In recent years, globalization has resulted in greater mobility, social interdependence, and electronic interconnectedness between countries, especially among professionals in the health care sector (World Health Organization, 2007). More than ever before, Australian nurses need to be aware of the impact that migration, culture and diversity have on the nursing workforce and on the patients for whom they care, who are likely to hold a wide range of diverse health-related beliefs and cultural values (Australian Bureau of Statistics, 2011; Caffrey, Neander, Markle, & Stewart, 2005; Kokko, 2011; Mill, Astle, Ogilvie, & Gastaldo, 2010).
Nursing education and policy needs to respond to the changing nature of global health and prepare nurses to work with diverse cultures within their own country and globally (Bradbury-Jones, 2009; Mill et al., 2010). The Ebola outbreak in West Africa in 2014 (World Health Organization, 2014) and other outbreaks, such as the swine flu (H1N1), Middle East Respiratory Syndrome (MERS), and severe acute respiratory syndrome (SARS), have raised awareness of the need for Australian nursing students to be aware of global health disparities, the health needs of other nations, and the social determinants of health (Chowell et al., 2015; Johnston, Rogers, Cross, & Sochan, 2005; Mill et al., 2010; Parker & McMillan, 2007).
Australian nurse educators and regulators recognize that nursing graduates should be capable of providing culturally congruent and safe nursing care. The Nursing and Midwifery Board of Australia (2006) has developed specific competency standards outlining that nurses must tailor their care to cater to the spiritual, cultural, familial, and language needs of their clients in a manner that achieves as positive an outcome as possible for the patient. Aligned with this, the Australian Nursing and Midwifery Accreditation Council standards require universities to provide opportunities for development of cultural competence, with international clinical placements being increasingly included in undergraduate nursing programs in universities. In Western Australia, all four universities providing preregistration nursing programs offer international clinical placements between 2 and 3 weeks in duration in developing countries. Although this study was conducted in Australia, it is applicable to any nursing program worldwide that is seeking to achieve cultural competency goals, particularly those that are engaging in international learning experiences.
International Clinical Placements
Much of the existing literature regarding international clinical nursing placements is written following the placement, with a focus on the professional and personal influences on students and their nursing practice. Studies have found improvements in cultural self-efficacy, self-confidence, assertiveness, and global perspectives (Amerson, 2010; Caffrey et al., 2005; Lee, 2004; St. Clair & McHenry, 1999; Walsh & DeJoseph, 2003). Exposure to cultural differences has enabled students to develop a greater appreciation of and respect for the cultural values and beliefs of others regarding health care (Ruddock & Turner, 2007). Communication skills have also been developed. Where students have experienced immersion in a host country whose official language differs from their own, new methods have been developed, such as a focus on nonverbal communication skills and a commitment to learning a new language (Hagen, Munkhondya, & Myrhe, 2009; Lee, 2004; Watson, 2015).
However, some concerns have been raised about international placements, especially in resource-poor settings. During placements of short duration, the experience may reinforce rather than challenge stereotypes and perpetuate perceptions of cultural differences (Smith-Paríolá & Gòkè-Paríolá, 2006). A lack of cultural competency training for students traveling on placements on the ethical dilemmas they may face in global health may leave them unprepared and at risk of causing harm to host patients and communities and experiencing emotional distress themselves (Pinto & Upshur, 2009).
A lack of structured, faculty-led discussions with students to help them to integrate the experience into their learning and future lives has been identified (Smith-Paríolá & Gòkè-Paríolá, 2006), raising concerns about the sustainability of any perceived benefits (Reimer Kirkham, Van Hofwegen, & Pankratz, 2009). Ethical issues must also be considered regarding the transfer of nursing theories and models from high-income countries to developing countries (Mill et al., 2010). This can be accomplished by reflecting on how the care provided may affect others and on the possibility of these placements becoming clinical tourism, where the focus is on exposure to different cultures and unique clinical situations for students without consideration of local needs and structures (Levi, 2009; Pinto & Upshur, 2009).
