Exchange programmes and student mobility: Meeting student’s expectations or an expensive holiday?

Introduction 

The dream to go abroad and learn from people representing different cultures was already mentioned by Shakespeare in “The taming of the Shrew”, when he wrote:

“Tranio, since for the great desire I had to see fair Padua, nursery of arts, I am arrived fore fruitful Lombardy.. .Here, let us breathe, and haply institute course of learning and ingenious studies. Pisa, renowned for grave citizens…” (Wells and Taylor, 1988, p. 29).

The last half of the 20th century saw a revival of this age old dream, and it was recognised that international mobility could be a powerful instrument in developing the personalities of students. The Bologna process was one of the contributing factors to this revival through its objective to promote student mobility and European dimensions in higher education.

Although student exchange is deemed important, we asked ourselves if such exchanges were previously evaluated on their real benefits to students. In this paper we are presenting the findings of our study about the possible advantages and disadvantages of student mobility. This was important, because we perceive young people entering the nursing profession as the driving forces behind the future development of the profession. They will have had the opportunity to see new health care systems, could compare the differences in providing nursing care, had to communicate with people speaking different languages and had the opportunity to be immersed in new cultures. This is in accordance with the statements of Austin (2001) who said that an international exchange programme at student level could enhance the student’s awareness of global health and cultural diversity, leading to good quality care to people from other cultures within our global community.

Exchange programmes in nursing 

The importance of international exchange programmes in Nursing was accentuated by Keteflan and Redman (1997), who stated that students often lack an international view on research and research findings, in spite of the availability of international literature. The authors indicated that an international clinical placement could enable the student to develop sensitivity to global issues and it would facilitate the student’s personal growth. However, as Shieh (2004) pointed out, exchange programmes are expensive, they are labour intensive to organise, but one of the benefits for the students, is a lived experience within a culture different from their own.

International placements are often viewed positively; however some authors also look critically at such programmes. Shieh (2004) found that exchange students often have feelings of “disintegration” during the onset phases of the exchange. If, however, the students do not develop feelings of loss of autonomy, dependence and interpersonal connections, and manage to integrate into the new culture, their experience will be mainly positive. Exchange students are faced with new cultural experiences, which could improve their knowledge about nursing. Against this background it becomes easier for a student to understand the complex dynamics of culture, health and nursing in foreign cultures. In the country of origin, the student should then be able to become a mediator in culturally difficult situations, which will be an indication of considerable personal growth.

Button et al. (2005) did a literature review on the impact of international placements for nurses’ personal and professional lives. They identified benefits in mainly four areas, namely:

These areas should be the aim of all lecturers supervising students participating in an international exchange programme. One could conclude the argument for student exchanges by looking at Frisch’s study (1990), where it was found that an international experience enabled the students to “step out” of themselves and view all previous experiences of learning, nursing and otherwise from a new and often very critical vantage point.

The German–Finnish exchange programme 

The Department of Nursing and Health Sciences of Fulda University of Applied Sciences was established in 1993. This Department identified the need for international contacts early on in their programme, and agreed exchange programmes with two Scandinavian Nursing Departments in 1996. One of these was a Nursing department in Finland.

Nine Students participated in the German–Finnish student exchange programme between 1998 and 2005. These students were not the only students participating in international exchange programmes, but represent the biggest single group of students going to a single destination. By selecting the Finnish exchange, we were able to minimise the external variables influencing the outcome of the exchange programme.

The exchange programmes are partially funded by the ERASMUS-programme. The Finnish Partner is in a Region where both Swedish and Finnish are spoken, which in itself can be seen to present a major language barrier. However, the students choosing to go to Finland saw communication with both nurses and patients as a challenge.

Specific objectives are set for all exchange students. Apart from working within the health care system of the host-country, they also have to compare the health care system of the guest- and home countries, describe the development of the nursing profession in both countries, and define the roles of the professional nurse, thereby creating a complete comparison of the frame of reference for nursing in both countries. Each student must submit a written report on his/her placement, providing evidence about the success of the placement. However, the personal and professional benefits of the student were not evaluated and therefore remained allusive.

The aim of this project was to find some evidence about the success of this specific exchange programme by asking the students to identify their benefits from their experience, instead of merely looking at the numbers of students in the exchange programme.

