. It was against the background of European support and the sympathy with European ideals, coupled with the notion of studying in a more diverse educational setting with the potential for acquiring enhanced knowledge and skills that the current study took place.

Methodology and methods Aim The study explored the experiences of nursing students participating in international study programmes organised by a school in the United Kingdom (UK) and a school in Sweden. This involved exchanges between these schools and placements in other countries such as Norway, Denmark, Spain, Holland, USA, South Africa and Hong Kong.

Design Case study methodology was chosen due to its suitability for exploring contemporary events both in terms of processes and outcomes (Yin, 1994). It also lends itself to the use of multiple methods. Individual and group semi-structured interviews and documentary analysis were utilised. The study comprised two cases – the international exchange experience of a UK school and that of a Swedish school. The Swedish institution incorporates nursing within a multidisciplinary school of health science. Its university has 9000 undergraduate students, of which 600 are pre-registration nursing students. The University seeks to provide excellence in

Studying abroad: A multiple case study of nursing students’ international experiences specific focus areas, to have an international orientation, to co-operate with the surrounding society, and to build a strong academic environment in which academic schools work together. The University has 63 international partnerships worldwide. International collaboration is an integral part of the Nursing Department’s activities, with partner institutions in countries including Norway, Wales, USA and Hong Kong. The goal is that all students who meet the requirements for studying abroad should be enabled to do so and that 15% of students graduating from the School will study abroad for at least 10 weeks (School of Health Science action and quality plan 2004–06). The commitment to the international exchanges is underpinned by the Swedish Higher Education Act (2006) which calls for recognition of the educational value of students studying abroad. The UK institution is part of a University with similar principles. Its strategic plan includes a commitment to supporting international research collaboration and the Bologna process.2 The University has a student population of approximately 10,000, of which 800 are pre-registration nursing students. In 2004–05 the University supported 80 Socrates students who visited institutions in 16 countries. The UK School includes nursing education in its range of programmes. It has international collaboration with Sweden, the Netherlands, Germany, Denmark, Norway, Finland and Spain. Both schools were mindful of their duty of care to international placement students. This was manifest in the selection and preparations process and ongoing monitoring of students. In both schools students were recruited by advertising the opportunities on notice boards and through oral presentations to the student body. Selection took place through individual interviews where the interviewees were required to present a piece of written work justifying why they should be selected and what they expected to gain from the opportunity. Preparation for the visits was undertaken through individual and group meetings, where details of the placements, the objectives to be achieved and the lines of support and communication were discussed. Information packs and reports 2

Universities UK’s Europe Unit describes the Bologna Process as ‘‘an intergovernmental initiative which aims to create a European Higher Education Area (EHEA) by 2010 and to promote the European system of higher education worldwide.’’ Its objectives are ‘‘to remove the obstacles to student mobility across Europe; to enhance the attractiveness of European higher education worldwide; to establish a common structure of higher education systems across Europe, and; for this common structure to be based on two main cycles, undergraduate and graduate.’’

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back from students who had visited the placements previously were made available. Similarities in approaches arose from agreements achieved between potential collaborators prior to committing to the international placement scheme. Both schools that participated in this research designated a lecturer with responsibility for managing and co-ordinating the placements. In the UK this person was supported by a team of lecturers and administrators who were answerable to an international steering group comprising other lecturers and senior staff. In Sweden the international co-ordinator was accountable to the head of department. All students were allocated a link lecturer from their home school and in some instances from their host school. They were also allocated a clinical mentor if their placement involved clinical experience. Communication with the home university was supported by telephone contact, email and teleconferencing where this was available. A requirement of the placement was the preparation of a report which they were invited to present to other students and lecturers.

The research process The research was designed and undertaken in a systematic and rigorous manner as demonstrated in Fig. 1. Two important aspects of this are the link with the research question to the tools, the analysis and the final paper and the efficiency of tracking the data.

Sample The sample comprised a convenience sample of 32 participants who had undertaken an international placement during their preregistration nursing education programme. 18 were from UK and 14 from Sweden. The duration of the visits for the UK participants was 12 weeks. The duration of the visits for the Swedish participants ranged from five to 20 weeks. Age, gender, location and date of placement and status at interview are featured in Table 1.