In light of these concerns, it is important to review the motivations and expectations of nursing students undertaking international clinical placements. Only one study has been identified, in which nine students intending to travel on international placements from two Canadian universities were interviewed to explore their motivations for applying for the placement, their expectations of, and their understandings of global citizenship and social justice (Burgess, Reimer Kirkham, & Astle, 2014). Students' global awareness had been stimulated by interested family members, university teachers, media, and faith and led them to develop a desire to move beyond awareness to having actual global engagement through participating in an international clinical placement. This motivation to travel on international placement was fuelled by prior travel experiences, a desire to experience a different culture, and perceived personal and professional benefits. Students' expectations of the global engagement included a well-meaning wish to teach and help host nationals and to learn about a new culture. An expectation that they would be outside their comfort zone, both culturally and as related to resource levels, was revealed, and students viewed the experience as a potential testing ground for future international nursing work. Overall, understanding of social justice issues, the social determinants of health, and how they related to the pending placement was lacking. This included a sense of fatalism that conditions in these countries would remain unchanged (Burgess et al., 2014).
Themes that emerged from studies exploring the motivations of students from other disciplines, such as medicine, and physician-assistant seeking international experiences included family encouragement, previous travel abroad, interest in learning about diverse cultures, a sense of altruism, and personal challenge (Luce, Stewart, & Davison, 2007; Pan, 2012; Sarfaty & Arnold, 2005). Wehbi (2009) cited similar motivations for social work students. However, a dearth of evidence remains on nursing students' motivation to volunteer for such an experience and their expectations. The Canadian study (Burgess et al., 2014) that examined students before departure had a small sample size, and other studies collated their evidence after students returned (Luce et al., 2007; Pan, 2012).
This study examined the motivations and expectations of undergraduate nursing students from four Western Australian universities undertaking international clinical placements in the final year of their nursing degree.
To maximize the benefits in the host setting and minimize any possible harm arising from international nursing placements, for both students and the country where the placement takes place, it is important to have an understanding of nursing students' expectations and motivations in applying. In gaining this understanding, nurse educators will be more able to implement effective placements that demonstrate value to both students and the host country and ensure that expectations are realistically tempered.
A qualitative exploratory design (Polit & Beck, 2010) was deemed as appropriate for this study because it allowed the researcher to interpret the social reality of students and describe their lived experiences (Holloway & Wheeler, 2010). A purposive sampling technique was used to identify 66 students in their final year of preregistration nursing programs who had applied for and been successful in gaining a position in the international placement program offered by each university. Students were required to participate in an individual interview and meet minimum grade requirements to be accepted into the placement. Students were asked to describe their reasons for applying, examples of their previous experience with culturally diverse populations, their understanding of the demands of the various settings, how they felt they could contribute, and characteristics of positive team membership. The placements were offered to students as an alternative to a local community placement, where students are required to undertake service-learning in nonhospital settings. Purposive sampling of students with direct experience of applying and preparing for international student placements in multiple settings added to the richness of the data and increased the possibility of developing understandings from multiple perspectives (Graneheim & Lundman, 2004). In-depth, semistructured individual interviews were conducted with students from four Western Australia universities 2 weeks prior to departure to Thailand, India, Cambodia, the Philippines, and Tanzania. Interviews were conducted by the first author over a period of 12 months because the placements occurred at different times of the year. This allowed for prolonged engagement with the data. Interviews ranged in duration from 20 to 75 minutes, were conducted either in person at the students' homes and universities or by telephone, and were digitally recorded. Interview questions explored the themes of students intentions to travel on international placements, student expectations of the health system, their views on cultural competence, and how they expected the experience to affect them professionally. Prompts included asking about their expectations on coping with resource-poor environments and the potential influence on nursing skills and personal growth. Further questions examined aspects of career planning, which are outside the scope of this article. Transcription was completed by the first author (n = 40) and a professional transcriber (n = 12). The first author checked all transcriptions against the original recordings for accuracy, which allowed for further immersion in the data. Transcriptions were read and reread by the first author, which helped in identifying emerging codes.