The Finnish exchange has always been a long-term exchange with a minimum duration of 20weeks. This was done to accommodate the internship module for clinical practice, while simultaneously enabling the student to reach the set objectives for the internship. This is in agreement with the study done by Button et al. (2005) who, on analysing studies on student exchanges, found that students generally benefited from a longer placement abroad. Such placements gave them a better opportunity to get to know the influence of culture on health care through the longer exposure.

Methodology 

A qualitative approach was chosen, because it was easier to determine the success of an exchange programme after students experienced their host-country, and were therefore able to judge the benefits of an exchange programme for themselves.

Seven of the nine exchange students were interviewed, using a semi-structured approach. One graduate could not be traced, and because of technical difficulties in recording telephonic interviews, it was decided not to interview the remaining graduate, who lived about 500km from Fulda.

The interview duration was on average 15min. These were then transcribed. The analysis was done according to the Content Analysis method of Mayring, because it enabled us to break the content of the interviews down into manageable units that could later be analysed and classified into categories. This approach of breaking down the content and identifying the different categories is typical for qualitative research (Mayring and Gläser-Zikuda, 2005).

Mayring and Gläser-Zikuda (2005) identified three criteria for measuring the quality of the analysis of communicated materials, such as the content of the interviews. These are:

These principles were all taken into account while analysing the interview content. The material was read several times before commencing the analysis. It was the color coded to identify common themes. During this process we were looking at explicit statements made by the participants in the color coded areas. It was then possible to fit these into the final categories. Finally, it was necessary to reflect on each interview and in allocating the content to the final categories each interview had to be reread to ensure that the themes really fitted the identified categories.

The process was made easier by keeping to the steps of the analysing process as suggested by Mayring (2003). These are:

We adhered strictly to the identified steps, and constantly compared the identified categories with the available literature to guide us through the analysis process. We ultimately identified the following main categories: “health care systems”, “Defining Nursing”, “Scandinavia”, “Student support” and “Personal benefit”.

Ethical considerations 

There is no ethical committee in place at the Fulda University of Applied Sciences, and we therefore decided to follow the guidelines of the Nurenberg Codex on ethical behaviour in research. The students therefore participated on the basis of informed consent. They could discontinue the interview and leave at any time they wished, and were not coerced into participating. Some of the respondents already graduated from the programme, and had little contact to the researchers, whereas those who were still studying were in the 8th semester and had no professional contact to the main researcher any more. All forms of coercion were thus eliminated.

The students also knew that the information provided was going to be used for this project only. Permission was obtained to use an audiotape, and to transcribe these interviews anonymously. The respondents were only identified as Respondent 1–7 (R1–R7), to ensure anonymity. Once the guidelines were in place, the students were contacted by telephone and email, the aim of the study explained, and their permission to interview them obtained. After that appointments for the interviews made.

Triangulation was not used, because this study was deemed to be a pilot study for a future larger study. Reflecting about the research process, we now deem this to be a mistake, as triangulation would have enhanced the credibility and confirmability of the analysed data.

The interviews were conducted in German, as the students and graduates were more at home in their mother tongue. We translated only the chosen quotations into English because complete translations would have been very costly and time consuming. The translations were not done contextually, but rather verbatim because of particular German forms of expression. In retrospect this approach was probably not the best, however costs of a certified translator would have exceeded the limited budget for this study. The original translations can be made available to interested people.

Findings 

All the participants made comments supporting the identified five main categories. However, they also made some remarks of a more general nature, but were deemed important for the presentation of the findings, because they were intrinsic in the Students’ wish to study abroad.

Their desire to go abroad was often based on the wish to spend at least one semester in a different country. This was supported by statements such as “Directly after I wrote my final school examinations, it was clear to me, that I wanted to have a semester abroad” (R3, 9–11), and “Because I always wanted to go abroad” (R4, 13–14). The students were clearly very interested in spending some time abroad. Their choice to go to Finland was more complex, especially if one keeps some of the problems, such as language and the climatic conditions, in mind.

The five main categories will now be presented.

Discussion 

The fact that the students “just wanted to go abroad for at least one semester”, was congruent with a study by Grant and McKenna (2003, p. 532), who found that students saw going abroad as a personal challenge and simply as the opportunity to go abroad as a student.