Ethical considerations This research was conducted with due regard to the ethical principles advocated by the International Council of Nurses (2000). It was necessary to be mindful of this because of the potential vulnerability of the participants in respect of their continued relationship with their host institutions. Participation was entirely voluntary; participants were assured that a decision not to partake would not have any detrimental effect on current or future

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B.F. Green et al. Research Question Conceptual Framework Review of literature

Development of research tools

Ethical principles Selecting the sample Data Collection Face to face interviews

Group interviews

Telephone interviews Researcher’s notes Data processing

Audio tapes

Reflective

Field Transcriptions Eye balling data

Coding the data Identification of categories

Devising a framework Entering data Data immersion

Revising framework

1st stage analysis

Differential data by host institution and subjects

Validity checks

2nd stage analysis

3rd stage analysis

Inter-rater reliability checks Producing charts and diagrams Identification of themes

Emergent stories

Theme relationships

Themes and sub-themes

Written drafts

Figure 1

Final paper

Overview of the research process based on figure 13.1 Miles and Huberman (1994).

Studying abroad: A multiple case study of nursing students’ international experiences Table 1

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Demographics of the sample

Participant

Age (at placement)

Gender

Placement location

Placement date

Status at interview

UK 1 UK 2 UK 3 UK 4 UK 5 UK 6 UK 7 UK 8 UK 9 UK 10 UK FG 1 UK FG 2 UK FG 3 UK FG 4 UK FG 5 UK FG 6 UK FG 7 UK FG 8 SW 1 SW 2 SW 3 SW 4 SW 5 SW 6 SW 7 SW 8 SW FG 1 SW FG 2 SW FG 3 SW FG 4 SW FG 5 SW FG 6

21 30 22 20 20 27 32 29 26 22 20 49 35 29 24 37 19 19 28 23 25/28 22 29 24 23 30 22 28 23 22 22 22

Female Female Female Female Female Female Male Female Female Female Female Female Female Female Male Male Female Female Female Female Female Female Female Female Female Female Male Male Female Female Female Female

Sweden Sweden Sweden Holland Sweden Sweden Holland Sweden Spain Denmark Denmark Sweden Spain Sweden Finland Finland Sweden Sweden Wales USA Wales/Denmark Finland Denmark USA Pakistan South Africa South Africa South Africa Wales Wales South Africa South Africa

1996 1998 1997 1998 1998 1997 1997 1997 1998 1998 2002 2001 2002 2001 1998 2002 2003 2003 1998 2000 1993/96 1999 1997 1998 2000 1999 2002 2002 2002 2002 2002 2002

RN RN RN RN RN RN RN RN RN RN PRS PRS PRS RN RN PRS PRS PRS RN RN RN RN RN RN/Midwife RN RN PRS PRS PRS PRS PRS PRS

RN = registered nurse and PRS = pre-registration student.

education experiences. They were informed verbally and in writing of the purpose of the research and assured that their anonymity would be protected. Ethical approval was obtained from the UK School’s ethics committee. In the Swedish School, the study was scrutinised by senior researchers (as is the custom and practice).

Data collection and analysis Ten individual interviews were conducted by the UK school and eight individual interviews by the Swedish school in 2002/3, using a semi-structured interview guide. Three group interviews with a total of eight participants were conducted by the UK School and one group interview with six participants by the Swedish School. Documents from both schools were analysed, including preparation material for students, minutes of meetings, strategic plans, and student placement evaluations. The

data collection tools were designed by the researchers from both institutions, thus ensuring that the data collection was consistent and comparable. Qualitative content analysis techniques were used to identify emergent themes from the data. Core constructs were produced from the data through a systematic process of reduction and analysis (Priest et al., 2002). An analytical framework for the analysis of the individual and group interviews was devised and used by all researchers, through an examination of three of the interview transcripts to identify emerging categories. This formed the basis for an analytical framework which was used to examine the remaining transcripts. Included in the analytical process was a form of inter-rater reliability through peer review of the emerging categories. The documentary analysis also produced a number of themes and categories which, after further processing, were matched

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B.F. Green et al.

