Culture, courage and compassion: exploring the experience of student nurses on placement abroad

Abstract

Background

Nursing is emotional work and learning how to manage their emotions is a valuable part of nurse education. As the workforce becomes increasingly mobile nurses will care for people from diverse cultures and backgrounds. The development of cultural competence and a global mind-set is therefore a valuable asset and engagement in study abroad through overseas clinical placement can help to facilitate this. This study set out to explore the experience of student nurses involved in an exchange programme between Scotland and Western Australia. A particular focus was on the emotional aspects of the experience, responding to challenges and provision of care in a different healthcare setting.

Methods

A descriptive qualitative strategy of enquiry was used and semi structured interviews undertaken with a sample of 10 student nurses using emotional touch points. The interviews were recorded, transcribed verbatim and subjected to thematic analysis using NVIVO 11.

Results

Five main themes were identified. Making it happen, connections, feeling vulnerable, culture and assertiveness and affirmation.

Conclusions

This study makes a unique contribution to the nursing student experience of overseas placement as it focuses on the emotional elements. The study shows that the experience of care delivery in an overseas placement has many benefits but also challenges. Management of emotion is required and transition to a different healthcare system can be stressful. Cultural differences were more marked than anticipated but when students responded by questioning, respectful assertiveness and provision of compassionate care there were clear rewards. These manifested as a sense that caring is a privilege and affirmation of career choice.

Background

The workforce worldwide is becoming increasingly mobile and this includes within healthcare [1]. As a consequence nurses and midwives throughout the world are increasingly likely to encounter patients, families and colleagues from diverse cultures and backgrounds. There is an expectation amongst patients and families that the care they receive should be not only compassionate but sensitive to their cultural needs [2]. Papadopoulos and associates suggest a model for the development of cultural competence that outlines the progress from awareness through acquisition of cultural knowledge, to the development of cultural sensitivity and eventual cultural competence [2]. Cultural awareness relates to reflection on personal values and beliefs, cultural knowledge considers the impact culture has on health and illness, while cultural sensitivity embraces relationship and how health professionals view the people in their care. Together these enable appropriate interaction and care. One way for nursing students to advance in this journey of growing insight is to spend time in a different healthcare environment working with and caring for people from a culture other than their own. The experience has been found to help students to develop personally and professionally [3,4,5], including in terms of cultural sensitivity [6] and cultural competence [7]. These benefits are recognised by employers across many professions. Time spent overseas is associated with the acquisition of the attributes of a global mind set which is believed to be demonstrated in understanding and respect for other cultures.

Diamond and associates [8] asked employers what they rated most in prospective employees. The participants ranked global competencies, and the highest were found to be excellent communication skills and the ability to work with people from a range of backgrounds and countries. Drive and resilience were also highly rated, as was the ability to embrace multiple perspectives and challenge thinking. Self-awareness which is linked to cultural awareness was also highly rated.

The healthcare landscape worldwide is constantly changing with a shift from acute to primary care, and increasing numbers of people living for longer with complex physiological multi morbidities and psychosocial needs. Nurses and midwives provide care for patients within stressful environments that are short staffed and where acute settings experience high patient turnover [9]. The high expectations and fast pace of nursing can lead to burnout and associated reduction in quality of care [10]. Educators are faced with the dilemma of how best to equip students with the skills they need for professional registration while inspiring commitment to high quality equitable care, and this includes confidence to challenge practice. Study abroad opportunities can contribute to this, and this is actively encouraged as a way to enhance curriculum content [11]. The perceived advantages for students are well reported but study abroad can also be challenging, and for nursing students engaging in emotional work, it can evoke an emotional response.

In the current study students who engaged in an overseas exchange programme between Scotland and Western Australia (WA) were invited to share their experience. The study differs from others in that emotional touch points were used during the interviews to help students to reflect on and discuss not only their personal experience and perceived learning, but also how they felt and responded to difficulties they encountered. The findings uncover not only the challenges associated with clinical placement in a different healthcare setting, but the satisfaction and affirmation experienced in caring compassionately for people of diverse cultures.

Methods

Research questions

What are the views and feelings of nursing students who undertake a clinical placement abroad?

How do nursing students on overseas placement respond to cultural differences?

