Higher education internationalization involves integrating international and/or intercultural dimensions into an institution's teaching, research, and service provision (Currie et al., 2013; De Wit, 2009). Over the past decades, internationalization has become a prominent edifice in the higher education arena (Leask, 2009; Van Hoof & Verbeeten, 2005), partly in response to increasingly globalized societies and markets (Currie et al., 2013; European Parliament, 2016). In the European context, the European Community Action Scheme for the Mobility of University Students (ERASMUS) is a cornerstone of internationalization, with more than 3 million participants since its launch in 1987. The Erasmus+ program, as it is now known, enables student and staff mobility and cooperation in higher education, supports the creation of an international Higher Education Area and fosters innovation, growth, and employment in the European Union (EU) and beyond (European Commission [EC], 2017).
The current focus of investment and research in this area is the quality of students' exchanges rather than the numbers of exchange participants. Internationalization of curriculum (Leask, 2015; Mason & Valerie, 2014) and internationalization at home (Beelen & Jones, 2015) are also receiving increased attention. The evaluation of student mobility across a set of intended outcomes has received minimal attention to date. Against this backdrop, this study aimed to (a) explore the motivations for and experiences of University of Malta nursing students who had participated in Erasmus+ mobility, and (b) analyze the perceived outcomes of their mobility against the intended outcomes listed in the Erasmus+ program guide (EC, 2015).
Research Design and Participants
Data were collected in two complementary phases: (a) An online survey comparing participants' perceived outcomes of Erasmus+ mobility with the program's intended outcomes; (b) Focus groups exploring the key findings of the survey in more depth. In phase 1 of the study, all former and current nursing students at a university in Malta who took part in Erasmus+ mobility between 2009 and 2016 (n = 145) were invited to complete an online questionnaire consisting of three sections. Section A included close-ended questions about the participants' demographic data and the exchange pursued. Section B comprised two open-ended questions about the respondents' motivations for, and the main outcomes of, their participation in an Erasmus+ exchange. Section C used a 5-point Likert-type scale to assess the participants' perceived level of attainment of the intended outcomes of the program (EC, 2015, p. 31). The participants were also asked to indicate whether they were interested in taking part in the second phase of the study. In phase 2, two 2-hour focus group discussions, both moderated by one of the researchers with the other assuming the role of note taker (Mack et al., 2005), were held among phase 1 participants who opted in to the second phase (n = 16; 5 men and 11 women). The principal themes emerging from the analysis of the open-ended questions of the questionnaire guided the focus group discussions.
Participation was voluntary, based on verbal and written information. Completion of the online questionnaire implied consent. Written informed consent was obtained from focus group participants. The study was approved by the University of Malta Research Ethics Committee.
Quantitative data from the questionnaire were analyzed using descriptive statistics. Answers to the open-ended questions in the questionnaire and the data arising from the focus groups were thematically analyzed using Braun's and Clarke's (2006) six-phase approach: familiarization with and transcription of the verbal data; generating initial codes; searching for themes; reviewing themes; defining and naming themes; and producing the report. Qualitative data are therefore presented and discussed across the series of overarching themes that emerged through the analytic process.
Findings and Discussion
Sixty-five participants (11 men, 54 women; response rate = 44.8%) completed the online questionnaire. Most of the participants (n = 58; 89.2%) were between 20 and 25 years old during their study abroad experience; five students (7.7%) were between 26 and 30 years old, and only two participants (3.1%) were older than 30 years. Just less than half the participants (n = 30) had taken part in an Erasmus+ exchange in the past 4 years. The students had taken part in Erasmus+ Studies mobility (involving a minimum of 90 days and including a combination or theoretical courses and clinical placements) or Erasmus+ Traineeship mobility (a minimum of 60 days involving clinical placements only). They had been hosted by partner institutions in the United Kingdom (N = 26), Finland (N = 12), Ireland (N = 8), and seven other countries (N = 19). During their mobility period, they lived in student accommodation provided by the host university or in privately rented apartments. An overwhelming majority of participants thought that all the intended student mobility outcomes stipulated in the Erasmus+ Program Guide had been achieved to a very large or considerable extent (Table 1). The outcomes perceived as most successfully achieved were related to improving self-empowerment and esteem and to motivation for participating in future education or training. The data revealed congruence between the motivations for and outcomes of study abroad experiences.
Extent to Which Participants Perceived to Have Achieved Various Intended Outcomes of Erasmus+ Student Mobility
Analysis of the data from open-ended survey questions and the subsequent focus group discussions revealed the following themes. Although some of the themes directly pertained to the participant as a nursing student, others (e.g., language and citizenship) drew upon the broader impact of student mobility, transcending the actual study area, which is consistent with the intended outcomes of the program.