Table 2 Analytical framework themes and sub-themes

demonstrating

Themes and sub-themes

Aspirations and values

Aspirations and values: Expectations, opportunities, influences, values of experience Personal development: Confidence, personal enrichment, relationships Professional development: Theory: practice, healthcare systems, skills acquired, roles Enablers and disablers: Stressors, language, support, preparation Culture: Cultural engagement, cultural differences, culture shock

with the themes from the interviews. Five themes emerged from the analysis of the individual and group interviews and documentary data (see Table 2). From the constant reworking of the data from all sources it emerged that the themes were not mutually exclusive but were intermeshed. For example ‘aspirations and values’ were complementary to ‘enablers and disablers’ and ‘personal and professional development’ were inextricably linked and interfaced with the previous two themes in terms of expectations and opportunities provided. The placements were grounded in the culture thus this theme was pervasive overall (see Fig. 2).

Findings and discussion Eighteen of the participants had UK nationality and 14 had Swedish nationality, the Swedish on the whole were younger than their UK counterparts and more of the UK students had dependants. The age of the participants at the time of the placements ranged from 21 to 49, the ratio of male: female was 1:5. Whilst there were students of different ages and genders no significant differ-

3

2 1

1: Culture 2: Aspirations and values 3: Personal development

Culture 4

4: Professional development 5 5: Enablers and disablers

Figure 2

ences between the experiences of students in these different groups were reported.

The mutual constitution of the five themes.

This theme captures participants’ expectations prior to the placement, the opportunities and influences that they experienced during the placement and their estimation of the value of the experience afterwards. This is supported by post-visit evaluations and other documents. Participants from both the UK and Sweden anticipated that they would be undertaking something outside of their ‘normal’ experience, (this notwithstanding that the Swedish students were mostly well-travelled). They were not under the illusion that everything would be perfect or without problems. Some of them were looking forward to the challenges of venturing into the unknown or building on previous travel experiences. They had seized the opportunity, recognising that this would be a once in a lifetime opportunity and different from other options for travel. As one UK participant suggested, ‘‘You don’t experience real life . . . as a tourist’’ (UK FG4). The participants’ experience extended beyond curiosity; there was an expectation of symbiosis between the experiences gained and their practice, and the wider circumstances of their lives. A number of participants from both schools envisaged that the international programme could improve their career prospects through helping them to get job interviews, giving them an edge over other applicants, impressing employers and colleagues, or providing a useful preparation for future plans to work abroad. One UK student thought that ‘‘it might stand out on an application form’’ (UK6), whilst a Swedish participant commented that ‘‘I will probably be better paid. It had a positive influence on my career’’ (SW3). Influences on the students to take advantage of the international placements were from family, friends and colleagues or because they had previous experience of travel or expectations of working abroad in the future. Despite some difficulties, all of the students valued their international placements highly, describing them as enriching and enlightening. One UK student felt that the experience had changed her life, whilst one of the Swedish participants suggested that it was ‘‘the best thing I have ever done’’ (SW2). Another Swedish student said that the time spent abroad meant so much to her that she now described her life in terms of ‘‘before and after . . . Before I just used one eye, and then you lose a lot, but if you open both eyes you’ll

Studying abroad: A multiple case study of nursing students’ international experiences see a lot more. I learnt to see with both eyes.’’ (SW6). Whilst the overwhelming response to the experience was positive, negative comments were made with respect to the actual placement or country visited, the experience offered and the loss of social contacts from home. The enthusiasm shown by the participants for the opportunity to travel abroad and their determination to make a success of this despite the challenges faced was undoubtedly a factor in the beneficial impact this had on their lives and careers.