Design

A descriptive qualitative strategy of inquiry was used to understand the experience of student nurses on clinical placement overseas. Semi-structured interviews using emotional touch points were conducted to gather data on the phenomena of interest [12]. A study information sheet explaining the rationale for the research, who it would benefit and how the data would be used was sent to the students in advance of the placement, and informed consent obtained before commencing each interview. A method called Emotional Touch Points was used [13] which allows participants to describe their emotional experiences at particular points in time using words or pictures [14]. This method is known to help the interviewer engage emotionally with participants and to understand their experience at a deep level. It has also been found to uncover the needs of the participant [15], and to help them to see the positive and negative aspects of their experience in a balanced way [16]. Participants are invited by the interviewer to select a touch point such as “caring for patients and families” for them to talk about. A selection of words is laid out in front of them and participants are invited to choose words that help describe what happened and how they felt. This includes both positive and negative words which the participant may associate with the experience such as “safe” or “worried”. The participants may also suggest a different touch point or descriptive word other than the pre-prepared ones. These are written on blank cards. The participants then use the touch points and words to describe their experience [15].

The interviews were conducted in the same way in that participants were invited to choose the touch-points they wanted to discuss and the emotional words that helped them encaptulate what the experience meant for them.

An interview schedule comprising additional questions was also prepared in advance and used as a check list at the end of the interview to ensure that the principle phases and landmarks of the experience were included. In each case the students talked with ease about their experiences using the touch points and the resulting collection of rich data did not require prompting through additional questions.

The students were invited to choose where the interview would take place and the first one was conducted in a hotel as the participant had completed their programme of study and commenced a nursing post some distance from the University. The others were conducted within University or the National Health Service on completion of the Australian students’ placement. The interviews lasted between 30 and 75 min in duration.

The interviews were recorded and transcribed verbatim and sent to the participants to check accuracy of content. Field notes were also taken and the touch points and emotional words selected during the interviews recorded.

Sample

Data was collected from 2011 to 2017. The exchange agreement between the Universities allowed 1–2 under graduate nursing students from each University to participate per year and this recruitment limitation prolonged the period of data collection. The sample was purposive and composed of students from Australian (n = 6 second year) and Scottish Universities (n = 4 third year). Three of the students enrolled in the Australian programme held EU passports as they had lived in the United Kingdom (UK) and immigrated to WA. Four of the Australian students travelled in pairs while the remaining participants were alone but had a contact within the country of international placement. Four other students were also invited to participate and although they agreed, this was not followed through to interview due to competing demands on their time.

Students were interviewed by their University tutors to determine suitability for inclusion within the programme. Motivation, expectations and previous experience were explored during the interview. During the course of the placement the students were expected to meet the requirements of the practice module assessment which included demonstration of competence in specific skills such as those that related to compassionate care. On return to their home country students developed a presentation for peers and the module team as part of the module assessment which focused on their experience, personal reflection and perceived learning.

Data analysis

Data was organised and coded using NVIVO 11 and analysis employed thematic analysis guided by Braun and Clerk’s [17] six phases of analysis. The data was read repeatedly in order to become familiar with the breadth and depth of it. The data were then coded for initial codes. Initial themes and subthemes were identified and then reviewed and revised. The final themes were then named and a thematic map developed to demonstrate how they fit together (Table 1).

Table 1 Thematic map

Results

Table 2 contains the emotional touch points offered to the participants and the words they selected to help describe their experience and tell their story.

Table 2 Emotional touch points

The findings showed that overall the students felt there were many benefits to engaging in the exchange opportunities but also challenges and surprises. They were able to identify personal and professional growth and how this would influence their subsequent nursing practice. The themes and subthemes will be discussed in turn with supporting quotes interspersed within the text. The participants have been given a number to preserve confidentiality. SS refers to a Scottish student and AS to an Australian student.

Making it happen

The students spoke of the need for determination. Part of the intended learning experience was for students to take responsibility for preparation such as finding accommodation and securing a visa, while simultaneously managing other demands such as attendance at clinical placements within their home country and completing theory module assignments. They recognised that they needed to make sure this happened but found this to be stressful.

I was absolutely determined that this was my placement (SS 1)

I felt like I was quite determined to learn a lot (SS2)

The stress came from trying to do things in the right order like visas, and medicals and insurance and things like that was probably the biggest amount of effort (AS2)

We still had assessments to complete and course work to hand in while we were preparing and that was stressful (AS 6)

Pushing the boundaries

Students also spoke of choosing to travel to an international placement as a personal challenge as this was for some out of character.

