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 [3–5], 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.

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.

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.

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.