Personal development Changes appeared, for most students, to have occurred at a personal level. Students coped in a new country, despite challenges such as homesickness, and problems with accommodation. This engendered a sense of personal development and bolstered students’ confidence: ‘‘It totally enriched me and gave me a completely different outlook on life, you know. I was privileged’’ (UK FG2). Students reported a sense of achievement that they had lived and worked in a different country, prompting thoughts about future possibilities. There was a sense that this new confidence had a lasting effect and might influence subsequent personal and professional decisions: ‘‘I gained a lot of confidence from going because it was like ‘Oh I can do this. I organised it. I’ve done it ... I travelled and everything . . . If I can manage in a strange country I can manage in another city in this country.’’ (UK FG1) The international experience was also enriching because it fostered long term personal relationships, friendships which persisted beyond the placement. These student experiences and related increased confidence have been explained in previous studies as the untapping of previously untested inner resourcefulness, enabling students to cope with new experiences in a foreign country (Thompson et al., 2000; Lee, 2004).

Professional development Students reported professional development of knowledge and practical skills, and an increased awareness of differences in healthcare practice, and nurses’ role. Differences in practice and education were observed. Not all differences were viewed positively and whilst students did not condone poor practice they expressed a need to conform, possibly feeling compromised by their visitor status:

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‘‘Not the proper handcuffs but they were restrained, . . . if the same thing were to happen here, there would be such a . . . public outcry . . . You don’t criticise what people seem to ... what’s their culture. You know, ‘when in Rome do as the Romans do’.’’ (UK FG5) (meaning follow the customs and practice of the country visited) Conversely, some practices were viewed extremely positively – such as references by UK participants to infection control: ‘‘What I thought was excellent was [nurses] . . . go to the hospital in their own clothes, get changed into their uniforms and then at the end of the shifts get back into their own clothes and the hospital would clean it . . . Here . . . you find some nurses in the supermarkets and that could be after their shifts, so goodness knows what’s on that uniform.’’ (UK FG7) Most of the learning that facilitated professional development was experiential. There was often minimal formal teaching in the university, although students had access to university facilities. The alternative learning experiences of some students enabled them to approach the rest of their training differently. Students reported impressions of the healthcare systems at home and in the host country. Different attitudes towards patients and their care were observed. One UK participant felt that ‘‘patients are much more responsible for their own medications . . . they give them all more responsibility’’ (UK FG4). Differences in status and autonomy were noted: ‘‘Their nurses have much more power, more autonomy, they do a lot more, they’re much more professional in their abilities and looked upon as more professional.’’ (UK 5) Equally different nursing responsibilities were observed by students from both schools: ‘‘the nursing system is very different there, and like a staff nurse wouldn’t be expected to wash a patient or do any ‘hands on’ with the patient the under nurses do all the hands on care.’’ (UK2) ‘‘they work differently from what we are used to – only one category of nurses on the ward and they gave more attention to the patient.’’ (SW5) Some participants gained new insight into the possibilities of multi-disciplinary working, including differing perceptions of nurses. UK nurses realised

988 that interprofessional relations could be very positive and a strong multi-professional, patient-centred approach to care promoted: ‘‘It wasn’t demeaning for a doctor to fill in a form . . . as long as someone did the job that was the main thing that concerned them.’’ (UK8) Participants identified the development of technical, cognitive and interpersonal skills during their placement. UK nurses valued the opportunity to develop new, technical skills whilst the Swedish nurses spoke about developing other skills and reflecting upon their approaches to care: ‘‘nurses allocate more time to the patients and less on paperwork and they have less technical responsibilities.’’ (SW1) Becoming immersed in the healthcare of another country appears more beneficial than receiving formal taught education about the care provided (Duffy et al., 2005). The resultant experiential learning served to affirm some existing practices but also prompted students to review and change their practice ( Lee, 2004). The need to remain silent when observing ‘poor’ practice was echoed by another group of students, reluctant to offend their host practitioners (Koskinen and Tossavainen, 2004). Enlightenment about team-working and interprofessional relationships occurred for other UK students, who also reported that nurses were treated more respectfully in other countries (Scholes and Moore, 2000). In previous studies the benefits to professional practice have not been so readily articulated, with greater emphasis on personal growth. However, in this study the themes of professional and personal development are inextricably linked; even when participants were unable to articulate definite development of new skills they still evaluated the experience as worthwhile in relation to personal and professional development. A number of participants expressed a view that their international experience was instrumental in them securing their first post and others intimated that they were planning to nurse abroad in the future. There were examples of transferability of different nursing procedures in participants’ subsequent practice. These included piloting nursing rosters and implementing observation charts.