I am quite an unconfident person and I just thought if I could go out there and cope with working in a totally different hospital, in a different country that would really boost my confidence (SS 1)

I wanted a different challenge……….going out there and sort of putting myself out with my comfort zone and learning different clinical procedures and knowledge from a different culture (SS 2)

Feeling vulnerable

Out of my depth

The students described feeling lost and out of their depth and yet did not allow this to hinder their learning

I was a bit like lost just because I was unaware of things and a lot of people they didn’t even realise that I wasn’t a student from Perth at first so they just expected me to know everything you know all these small things make like massive differences (AS1)

I did feel quite lost, what if people didn’t like me what if I didn’t have the skills they expected (SS2)

I have never wanted to work in A&E (Accident and Emergency) and I was really really scared and I thought I was going to be totally out of my depth (SS1)

Managing emotions

The students described feelings and expressions of emotion they experienced in response the new and different environment and yet also determination to cope and find a solution.

On placement was quite challenging but in fact you had to bring in your own decision making skills, even after that panic and sitting crying, to decide well no I’m going to get help and actually out of it came a solution (SS3)

I was scared about how big the hospital was and frightened of finding my way around and being orientated to it and I was also scared that I may not perform at my best and not be a good model for the University, or say something stupid. I didn’t want to let anybody down either. But after the first day there I felt very relieved and surprised at how much I did know (AS2)

I never had much experience in coronary care and I absolutely loved it after my first day on my lunch break I burst out crying (SS2)

Connections

Friends and relatives

It was important for the students to be connected. Most had a relative or friend in the host country.

My friend had found out where I needed to go to register at the University to become a student with them, so I was quite lucky that I had a lot of support (SS1)

I was helpless because I was on the other side of the world, I didn’t have anyone (SS 4)

Support and mentorship

The Students spoke highly of the welcome and support they received from their mentors and the staff in general, and looked to them for guidance and reassurance. They also appreciated support given by the University in the host country.

The university over there were very supportive (SS 2)

My mentor immediately took me under her wing and she was absolutely brilliant (SS1)

I did have a patient who was an old gentleman… he had a bleed from his rectum. A Doctor did a rectal examination some time later and he found no abnormalities….I told my preceptor about it and she had a look as well and told me to document it so I did. It did happen again and taught me the value of documentation because that patient’s blood pressure dropped and it was an emergency (AS1)

You could take it to your clinical educator and say can you show me this and she was quite happy to spend hours with me and she would get all the kit out and show you how to do it until you understood it (SS3)

There was a sense of disappointment for some students when the staff were unfriendly but they found ways of coping and remaining positive

…I made the most of it, kept my enthusiasm up, made sure that I kind of went and got on with it…. and it paid of (SS2)

Culture

Healthcare system

There were clear differences in the healthcare system and learning environment. Australian students struggled with understanding the different staff uniforms, different names for medication and documentation. Scottish students placed in private hospitals found the system very different such as a greater focus on cost in comparison to their experience of working within the National Health Service.

I just thought it was going to a hotter version of the UK. I generally thought the attitudes and that would be very similar but they weren’t. They were very conscious of the price of everything down to a pair of ted stockings which was charged to the patient’s bill. Everything little thing that was used was noted down and they were billed for the whole lot so that was very interesting. They were paying privately and they thought they could demand a lot so it was almost like working in a hotel (SS2)

Attitudes and behaviours

The students found the cultural differences marked and surprising.

Coming from the environment that we have here where we treat everyone the same I was embarrassed about the way they treated their Aboriginals because they didn’t give them the time of day like they would the white Australians (SS 1)

I was quite surprised when I went in and realised the way the nurses treated them (SS2)

I had to do quite a bit of study myself on Aboriginal culture……, it’s very difficult unless you know that but I soon sort of studied it myself and got quite used to that and found it easier to care for the patients and the families (SS 1)

Assertiveness and affirmation

Challenging practice

The students questioned staff and patient attitudes and behaviours, sought out information and chose to role model what they believed to be best practice in caring for patients even when it was contrary to custom and practice in their placement.

Different attitudes towards the different cultures was quite shocking I was embarrassed about the way they treated their Aboriginals. I would get a chat with them I (Indigenous people) and get the kids some, ice-lollies ‘cos they had ice-lollies … they might say thank you but they will never make eye contact, but that is a part of their culture and you just get used to it, you just pick it up. I had to do quite a bit of study myself on Aboriginal culture and stuff.* I did speak to my mentor about it and she just said that they don’t get many Aboriginals. That was her answer. They didn’t have any information and my clinical educator seemed embarrassed and said that they would have to do something about it (SS1)

I had a gentleman who called me, Scotsboy, and would ring his buzzer and shout, haw Scotsboy get me this and get me that, and eventually I just said to him ‘my name is …. and I am willing to help you but I would appreciate if you wouldn’t call me Scotsboy’ (SS 2)

The little things that matter

The students discussed the value of caring for vulnerable people. They were able to identify specific events with their patients that resulted in therapeutic and compassionate care. The students voiced altruistic outcomes from their interactions. There was a sense that the students regarded provision of care as a privilege.