The category on health care systems can probably be seen as the most important of all. Button et al. (2005) found that students going abroad for a period of time obtained a more accurate overview of the health care system in the guest country. Furthermore, they all mentioned the explicit wish to compare the system of the guest country with that in their own country A study by Goldberg and Brancato (1998) was quoted by Button et al. (2005), where it was found that a period abroad enabled the students to compare the differences between the countries, but also to identify the strengths and weaknesses of the system in their own country. This was also found in a study done in Australia, which showed that students found that an international placement helped them to understand nursing and health care in the host-country better (Grant and McKenna, 2003).

The most striking difference in the approach towards health care delivery would probably be the pure medical approach in Germany against the more public health oriented services in Finland. In Germany, all public health services (ambulatory care) including primary- and outpatient care, are organised exclusively as “primary medical care” in doctor’s surgeries (WHO, 2000a). There is also no German nursing qualification in either community or public health nursing (WHO, 2000b). The only approach towards community care is the so called “community nursing services” which are comparable to domiciliary nursing services in other European countries. There are also no educational programmes preparing nurses for this field. The services are financed through a “service-oriented” payment system, and are either privately owned or provided by church organisations. This means that there is no demand for health care centres similar to those found in Scandinavia or the UK. Patients either go to a doctor, or are cared for at home by nurses, acting only on medical orders issued by the patient’s general practitioner.

All the students indicated that they wanted to work in a system, where nurses had more autonomy. Böhme (1996) stated that no area in a German hospital is without a doctor in close proximity. Furthermore, medical staff was legally given the responsibility for total patient care, thus prohibiting any independent decisions or actions by the nursing staff. The scope of autonomous practice in Germany is thereby limited to the so called “basic nursing” (washing patients for example), and interventions such as intramuscular injections are seen as medical tasks to be performed by physicians only. Hanika and Roßbruch (2007) mentioned the dependency of nurses on medical orders. They saw the treatment of chronic wounds as an example for a special nursing problem, as nurses are educated as wound managers, but need prescriptions from the doctors. These, on the other hand, very often know far less about the treatment of these wounds than the nurses, thus leading to ineffective treatment regimes and a rise in the costs of medical services. This situation can be seen as the reason why the students wanted to experience clinical practice in a setting where nurses can work and decide autonomously.

Kuehn et al. (2005) found that worldwide professional nurses were challenged by the increasing complexity of their own health care systems. This is aggravated by them being confronted by an increasing nursing shortage worldwide. The literature review done by Button et al. (2005) revealed that the exposure of students to a variety of nursing experiences could provide the student with a basis to compare their own definition of nursing with that of the host-country.

Grant and McKenna (2003) cited Leininger (1997) who stated that students might suffer from culture shock whilst on international placements. They also cited studies done by several other researchers, who all found that students may suffer from an inherent “fear of the unknown”, whilst being in the guest country and might therefore make mistakes. This could not be supported. This small scale study is however, not challenging the findings of Leininger.

Bartholomew (1996) supported the aspect of nurses challenging their own practice once they came in contact with nurses from other countries, and found that Russian Nursing students coming to the UK were able to redefine their own nursing practice by including concepts such as humanism, holistic care, nursing interventions and care management.

One can therefore say that students do benefit from an international exchange. They can redefine nursing practice; they can develop a more positive attitude to health itself, which in itself is already a valuable contribution in developing a more global attitude towards health and health care delivery.

The fact that the students chose Scandinavia was very interesting, for reasons already mentioned. The later groups were offered an introductory course to the Finnish language before leaving for Finland. Those who attended the course did say thought, that they were only able to greet people and count to 10 when arriving in Finland.

Duffy et al. (2003, p. 400) pointed out that an adequate preparation for students going abroad is essential, more ideally, that students should be fluent in the language of the host-country. Luckily this was not in agreement with the findings in this study, as the respondents indicated that they always found a way of communicating with patients, colleagues and the lecturers, even if they had to use their “hands and feet”! Some authors clearly stated that language difficulties could be very negative for the students if they did not find a means of communicating with lecturers, supervisors or patients in the host-country.

An important subcategory identified, was getting to know a new culture. Duffy et al. (2003) stated that the students going abroad need cultural preparation. This preparation should be at the level of a personal reflection and education about the history, culture and nursing roles of the host-country, but the students also needed the ability to critically reflect their experiences both professionally and personally. Koskinen and Tossavainen (2004, p. 112) warned that students could develop a culture shock through intercultural immersion. Language difficulties could lead to loneliness, isolation and feelings of home-sickness. Luckily this did not occur to any of the interviewed students, and they were even able to find new friends either from amongst the international students or amongst some of the Finnish hospital staff.