Enablers and disablers Sending students abroad to study is a huge endeavour, ensuring that they are provided with a safe experience that fosters their academic and per-

B.F. Green et al. sonal growth and affords them freedom to become self-reliant. It is clear from the documentation that both schools intended to work with partner institutions to ensure that the study abroad programme was well planned and managed. For some of the UK students being away from home gave rise to feelings of stress, but as one UK student remarked ‘‘you get used to it’’ (UK6) a finding echoed in work by Ryan and Twibell (2000). Homesickness and loneliness were compensated for by the help and support they were given. The amount of support given to the students ranged from near overprotection to almost total lack of support. An example of the former was the difficulty in persuading clinical staff that it was safe for them to do more than observe and for the latter having very little contact with tutorial staff, both home or host. There were different expectations of the students from host-universities; some expected a high degree of self-reliance. Telephone, email and teleconferencing contacts were useful in maintaining or providing support but can be difficult (McElmurry et al., 2003). Some of the Swedish students visited developing countries where support and resources could be limited so they had to be resourceful and self-reliant. Mentors – whether clinical staff or tutors –, played a large part in ensuring that the participants had a good learning experience. One UK student commented that ‘‘There were some mentors that were exceptionally wonderful’’ (UK1) and the positive influence of mentors for international placement has previously been a recurring theme (Sanner et al., 2002; Koskinen and Tossavainen, 2003, 2004; Duffy et al., 2005). Whilst for the majority of participants, personal safety was not a concern, there were concerns that revolved around the external environment, crime and disorder. Some students from Sweden experienced the society and the political situation in developing countries as unsafe, commenting ‘‘there was political disturbances and things happened in the area’’ (SW7). Button et al. (2005) suggest social support is more important to study abroad students than language proficiency. However, the international experience raised an awareness of the importance of communication and the limitations of not being able to speak in their host country’s language. It was easier for both the Swedish students (who were proficient in English) and UK students to go to English speaking countries. Proficiency in the language of the country visited enables students who study abroad to demonstrate their competence and facilitates their learning (Scholes and Moore, 2000) and enhances their

Studying abroad: A multiple case study of nursing students’ international experiences experience (Duffy et al., 2005). Conversely inadequate communication skills can contribute to social barriers and lead to isolation (Ryan and Twibell, 2000; Koskinen and Tossavainen, 2004). This was supported by one of the UK students who commented that ‘‘without proper communication it was much harder to make the best out of the visits’’ (UK FG5) whether socially or clinically. Language can be a barrier to providing nursing care (Jones et al., 1998). This can be mitigated by the use of non-verbal communication (Haloburdo and Thompson, 1998). Impoverishment by a lack of language ability as identified by Tateyama (2001) also emerged in the study. This was manifest in clinical placements and the limitations on opportunities to be taught alongside host students if programmes were not delivered in English. Acquiring a second language is a formidable task for student nurses who have competing demands (Thompson et al., 2000) and existing high student contact hours. Work overload was a problem for some participants, who had difficulty in meeting both the host’s and home institution’s assignment requirements: ‘‘although I coped with the amount of education or academia that was expected of me with the two courses um, and the assignments back at home . . . I don’t quite know how I did it.’’ (UK FG2) Some students worried that they might be disadvantaged in exam situations on their return through limited study time and resources whilst they were away. None of these worries were realised, all participants were either continuing with their preregistration studies or had progressed to qualification. Some UK participants were worried that their international experience differed from that of their home colleagues. There was an isolated incident where it was suggested to a UK student that she needed to repeat the obstetric experience she had undertaken as part of the international placement (this decision was subsequently reversed). This was not a problem for the Swedish students. They experienced more flexibility regarding their study and practical experience, despite both institutions having to comply with EU regulations. ‘‘The more flexible the programme is the easier it is to arrange the exchange period abroad. The home university has to be very open-minded in what the student is able to take part in and learn from.’’ (SW FG2) Despite the preparation process instituted by the schools preparation for the placement was not always ideal, one UK student commented ‘‘I