I remember there was this eight day baby that came in I held him while the doctor put an IV cannula in a little tiny wee arm. I just felt awful …the mum had to walk out so I went and sort of comforted the mum and just talked her through the process…I felt very fortunate. I find the whole experience of nursing very humbling, to be able to take care of people when they are at their lowest (AS3)

I suppose the little things. I felt happy when I had one patient I offered him a cup of tea… I didn’t really do much for him he thanked me for taking care of him. That is one of the good things I took away from it. If someone is thirsty just get them a drink…(AS4)

Care here is different. You provide personal care so you get the chance to build a therapeutic relationship with your patients (AS6)

I work in aged care and I find it very humbling to be able to take care of somebody. They are the most vulnerable and they are scared. For them to talk to me, trust in me….(AS4)

Confirmation of career choice.

The students could see for themselves how they had grown in autonomy, and gained a fresh awareness of their capability as nurses.

When you are training you always have your doubts, like I don’t know, am I really cut out for this and you know I really want to go ahead now (SS2)

I had to be always following the group…. I know I am capable now of setting things up and doing it (SS 1)

I am a little different now. And determined to get where I want to go in nursing (AS 4)

Discussion

Relationships and interaction are central to nursing and sharing a personal experience or story has been found to be an effective way to describe an experience and how the story teller felt at that time [18]. In this study student experience of international clinical placement was explored with a specific emphasis on the emotional aspects, the highs and lows of the overall experience and how the students responded. Despite apparent challenges all the students involved in the exchange completed their placement.

The main themes will be discussed in relation to relevant literature.

The students found preparation for travel to and work within an overseas placement stressful and anxiety provoking which is consistent with previous findings [19]. In order to follow through, a deliberate choice and determination to make it happen was required. Responsibility for applying for a visa, booking travel etc. lay with the students. It was interesting that some students chose to embark on the placement as a way of moving out of their comfort zone and challenging themselves. The ongoing demands of study and assessment required managing, as preparation for the overseas placement manifested itself as additional work.

Levels of preparation provided by Universities who engage in overseas placements vary. Some students experience a “sink or swim” approach to study abroad with little preparation. In this case an onus of responsibility was placed on the students to research the placement and people in advance. It has been suggested that anxiety could be reduced and students would benefit from greater formal preparation and connectedness [20]. Strickland and associates [21] connected student groups in the UK, Finland and the USA as part of an international learning experience using a Wiki where students learned about and discussed their differing healthcare systems. This model offers an alternative approach to an international experience where students can build relationships prior to travel. If utilised as a preparation activity prior to commencement of the placement this model could ensure that students are better informed and equipped to care for diverse cultures. It could also soften the reality shock apparent in this study, where students were faced with the realisation that the decision to go was enormous as expressed in the question “what have I done?”

Clinical environments can be stressful for students [22]. The Australian students were at an earlier stage in their programme of study than the Scottish students and had not yet experienced work in a large hospital. Familiarisation and adjustment was necessary and connection with others was important to the students. Most travelled alone and valued having a friend or relative to connect with.

The relationship with their mentor or preceptor was also important. The students looked to them for reassurance and spoke of the value they placed on this support. Allan, Smith and Lorentzon (2008) go further to say that “mentors provide access to cultural knowledge and practices of the clinical team” page 552 [23] . The relationship that students have with their mentor is known to be fundamental to their learning and perceived emotional aspects and fear of the impact on mentor-student relationships can influence their actions [24]. When a registered nurse’s behaviour is in conflict with what the students believe to be right they face a dilemma. Bradbury-Jones and associates found that students are reluctant to speak out [25]. In this study, though it was clearly challenging, with skilled communication and a respectful manner the students found themselves able to question practice and received a positive response which encouraged them as learners. Working in diverse cultures brings additional challenges but provision of support for students to exercise a strong voice could in turn influence them to encourage patients to speak out and question decisions of care [25].