Qualitative analysis allows for subjective interpretation of text content through the classification of manifest and latent themes into themes of common meaning (Graneheim & Lundman, 2004; Hsieh & Shannon, 2005). In this study, inductive thematic analysis was used to identify the themes from transcribed data from the interviews. Analysis involved three stages of coding that moved from description of the data to the development of themes and ordering of subthemes.
Initially, the codes were descriptive in nature, capturing key thoughts and concepts of both latent and manifest content. This led to the identification of interpretative codes as insights were gained into the processes occurring and meaning could begin to be attached to the statements (Burns & Grove, 1997). Further analysis of the codes revealed links in the meaning and context and allowed for the collapsing of the codes into subthemes. As the study progressed, commonalities of meaning across subthemes and differences between subthemes began to emerge. At this point, themes were developed and clustered, leading to a conceptual overview of the findings (Graneheim & Lundman, 2004). Analysis was done in tandem with the data collection, allowing questions to be refined with subsequent interviews. Any new data that differed from previous findings were explored with deeper questioning of the participant. Themes and subthemes were discussed against the raw data with the rest of the research team prior to interpretations being made final (Holloway & Wheeler, 2010).
An information sheet introducing the researcher and explaining details of the study was provided at information evenings arranged by each university prior to travel to the placement. Interested students voluntarily contacted the researcher and expressed their interest in participating. Written consent was obtained from students who agreed to participate. All students were informed that they could withdraw at any time without compromising their position in the international placement, or in their graduate year. The researcher was not directly involved in providing education to the students. Approval was obtained from the Human Research Ethics Committee at Curtin University. Following this, reciprocal ethics approval was obtained from the other three Western Australian universities students were attending, and permission was obtained from the heads of schools of nursing to access students. Audio files and transcriptions were stored on a secure shared drive at the School of Nursing, Midwifery and Paramedicine at Curtin University.
Of the 66 students identified, 52 agreed to participate. Just under half of the predominantly female students were traveling to Tanzania, with the remainder visiting southeast Asian countries. The majority of the students (n = 29) were in their final semester, although 12 were in only their second year of the course (Table 1). The second-year students had been allowed to apply for the placement program after all interested final-year students had been assessed. The content of the nursing courses being undertaken by the students across four universities was similar, leading to registration as a nurse; however, one university offered a unit in Global Community Health Nursing, which had some content on health in developing countries. To meet the assessment criteria of that unit, students were required to undertake additional assignments while on placement.
Participant (N = 52) Characteristics
All participants were required to participate in a number of preparation sessions conducted by their universities or by the Global Health Alliance of Western Australia, an amalgamation of the schools of nursing of all five universities in Western Australia and the Western Australia Health Department. The sessions covered language, cultural considerations (such as cultural understanding, sensitivity, and safety), clinical safety, accommodation, and itinerary.
Four themes were identified from the data that centred on expectations and motivations: Cultural Learning, Challenge and Flexibility, Personal and Professional Growth, and Gratitude. Each theme had a number of subthemes (Table 2).
Themes and Subthemes Identified in the Pretrip Interviews
Theme One: Cultural Learning
Students revealed their decision to apply for the international placements had been motivated by a love of traveling and an interest in foreign cultures. Students expressed a strong desire to develop cultural knowledge and awareness and expected the greatest cultural learning to come in the form of enhanced communication skills with culturally diverse patients. They anticipated this would be of use in their future work as an RN in Australia, which has a rich sociocultural diversity. Students commented:
• I just want to learn and educate and get an idea for remote and rural health care. But I just expect to gain…knowledge. I'm expecting to learn a lot.
• It will also help me in understanding people that are over here, that are away from their homes and their family who have moved here. Being in such an isolating experience will help me be a bit more knowledgeable and more sensitive to cultural differences.
Cultural Preparedness. There was a strong sense of uncertainty and of being unsure how to prepare for the placement. Students described emotions ranging from excitement to concern. Preparation strategies included Internet searching on the destination culture, speaking to students who had undertaken the same placement in previous years, language learning, and a specific university unit on global community health. Students who completed this unit revealed greater understanding around structural factors such as health systems, political and economic factors, and the value of primary health care.