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didn’t find it very structured and I think that I would have liked a set of objectives that I had to work through’’ (UK1). Misconceptions, disappointments and problems related to the type and nature of the experience and the workload have also been reported by Ryan and Twibell (2000). Concern about academic requirements from their home and host institution and language difficulties are also reported by Duffy et al. (2005) who state that this reflects institutional problems and student perceptions. Verbal and written preparation for study abroad prior to departure is important (Duffy et al., 2005; Grant and McKenna, 2003; Ryan and Twibell, 2000). Lack of preparation occasions a difficult transition (Koskinen and Tossavainen, 2004). The material prepared for the travellers in the first years of the exchange was well evaluated in the documentary evidence and effective in clearly stating objectives and in providing information on the countries visited, however, this was not regularly reviewed and updated. Conflicting advice given to the participants in this study on the adequacy and acceptability of the study abroad experience was not totally consistent with the principles of student mobility whereby exchange students are supposed to be able to meet their course objectives in the host country (Teichler, 1996). These problems will perhaps be resolved when the Bologna agreement is implemented.

Culture Culture was pivotal in the thematic model that erupted from the data. It was embedded in participants’ experience of engaging with the cultures of the different countries in which they studied, consequently becoming aware of the differences between people. During their international placements all students interacted with people from different cultures and became accustomed to new cultural norms. They gained an increased awareness of differing cultural values which facilitated greater tolerance of others and an understanding of how challenging life might be for members of minority ethnic groups. Such insight was gained from participants’ temporary experiences as a minority group facing the challenges of language and cultural understanding. This new awareness would prove valuable at professional levels, when working with overseas nurses and at a personal level of tolerance of ‘different’ people.

990 ‘‘It is useful to be there in a different culture . . . I can understand immigrants better, especially the women . . . I have experienced this myself and I can understand their situation . . . ’’ (SW8) The opportunity to observe differences between cultures was anticipated by participants and their expectations were realised in general. Participants experienced cultural differences when working in clinical placements, socialising with others and interacting with the wider population. ‘‘I was very interested in culture and cultural differences before I went, and going over there and being part of a multi-cultural group as it was my awareness became even more heightened.’’ (UK FG2) Experiencing different cultures provided some participants with an array of knowledge which could be influential in how they perceived others and their associated cultural values. This enabled them to be more understanding and accepting of cultural differences, especially in healthcare. ‘‘They see things in different ways. They approach things in different ways, so if you have got some background then you can understand where they are coming from as well.’’ (UK7) There were however certain practices that shocked some students. Nudity was a specific concern for UK students, experienced in clinical practice and in their leisure activities in changing rooms at swimming baths. Despite recognising that practices were culturally determined participants perceived some clinical activities as bad practice, with which patients were uncomfortable but had to comply. Participants appeared to believe that respect for patients’ dignity should override any acceptance of cultural norms. ‘‘. . . I remember this one instance which I reflected on and the lady had to strip . . . she only had one breast, and it was in front of the patients and staff and I thought ‘oh that’s awful . . . I thought this was disgraceful and even though it is their culture they could have at least asked the lady ‘would you mind if we took your top off in front of these patients or do you want to be covered’ . . .’’ (UK FG7) Cultural shock was also experienced by Swedish students being exposed to deprivation in a developed country for the first time. They were surprised during placement in the United States of America to observe that some people are very rich,

B.F. Green et al. and can afford to buy care whilst others are poor and unable even to afford their medication. Conversely those visiting third world countries expected a level of deprivation. Evidence of transformative learning as the result of international experience has been highlighted in previous studies (Scholes and Moore, 2000; Duffy, 2001; Duffy et al., 2005). The consequential growth in confidence and personal cultural awareness and tolerance has been reported by other students (Carlson and Widaman, 1988; Haloburdo and Thompson, 1998; Scholes and Moore, 2000; Lee, 2004). Personal experience of being a member of a minority group, albeit for a short time, was for most students a vital antecedent to forming new, enlightened personal cultural attitudes and tolerance (Haloburdo and Thompson, 1998; St. Clair and McKenry, 1999; Scholes and Moore, 2000; Duffy et al., 2005). Conversely a group of students, with less well established intercultural sensitivity, reported that their time abroad served to confirm their native beliefs and behaviours (Koskinen and Tossavainen, 2004), suggesting that students have to be open to new experiences in order to benefit from them, and able to cope with the sense of vulnerability that accompanies many of those experiences.

