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.