Theme 1: Enhanced Employability as a Nurse
All the participants believed that Erasmus+ mobility enhances subsequent employment prospects and job opportunities, with some participants claiming that “Having had a study abroad experience looks good on a CV and helps when applying for employment in nursing posts.” This perception mirrors the views of the various stakeholders (academics, students, and employers) participating in an Australian study by Crossman and Clarke (2009). A European study revealed a favorable association between Erasmus+ participation and employability, confirming that the challenges and costs involved in securing overseas experiences for students translate into “increased employability skills” (EC, 2014, p. 18). However, it is important to note that most of the participants of the current study were recently employed new graduates. A longitudinal study could explore whether this favorable view changes over time.
Theme 2: Exposure to Nursing Beyond the National Shores
The participants were seeking, and indeed felt they were provided with, exposure to “cultural diversity from all around the world.” Apart from establishing friendships with students from different countries, the participants emphasized that this extended beyond the social aspect. They valued the professional dimension of being exposed to realities beyond the confines of national shores in which they lived, studied, and worked. Most participants remarked that their interest to witness and learn about other health care systems was significantly addressed through Erasmus+ mobility. They appreciated nursing care delivery in contexts with different resources to what they were used to and opened their mind to students, educators, health professionals, and patients with different perspectives and mentalities. This aided the development of “new ways of thinking, both at the place of work and in one's personal life,” according to one participant.
Data pertaining specifically to learning about clinical practice through the study abroad program were also elicited. One student remarked that, despite language barriers, during the mobility his skills improved considerably due to more opportunities for hands-on practice with minimal supervision than in the home country. Another student similarly noted that “working in a UK hospital increased my confidence as I had to face challenges which were out of my comfort zone.” A similar increase in confidence was reported by the Irish and Scottish study abroad participants in Casey's and Murphy's (2008) and Milne's and Cowie's (2013) studies, respectively.
These experiences highlight the learning achieved due to being away from familiar contexts and are comparable to those of the midwifery students participating in Marshall's (2017) study. Such observations underscore varying realities in different nurse education contexts and experiences. Consequently, they reveal scope for discussion about the differences in the approaches and delivery of nurse education across different contexts, despite international frameworks and guidelines (Robinson & Griffith, 2007).
Theme 3: Personal Growth
Like the U.K. nursing students in Lee's (2004) study, the participants in the current study sought and experienced growth on a personal level through their study abroad experience. Enablement of skill development toward independent living, ranging from enhanced management of domestic chores, personal finances, and budgeting, to the successful navigation of lone travelling within and between countries, and from getting to know oneself to increased assertiveness and decision-making ability because of space and time for personal reflection, was noted in the data. One participant wrote, “I became a better person…accepting new challenges and being more confident in decision making. Besides, coping with cooking, cleaning, shopping, and travelling to the other side of the continent makes you more independent and that boosts your self-confidence to a whole new level.” Similarly, the Maltese midwifery students in Marshall's (2017) study identified “learning how to use a washing machine and cook for themselves” (p. 11) as part of the unplanned benefits arising from their Erasmus+ mobility experience. This reflects the reality of students living in Malta, where, due to the short traveling distances and other sociocultural issues, the proportion of Maltese students living with their parents is the highest in the EU (Eurostudent Project, 2019).
Participants shared experiences of “enlightenment” during an Erasmus+ exchange. One participant explained that “it sparked an overwhelming need to travel around the globe.” Another stated, “I confirmed how interested I was in working abroad; also, my love for travel flourished.” Enlightenments of a different nature included: “I started to appreciate everything my parents give me much more,” “I found a desire to further my studies,” and “I realized that once I successfully completed an Erasmus exchange I can do anything.” Thus, the outcomes of students' study abroad experiences clearly extended beyond the area of study, as intended by the Erasmus+ program itself (EC, 2015).
Theme 4: Context-Sensitivity of Nursing Care Delivery
Given that all the participants were nurses or nursing students, it was not surprising that most of the data pertained to some aspect of the profession. However, the participants were keen on highlighting the occasionally surprising practices they witnessed in the host country. Data examples include: “the box for depositing unwanted babies outside the hospital was shocking!” and “it was strange to see tea being poured down nasogastric tubes!”
The underpinning contention around these observations was the participants' realization that despite the presumably universal nature of the nursing profession, the delivery of care was, nevertheless, sensitive to the context in which it was delivered. These and similar examples highlight the importance of fostering open-mindedness among nurses in their practice, besides a curious and accurate eye for learning from what is new and different to what one is used to. This was previously underscored in primary studies among Swedish nursing students (Bohman & Borglin, 2014), Maltese student teachers (Caruana & Vella, 2012), and English and Maltese midwifery students (Marshall, 2017), as well as in a comprehensive review of international studies by Button et al. (2005).
