Issues in Comprehensive Pediatric Nursing, 2014; 37(2): 87–102 ß Informa Healthcare USA, Inc. ISSN: 0146-0862 print / 1521-043X online DOI: 10.3109/01460862.2014.880531
THE BENEFITS FOR CHILDREN’S NURSES OF OVERSEAS PLACEMENTS: WHERE IS THE EVIDENCE?
Richard Standage, MSc1, and Duncan Randall, PhD2
Overseas placements are presumed to provide students with experiences to enhance their cultural competence and to give them insights into other healthcare systems. However, the literature has not focused on what students of children’s nursing might gain from an overseas placement. This paper is a report of a literature review (2003–2011) and our own student evaluation, both aimed at shedding new light on this important opportunity for learning for children’s nurses. The literature review indicates that current research does not address the learning from overseas placements for children’s nurses. Our student evaluation suggests children’s nursing students are able to explore the position of children in the host culture and to place this in a healthcare context. Students also reported that they adhered to UK scope of student practice when delivering care to children on overseas placement. These placements provide a valuable learning experience for children’s nurses. However, consideration in the shorter term is required to address issues of equity. Looking forward, further large scale studies are required to determine the long term effects of such experience on the health outcomes for children, and development of children’s nurses and children’s nursing globally.
20 14
1 School of Health and Population Sciences, Nursing, University of Birmingham, Edgbaston, Birmingham, United Kingdom and 2Family and Community Health University Research Group, University of Western Sydney, Penrith, Sydney, Austrails
Keywords: children’s nursing, cultural assimilation, elective placement, nursing education Received 27 August 2013; revised 7 December 2013; accepted 8 December 2013
Correspondence: Duncan Randall, Family and Community Health University Group, School of Nursing and Midwifery, University of Western Sydney, Campbelltown Campus, Locked Bag 1797, Penrith, NSW 2751. E-mail: [email protected]
87
88
R. Standage and D. Randall
INTRODUCTION While issues of comparative healthcare and globalisation can be taught in a classroom setting, there is a body of literature that suggests that immersion in another culture is more effective (Duffy et al., 2005). One of the presumed benefits for students of overseas placements is an increase in their cultural awareness (Kulbok et al., 2012; Law & Muir, 2006; Tabi & Mukherjee, 2003). This is important for students, and qualified nurses who are required to deliver culturally sensitive care to a range of communities. It is therefore imperative that as undergraduates, students are given exposure to cultural diversity to equip them both for clinical placements and for their future careers. In addition to cultural safe practice at home, there is an increasing blurring of international boundaries and the single employment market particularly within the European Union (EU) (Law & Muir, 2006) which makes knowledge of other healthcare systems a major asset for future career development and portability (Frenk et al., 2010). The Bologna Process in particular has the stated aim of increasing the mobility of graduate nurses within the EU via unification of pre-registration programs and reciprocal recognition of qualifications (Davis, 2008). The Bachelor of Nursing programme at our university requires students to undertake a 4-week self-organized experience to an area or institution that does not form part of our usual clinical placement circuit. Although there is no specific requirement to go overseas, the majority of students choose this option as demonstrated by statistics from recent cohorts: 66%, n ¼ 82 (of which 17 were child field of practice) in 2010, 71%, n ¼ 74 (of which 18 were child field of practice) in 2011. Students receive preparatory sessions that address issues around culture shock and how this can be recognized and dealt with. As the placement is for 4 weeks there is no requirement for the host organization to be audited or to have accredited assessors (NMC, 2010), nor would students be expected to be fluent in the host’s language. Placements are covered by the University’s indemnity insurance. Kulbok et al., 2012 provide a literature review of overseas placements. They note the two previous reviews of overseas placements, both published in 2005 (Button et al., 2005; McAuliffe & Cohen, 2005).These 2005 reviews reported on papers from 1980 and 1983 respectively up to 2003, and found that nursing students reported enhanced personal development, a wider perspective on practice, a wider appreciation of diverse healthcare systems and an increased sensitivity towards cultural issues. Kulbok et al., 2012 reviewed papers from 2003 to 2010.
Children’s Nurses and Overseas Placement
89
They found that only 2 of the 23 studies reported a program evaluation which went beyond student feedback. Few of the studies use a theoretical framework (3 of the 23) and the research had not addressed the recommendations of the previous reviews to evaluate programme over longer periods. However, none of these studies considered the specific issues in relation to children’s nursing. The lack of previous literature on children’s nursing students’ overseas placements can be explained by the fact that few countries have separate education programs for children’s nurses at undergraduate level, and by the lack of a trans-cultural focus in children’s nursing more generally (Shields & Nixon, 2004). REVIEW OF LITERATURE 2003–2011: METHODS The literature review presented here uses a scoping review methodology as suggested by Arksey & O’Malley (2005) to review the literature looking specifically at children’s nursing students’ experiences of overseas placements. A scoping method was used rather than a systematic or meta analysis approach because it was unclear whether the research included children’s nurses. Even in the studies involving UK students it was difficult to ascertain if the sample included students on child field of practice and to identify the data associated with these participants. The advantage of a scoping review is that instead of trying to synthesize disparate findings, a scoping review allows for a broader approach and attempts to capture all the literature irrespective of the quality of the data or method. The research question used was: What issues of children’s nursing have been addressed in the research literature between 2003 and 2011 relating to students learning from overseas placements? English language, published research relevant to the research question was included. The keywords used were adapted from Button et al. (2005): international exchange, international studies, international education, international placement and exchange programme, all combined with nurse* and education. The data bases used were CINAHL, British Nursing Index. and Medline. Twenty-one articles were retrieved, of which 11 were rejected as they were either personal accounts or descriptions of the overseas/exchange programs rather than methodologically based research. Two of the papers were reporting different findings from one study. These were combined and considered as one. The remaining nine studies (see Table 1) formed the basis for this review. The first author (RS) performed the search, both authors read all papers independently and then agreed on the analysis.