In some cases, students had decided on a deliberate strategy of not preparing at all, to prevent the development of unrealistic expectations. The need to keep an open mind was particularly important to the students. Most of the students anticipated that they would not begin to understand the culture and context until they were immersed. Students were also anxious not to appear to be imposing their world view on the host culture. Their comments included:
• I don't really know how to prepare and I don't know what to do.
• I am mentally preparing myself for it not to be easy. I don't want to get there thinking it's going to be easy and then not have a good time because I'm stressed. [I am] just preparing myself to go with the flow a little bit.
Theme Two: Challenge and Flexibility
Students expressed a strong expectation that the experience would be physically and emotionally challenging. There was general consensus that “everything would be different” and that it would be “an amazing experience.” Students expressed:
• I'm expecting to be shocked. I'm expecting it not to be easy and expecting to really enjoy it.
• I see this as possibly one of the most challenging things that professionally and personally I can probably do at this particular point in my life.
Resource-Scarce Setting. On a professional level, students expected to be confronted by the low-resource settings they would be working in and that they would need to develop resourcefulness, adaptability, and flexibility to provide care with the resources available. There was a strong sense they would learn these skills from their nursing colleagues in the host countries, who, they anticipated, would be adept at using resources efficiently and creatively. Students' comments included:
• I feel that I'm going to come back and be the MacGyver of nurses, like I could take a blood pressure with a paper clip and a rubber band.
• I think they will be quite good with their resources and those sorts of things and they would make the most of what they have but I think it's going to be… very third world, I suppose.
Theme Three: Personal and Professional Growth
Students clearly articulated the perceived differences between the host country's culture and their own, indicating a desire for cultural experiences that would “open their eyes.” They expected the experience to increase their nursing confidence and knowledge, reaffirm their belief in the nursing role, and build resilience. They also saw the placement as a safe and structured opportunity to confirm their own capacity to work internationally in the future. Students said:
• I think it is going to open my eyes to a lot more health care needs of people of third-world countries. I guess it is easy for us to say what we think they need, but it will be good to actually go there and see what their main needs and requests and wants are to improve their health and well-being.
• I think it will decide whether I really do want to go overseas and live over there for a few years and whether I want to nurse there.
Desire to Help. A desire to help others and to teach local colleagues was salient, with a view that patients in the destination countries were in greater need than those in Australia. Participants thought providing care in those contexts would therefore be rewarding. Although the perception existed that long-term systemic change was not possible over such a short duration, there was a belief that the host patients would be grateful for, and pleased with, small contributions. They hoped their skills would be sufficient to quickly and easily alleviate suffering on an individual level where possible. This desire to “give back” was expanded on, as some students revealed an expectation that nursing in a developing country context would be more fulfilling than working in hospitals in Australia. Their comments included:
• I've always wanted to go [to the Philippines], just to be able to say that you've been able to give back to someone else and this I guess is my personal journey as well.
• And also it'll be cool to help and to make a difference. That's also a huge reason why [I applied]. I wanted to help.
• Here [in Australia], I don't feel as nurses we are much of a help.
• We are going back to the basics, which will be interesting. That is one of the reasons I chose it because most nurses these days rely on machines.
• I don't find nursing [in hospitals in Australia to be] challenging, and I want to be challenged.
• Conditions will be really tough and completely different to what we experience here but I think it will be rewarding and worthwhile.
Resilience. Students expected to confront the challenges they would be facing, becoming more resilient and resulting in improved coping skills. They anticipated these skills would be of use at both a personal and a professional level, stating:
• I expect to be challenged and I expect it to be scary and I expect to be more confident when I come home because of it and to have gained insight. I expect as a whole to have improved transcultural skills and develop resilience because we have to see things that we wouldn't be exposed to normally.
• I think I will learn coping skills…. [Skills learned] probably help me develop not just career wise but as a person as well. Just coping.