Koskinen and Tossavainen (2004) also explained the importance of intercultural nursing. In Finland the number of foreign citizens virtually quadrupled itself between 1990 (26300) and 2001 (98600). The same phenomenon was noticed in Denmark, where the number of immigrants increased dramatically between 1991 and 2001 (Ruddock and Turner, 2007). Ruddock and Turner (2007) cited Roland (2002) who also wrote about the fact that registered nurses in Scandinavia were not educationally prepared to meet the needs of patients coming from different cultural backgrounds. Grant and McKenna (2003) quoted the study done by Fenton (1997) and stated that nursing students will need multicultural experiences because of an increase in ethnic diversity of the people needing nursing care, and international exchange programmes could provide this experience. In response to this problem, the Finnish Ministry for Education wanted to ensure that all patients were treated with dignity. Koskinen and Tossavainen (2004) indicated that international exchange programmes could be an important method to enhance cultural awareness in students, while increasing their global understanding of health care. This supports the need to include intercultural content in pre-registration nursing programmes.

The students all indicated that they had “some communication problems” but all indicated that they found ways to bypass these problems, while finding the Finnish culture fascinating. They mentioned that patients and nurses were interested in their backgrounds and wanted to know more about Germany. Ruddock and Turner (2007) reported similar findings in their study done with Danish students. In our study, most of the respondents returned to Finland later on to maintain their new friendships. This was also one of the categories where the students all benefitted maximally from the exchange programme.

The category on Student supervision was the only one discussed slightly controversially. Five students deemed student supervision to be extremely important, whereas two respondents agreed that supervision is important, but felt they were “over supervised” and indicated that students should be left alone to collect their own impressions. Ruddock and Turner (2007) indicated that students felt accepted because they were invited to the houses of students in the guest countries. Although five of Germany students indicated the same, two felt that such invitations were infringing on their personal freedom.

The students agreed that they had excellent access to the supervising lecturers, and had ample to too much personal contact. The aspect of access to lecturing staff was supported by Grant and McKenna (2003, p. 534) who stated that it was very important in the event of students having situations of concern and conflict.

In this small scale study, all the respondents saw the exchange programme as a big personal benefit to their future clinical practice and to their personal development; they made friends in foreign countries, and became more critical about the German health care system and Nursing practice specifically. One can argue that students should be encouraged to participate in the available exchange programmes if they want to and if they have the opportunity.

This is in congruence with the findings of other researchers, as summarised by Button et al., 2005, Koskinen and Tossavainen, 2004, who found that the students matured personally and professionally because of the international placement.

Conclusion 

The findings of our study are congruent with most of the findings in the available literature. It was found that the respondents benefited from the exchange programme on several levels. They were all satisfied with the access to supervising personnel. All of them indicated that the supervision on the wards was excellent, and they were amazed that the nurses accepted them and gave them the opportunity to learn new skills. All the students complained about their clinical supervision back in Germany, which made their experience in Finland so satisfying.

Perhaps the most noticeable benefits referred to them acquiring new competencies in the clinical field, which directly relates to the supervision on the wards. They viewed nursing practice on a more professional level and indicated the desire to be given more autonomy in nursing practice.

The fact that they lived in another country for 5months enabled the students and graduates to compare different health care systems not only on a theoretical basis, but also based on their personal experiences. Their analytical capabilities improved, and they were able to critically discuss the different health care systems.

The respondents all acquired trans-cultural competencies. They learned a third language, if only at a rudimentary level, and were able to communicate with patients, their supervisors and fellow students. They became sensitive to cultural differences, and could incorporate these feelings in their nursing practice, which ultimately improved the quality of care given to patients.

The findings definitely supported the necessity to do a follow up study when larger numbers of students attended an exchange programme.

Although the study cannot be seen as being representative for all Student Exchange Programmes, the findings supported the aim of the Bologna Process regarding student mobility.

Student mobility can make a contribution to a bigger European integration, as demonstrated by one student, who said: “Then perhaps even new legislation can be implemented perhaps even a single European Nursing Act, with a uniform education and examination system” (R6, 135–145).