Conclusion This research has sought to provide evidence to inform policy and practice and to make an original contribution to the developing literature on nursing student international placements. One of the other main insights provided by this study surrounds the importance of managing effectively international placements, both in relation to preparation and support for students whilst they are in the host country. Whereas previous research on international placements has emphasized personal development as a key outcome, participants in our study also spoke of significant professional development and their stories suggested that personal and professional growth shaped each other in complex ways. Another important theme to emerge in the narratives of participants was the complex ways in which they sought to make sense of culturally specific practices alongside perceived ‘universal’ values of nursing as a profession. The results from the two cases are largely consistent with the findings from the literature whereby the beneficial effects of students having an experience abroad enhance their personal growth

Studying abroad: A multiple case study of nursing students’ international experiences and professional development. They are also consistent with the literature findings that such experiences raise the students’ cultural awareness and lead to the development of a multicultural dimension to their lives. The commitment to providing an international experience was more prominent in the Swedish institution and their students have opportunities to visit more countries with greater diversity than the United Kingdom students. However, the findings were similar for both cases although there was a difference in emphasis attributable to programme differences. There was considerable personal and professional development for all participants; many claimed increased confidence and self reliance although this was more marked in the United Kingdom students. There was an enhancement in professional knowledge, technical and interpersonal skills as well as a greater understanding of other healthcare systems and delivery although this was less than anticipated. Participants also demonstrated a greater understanding of roles, relationships and the division of labour between nurses and other healthcare professionals at home and abroad. But perhaps most importantly they had a greater awareness of their own attitudes to others from different backgrounds and cultures and demonstrated greater tolerance and political astuteness. Notwithstanding that some students experienced difficulties, the international experience were very beneficial to students from both institutions. The key aims of the placement scheme of enhancing students’ cognitive skills, cultivating an appreciation of different forms of healthcare delivery and promoting personal growth all appear to have been broadly realised.

Recommendations Whilst participants experienced and acknowledged considerable support from both their home and host universities there was variation in this amongst the international placement providers and there were instances where this was insufficient to meet the needs of some of the nursing students. The shared responsibility with partner institutions to ensure that the study abroad programme was well planned and adequate preparation made was not always realised. There is therefore, a need for change in the preparation, support and monitoring of students, greater engagement with institutions involved in international student mobility and more effective mentor-

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ing of staff. Written information packs for students need to be regularly updated, and feedback sought from placement participants on the kinds of advice and support which they find most helpful. To ensure that the international exchanges are personally and professionally beneficial and educationally viable it is imperative that resources are made available to support the planning and preparation. There are timetable and programme implications, and commitment to the idea of the international programmes from academic staff is essential. An appropriate establishment and infrastructure would facilitate the efficacy and efficiency of managing international exchanges. Grant and McKenna (2003) report positive and negative responses and argue that adequate preparation and support are necessary; there is a possibility of risk. It may be that all institutions engaging in student exchanges should undertake a formal risk assessment and institute risk management procedures. Planning the exchange experience is complex and can be onerous if there are inadequate resources allocated for this. The identification of a dedicated individual to provide administrative support could prevent some of the problems that have occurred in relation to international programmes in the past. Dedicated time from other academic staff allocated to this work could ensure that the objectives are appropriate and in accordance with the programme being studied. International placements enable students to develop both as individual people and as nurses through the experience of engaging with unfamiliar cultures, different health care systems, and mastering new challenges (such as speaking a foreign language). The findings of this study suggest that such changes may be multifaceted and complex, with personal growth impacting on professional development. Further research is needed in this area if we are to fully understand how these changes take place. Such work might also increase current understanding of how best to provide a framework of support which still gives international placement students the freedom and independence to become self reliant and confident practitioners who are open to other cultures and different ways of understanding the world.

Acknowledgements To Lori Button for her invaluable contributions and to all the students who participated in the study.

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