Getting Back to Basics. Students expected they would be required to “get back to the basics of nursing,” which was something they were anticipating with pleasure. The opportunity to undertake head-to-toe assessments without technology and to use their observational nursing skills to lead to a diagnosis was appealing to them. Students were hoping to have autonomy in their practice, while working under the supervision of a clinical supervisor within their scope of practice. They commented:
• I think it will really give me a perspective of basic nursing care…[and] the foundations of nursing and how they are so important.
• Things like doing [obtaining a manual blood pressure reading], which you don't really do in hospitals now, and looking at patients holistically is going to be good.
• And I think the head to toe assessment, that'll be good to do. Just to be able to actually try and get information from them to try and work out what their complaints are. [For] all the other [practicums] I've done, people have already been admitted and diagnosed and everything is already done. Where with this we need to do a broader assessment.
New Nursing Knowledge. Students expected to learn new ways of doing things and to be exposed to diseases and acuity they would not experience in Australia. Their comments included:
• Hopefully, they can show us some things. I'm sure they have really crafty ways of doing wound dressings.
• Hopefully, I will pick up a bit of an understanding of some of our diseases that we probably shouldn't see anymore. But we do, and I have a personal hate for malaria.
Theme Four: Gratitude
Nearly every participant expressed an expectation of returning with a heightened sense of gratitude for perceived personal and professional advantages of living in Australia. This included amenities of living, such as running water and electricity, and access to a wide range of comparatively unlimited health resources, consultants, technology, and equipment. One student stated:
I think it will give me an appreciation for what we have and how lucky we are to be able to get everything we really need. Maybe I won't be one of those complaining nurses that complain about money.
On a more intangible level, students expected that the experience of living in a resource-scarce environment would “help them to appreciate the little things in life” and “realize there are bigger issues out there.” There was a strong sense of living in “a lucky country” and a hope that they would no longer take that for granted, as reflected in this comment:
Hopefully, I'll be reminded of what is really actually important. It does really sound clichéd but it's true.
Aligned with the theme of gratitude, there also emerged a belief in some students that people in the host countries would be “happy with what they have got,” which is a concept that was viewed as an admirable attribute and one they hoped to emulate. One student said:
And the people are so friendly, as well, in some countries. I just love…how happy they are with what little they have, so I think that's good.
This study examined the motivations and expectations of undergraduate nursing students from four universities in Western Australia participating in international clinical placements. Students in this study were seeking global learning and teaching experiences, challenges, opportunities to develop resilience, and personal and professional growth in a diverse environment. They expected the placement to confirm or provide direction for future nursing pathways. These findings align with previous research in this area where students were motivated by a “cultural curiosity” and a desire to make small but helpful contributions (Burgess et al., 2014; Wehbi, 2009). A desire to help and to teach nursing colleagues in the host country could be interpreted as somewhat paternalistic (Burgess et al., 2014); however, these motivations were moderated by a strong desire to learn from their experience and from the nursing practices of their hosts, fueled by a strong sense of altruism and cultural interest.
Students' descriptions of expectations of the cultural environment they were about to enter into were primarily essentialist—an understanding that culture is fixed and unchanging, rather than seeing it as a dynamic process (Gregory, Harrowing, Lee, Doolittle, & O'Sullivan, 2010). Some were quick to ascribe moral superiority to their hosts and were reluctant to criticize any aspect of the host culture. This indicates they were starting from a point of ethnorelativism, where the cultures of others are considered superior to one's own (Sutherland, 2002). The emphasis appeared to be on recognizing the other, without necessarily beginning with an awareness of their own culture (Campinha-Bacote, 2007; Cushman et al., 2015).
This essentialist view of culture has been found previously among nursing students (Gregory et al., 2010). In that study, Gregory et al. found that students from other disciplines were more constructivist. That is, they viewed culture as constantly changing and complex and thought that individuals within a culture may not necessarily adhere strongly to the cultural norms. This raises questions about the way culture is taught in nursing education and, by extension, how cultural competence is also taught.