Transition to the new healthcare environment and the many differences was challenging and the students felt vulnerable, lost and out of their depth. The depth of feeling the experience evoked could be seen in the show of emotion described. The students demonstrated a resilient response however, with a determined decision to manage their emotions, solve problems and move forward. Kramer and associates explored transition from student to registrant for newly qualified nurses and introduce the notion of environmental reality shock [26]. Duchscher (2009) suggests a similar adjustment process in response to transition shock [27]. Other studies that focus on transition required during student placement acknowledge similar challenges and advocate greater preparation and support prior to and during placement [20]. Thomas, Jinks and Jack (2015) suggest that resilience, determination to be professional and student personal values in terms of care for those in need, helps student to transition within clinical placement [28].

In Greatrex-White’s study (2008) of the experience of students on an overseas placement participants described a sense of foreignness and feeling on the outside [29]. The participants spoke of everything feeling twice as hard in the foreign environment. This experience of foreignness could however help students to identify with minority groups and associated empathy could in turn be translated to practice within their home country. Increased understanding for patients and families who also feel foreign, excluded and lost could be developed as a consequence. The students in the current study were sensitised to the little things that mattered to those in their care and expressed a wish to help. They also described feelings of humility as they engaged in helping others and how changed they felt after the experience of the overseas placement.

Differences in Culture were discovered to be more marked than the students anticipated. It was interesting that the students experienced this despite placement in what could be regarded as a similar Western culture where English is predominantly spoken. It was also noteworthy that the Scottish students used words such as surprised, confused and embarrassed to describe cultural differences that related to staff interaction with indigenous people. Other research refers to culture shock [3]. Despite having concerns about perceived inequalities in care, students responded respectfully to staff, asked questions and took the initiative to seek out information about how to provide care within this new environment. They also took risks in testing out connecting with Indigenous patients and their families with what was perceived by them to have encouraging results in providing person centred compassionate care.

Taking risks to connect with people mirrors findings from the Leadership in Compassionate Care Programme [15] where flexible person centred risk taking was found to be, in particular circumstances, a characteristic of compassionate relational care. The students though themselves emotionally challenged chose to take a risk and connect with patients and families. It took courage especially in a different culture and where they felt alone. This was however clearly satisfying and affirming. They further demonstrated courage in challenging behaviours in a respectful way. Courage is one of the six ‘C’ s of Compassion in Practice outlined in the Department of Health’s Strategy for Nursing Midwifery and Care Staff [30]. Pam Smith and associates [31] introduce the notion of emotional labour where “what one feels can be in conflict with what one thinks they should feel” (page 12) and this can happen in clinical practice when a nurse or student is confronted by challenging behaviours. It was interesting in this study that when a patient persistently addressed the student in what was perceived to be an insulting and derogatory way he chose to respectfully ask him to stop while reassuring him that he was willing to provide the help and care that the patient was requesting.

It was noteworthy that at the end of the placement the students believed that they had not only grown in confidence but expressed a sense of overcoming and accomplishment similar to passing a test, they also gained assurance and affirmation that they had the capability to join the nursing profession. The students all found the international placement a worthwhile learning experience. Australian students experience significantly less hours working in clinical practice during their programme of study that those in the UK and are known to want more [32]. Provision of an international learning experience within an acute clinical setting is therefore particularly valuable.

Overall the students expressed the high value they placed on participating in the exchange and a determined resolve to apply their learning in practice on return home.

Recommendations for practice

Provision of opportunities for students to make contact with fellow students in the host country and explore and discuss different Healthcare Systems prior to overseas placement.

Improvement of support systems for all students whilst aboard. In particular for those without family or friends in the visiting country.

Active encouragement and facilitation of a structured debrief for students.

Limitations

The study sample was small and data collection carried out over an extended period. This limitation was a consequence of student numbers dictated by the exchange agreement and unexpected personal circumstances that caused some students to drop out prior to commencement of travel. The short notice did not allow for the opportunity to be offered to others and meant that where four students per year could have participated in the exchange the numbers were sometimes reduced. The study results cannot be generalized however, the researcher believes that the findings are applicable to similar contexts.

Conclusions

This study demonstrates that overseas placements can provide a valuable learning experience for nursing students but it is not without its challenges. These relate to cultural and healthcare differences and adaptation to the new care environment. Students are required to acknowledge and manage their own emotions while responding sensitively to the needs of others. Judgements about how best to respect cultural differences without compromising care must be made and followed through, but through executing this successfully the experience can be rewarding. Perceived benefits included personal and professional development and confirmation of career choice, however greater preparation would have reduced stress and increased cultural awareness in advance of the placement.