Theme 5: Language and Citizenship
The Erasmus+ program specifies the development of language and citizenship as intended outcomes of student mobility. The data suggest a varied experience among participants regarding these two outcomes, ranging from “I did not manage to learn the Finnish language at all” to “I went from being barely able to speak the language to filling in as an interpreter between English and Italian.” One participant lamented that “there was a huge language barrier to my learning.” Indeed, language has consistently been reported as a perceived barrier in previous studies about factors influencing students' intentions to study abroad (Goodman et al., 2008; Kent-Williamson et al., 2015; Owen et al., 2013). Securing a basic introduction to the host country's language may enhance students' eventual learning experiences. In turn, the measures and structures with which the language skills of individual outgoing students are assessed may need to be reviewed and adjusted accordingly.
The data suggest a favorable effect of the mobility on citizenship. Several students claimed that they became more aware of both their rights and their duties as EU citizens. Some were prompted to join voluntary organizations “to give something back out of [their] own free will.” Others increased their awareness about environmental issues through practices (such as cycling to work) observed in the host country, which they tried to adopt.
Because the expected nature, extent, and magnitude of outcomes related to citizenship and language are not specifically determined by the mobility program, the actual measurement and evaluation of such outcomes is, to date, limited. This emphasizes the importance of developing institution- or context-specific expectations and objectives. Defined expectations and objectives pertaining to these intended outcomes of citizenship and language are a prerequisite for developing measures and initiatives to enhance and support their attainment.
Strengths and Limitations
This study used two data collections methods, thus enhancing both completeness and confirmation of data (Adami & Kiger, 2005). The response rate for the online survey is satisfactory, but the participants were from one department at one university, which calls for caution in generalization. Former Erasmus+ participants who did not volunteer participation in the study may have had different motivations and perceived outcomes. Focus group participants were self-selected from the online survey phase. This may have led to biased confirmation of positive results in the survey data, given that participants with favorable experiences might have been more interested to extend their participation in the study. Variations in the participants' perceptions may have been partly due to the difference in the amount of time that had passed between their study abroad experience and their participation in the study. A more balanced selection of focus group participants, although desirable, was not possible because the online questionnaire was completed anonymously.
This study reveals congruence between the consequences of a structured student mobility program as envisaged by the program provider and intended and actual outcomes as perceived by the participants. Given that the Erasmus+ program is a key driver in student exchanges across the globe, these findings should be relevant to policy/program developers and international coordinators of higher education systems elsewhere. Indeed, although the study focuses on a specific exchange program, it is believed that the findings are relevant for students, educators, and administrators involved in other types of student exchange programs, including those available outside the EU, such as the International Students Exchange Programs and programs administered by the Institute for the International Education of Students. Caution is, nevertheless, indicated in view of contextual differences. Future research might incorporate comparative case studies of students from countries with varying sociodemographic and geographic indices and may explore the impact of factors such as the precise nature of the mobility, and accommodation type and setting, on the overall experience.
The positive experiences reported in this study confirm that nurse educators should continue promoting and facilitating study abroad experiences. Research exploring any negative outcomes of student mobility experiences that the current study might have failed to capture is indicated. Longitudinal studies exploring participants' views at several points after their study abroad experience are also indicated to investigate the extent to which students' perceptions are retained or may change with the passage of time.
Students' perceptions of their study abroad experience is generally positive and personal, academic, and professional growth is associated with the experience. Therefore, these findings impart a message of encouragement and support toward effort and investment in exchange programs.
The study unveils factors, such as language barriers, that may be addressed in advance in view of optimizing study abroad experiences. Educators and program administrators need to channel attention onto such factors in parallel to their focus on identifying expected outcomes of study abroad experiences. This should enable students to actually achieve the expected outcomes.
Collaterally, the conduct of this study revealed that students largely embark on such study abroad experiences with little knowledge of, or interest in, the program providers' intended outcomes. Nonetheless, it is interesting to note that students' perceived outcomes were indeed congruent with those of the program itself.
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Extent to Which Participants Perceived to Have Achieved Various Intended Outcomes of Erasmus+ Student Mobility
|The Erasmus Exchange Has:||To a Very Large Extent||To a Considerable Extent||To a Moderate Extent||To a Minimal Extent||Not at All|
|Enhanced my employability and improved my career prospects||18||28||11||2||6|
|Increased my sense of initiative and entrepreneurship||28||28||7||2||0|
|Increased my self-empowerment and self-esteem||40||20||2||3||0|
|Improved my foreign language competences||19||18||17||5||6|
|Enhanced my intercultural awareness||38||20||5||1||1|
|Made my participation in society more active||18||28||14||2||3|
|Improved my awareness of the European project and the European Union values||16||28||11||6||4|
|Increased my motivation to take part in future (formal/nonformal) education or training after the mobility period abroad||40||18||6||1||0|