Students expressed an overall desire to learn from their host colleagues but did not reveal an awareness of how socioeconomic, political, and other factors might determine health status or disparities. An overriding interest in cultural differences and a desire to help at the local level seemed to be driving the students more than a need to understand or be critical of the global context (Burgess et al., 2014).
Of interest was the evidence that some students expected nursing in a developing country context would be more fulfilling than working in hospitals in Australia. This indicates a level of misunderstanding of the Australian nursing context, with an undertone of dissatisfaction. Their desire to practice holistically, with time to focus on the whole patient, possibly reflects a sense of frustration at the conflict between nursing ideals and values developed during their training, and the efficiency and time demands of nursing in Australia, with students reporting that “it burns people out a lot just because it's so busy.” Difficulties with new graduate transitions to professional nursing are well established (Maben, Latter, & Macleod Clark, 2006; Pineau Stam, Spence Laschinger, Regan, & Wong, 2015), but the current study has found that students are anticipating those difficulties before graduation.
A desire to care for others and to work in a fulfilling profession have been cited as reasons for choosing nursing as a profession by beginning nursing students (Cook, Gilmer, & Bess, 2003). The students in the current study were mostly in their final year; however, they clearly still held a desire to care and to be fulfilled. That some students expected this would not be forthcoming after they entered the nursing profession needs to be explored further.
Students' uncertainty about how to effectively prepare for their placement was clear. Cultural competence training, beginning with gaining an awareness of self, could lead to a more transformative experience that allows students to develop a greater understanding that culture is changing, evolving, and complex. This could help them challenge the essentialist conception; consider the difference between generalization and stereotype and recall that there is often more diversity within groups than between them (Campinha-Bacote, 2007). Prior to departure, nursing students should undergo preparatory programs to assist with gaining an awareness of the myriad cultural influences on one's own biases and values, as well as relevant training to guide students toward becoming culturally competent health practitioners in diverse settings (Campinha-Bacote, 2007). Helping students to reflect on their own expectations of the placement could highlight the ethical demand to do no harm so that the international experiences are sustainable, mutually beneficial, and culturally safe for visitors and hosts.
Nursing students participating in international placements in this study were seeking learning and teaching experiences, fulfilment, challenge, growth, resilience, and an opportunity to make a difference. They were determined not to impose their own cultural values on the host culture, yet were not able to clearly articulate their own cultural framework. They revealed a respect for cultural differences but did not know how to prepare for encountering them. Further research could explore how nursing students understand the concept of culture, the influence of cultural competence training on students' experience of international placements, and how students perceive their role as graduate nurses in Australia.
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Participant (N = 52) Characteristics
|Country of birth|
| United Kingdom||9|
|Country of placement|
| The Philippines||5|
| Rural and urban||22|
|Length of placement (weeks)|
|Point of placement in nursing course|
| Second year||12|
| Third year||35|
| Fourth year||5|
| Third semester||1|
| Fourth semester||11|
| Fifth semester||10|
| Sixth semester||23|
| Seventh semester||7|
|Previous overseas travel experiences|
| > 5||18|
|Travel capacity (n = 49)|
| Work or volunteer||7|
Themes and Subthemes Identified in the Pretrip Interviews
|Theme||Motivation, Expectation, or Subtheme|
|Cultural Learning||I love to travel.|
|I will have better cultural awareness.|
|I will have improved cross-cultural communication skills.|
|I don't know how to prepare. I am keeping an open mind.|
|I am willing to learn. I am hoping to teach.|
|Challenge and Flexibility||It will be a physical and emotional challenge.|
|Everything will be different.|
|I will need to be flexible in my use of limited resources.|
|Personal and Professional Growth||I will reinforce basic nursing skills, learn new nursing skills, and|
|develop nursing confidence.|
|I want to help. It will be fulfilling and rewarding.|
|It will open my eyes.|
|I will become more resilient.|
|It will be a testing ground for future international nursing work.|
|Gratitude||I will come back with heightened gratitude.|