Qualitative Qualitative
Qualitative Qualitative
UK
UK/Sweden
Norway/Malawi
German/UK
UK
USA
Denmark/ Australia
Greatrex-White (2008) Green et al (2008)
Hagen et al (2009)
Keogh & RusselRoberts (2009)
Lee (2004)
Smith-Miller et al (2010) Ruddock & Turner (2007)
Qualitative
Qualitative
Qualitative
Qualitative
Australia
Grant & McKenna (2003)
Qualitative
Method
USA
Country Based
Callister & Cox (2006)
Author
Interviews
Interviews and focus groups Reflection papers
Interviews
Interviews
Interviews and document analysis
Diaries
Journals and interviews
Interviews
Data Collection
Table 1. Selected papers in scoping literature review
5 students, 2 Norway to Malawi, 3 Malawi to Norway 7 students in a German to Finland exchange programme 4 module facilitators and 18 students 15 Baccalaureate or masters degree students 7 students exchange visit Denmark to Jamaica, Malta, Greenland and Australia
18 students UK to Sweden, 14 Sweden to UK
9 students. 3 interviewed only, 6 interviews and journals. 26 students UK to unknown
20 students, USA to Argentina, Guatemala, Jordan and Native Americans
Participants
Leaving behind the familiar, the experience of being a foreigner Increased self-reliance, professional knowledge and skills, awareness of different healthcare roles, change in attitude to others from different cultures Similarities and differences in practice, learning relational skills, developing cultural competence Diffusion of knowledge between different countries, education needs met despite language differences Personal development and enhanced transition from student to qualified nurse Personal growth and broader insight into multicultural care Development of cultural sensitivity and personal growth
Increased understanding of other cultures, increased understanding of global health issues, increased commitment to make a difference, personal and professional growth, contribution to professional growth in host countries, interpersonal connections, developing cultural competence Differences in nursing culture
Key Findings
90
R. Standage and D. Randall
Children’s Nurses and Overseas Placement
91
LITERATURE REVIEW UPDATED 2003–2011: FINDINGS The nine studies all used qualitative methodology incorporating interviews, focus groups, and diaries or reflective journals/writing. Five of the papers detail UK students’ overseas placements including exchange programmes. In these five papers it is not clear which field of practice students are undertaking. It is possible that children’s nursing students were included in these studies, but none of the papers refer explicitly to child field of practice. The four studies based outside the UK do not report aspects of children’s nursing. Thematic analysis of the data produced four axial themes: developing cultural competence, identifying health care differences, personal and professional growth, and contributing to the host. Developing Cultural Competence Cultural competence is a multi-faceted concept and is manifested in a variety of ways within the studies. Callister & Cox (2006) for instance use the term ‘‘opening our hearts and minds’’ and specifically refer to their study participants having an increased understanding of other cultures and peoples. Participants in the study by Greatrex-White (2008) described this concept in terms of them being the outsider or foreigner, which made them reflect on how this must feel for people who come from overseas and engage with healthcare provision. A key concept here was the participants looking on ‘‘we’’ as a sort of ‘‘they,’’ which she goes on to describe as an understanding of otherness and a clear development of cultural awareness and recognition of cultural diversity. Participants in the study by Green et al. (2008) spoke in similar terms about an increased awareness of other cultures, leading to a greater tolerance and empathy for minority ethnic groups. Similar ideas emerged in the study by Smith-Miller et al. (2010), where participants talked about their difficulties being in a non-English speaking country and how this enhanced their understanding of similar problems that face people in the UK for whom English is a second language, forcing them to review previously held opinions and assumptions. A key example was the participants’ desire to stay close together in a mutually supportive group, which increased their understanding of minority ethnic groups who form close community bonds in the UK. The importance of mutual social support was brought out in Ruddock & Turner’s (2007) study, who also reported on the experience of being a foreigner with a subsequently enhanced empathy, respect and understanding for immigrants in a similar position, along with the importance of being non-judgmental.
92
R. Standage and D. Randall
None of the studies discuss students learning about cultural practice in relation to children and childhood. Identifying Healthcare Differences Differences in children’s healthcare provision were not discussed in the literature. Findings under this heading can be usefully divided into micro factors relating to nursing roles and responsibilities, and macro factors, relating to wider healthcare systems and policies. Healthcare Differences: Micro Differences in technique were picked up on by students in the study by Keogh & Russel-Roberts (2009), who reported that they had observed disparities in technical skills and levels of autonomy between the two countries (Germany and Finland). Neither system was thought superior, and both groups felt that they had learned something from observing and participating in a different culture of practice. Similarly participants in the study by Lee (2004) compared and contrasted clinical procedures, roles and responsibilities, and also extended this to commenting on perceived differences in nurse education between their UK experience and the various host countries. Participants in the study by Grant & McKenna (2003), which looked at Australian students who travelled to a variety of overseas settings referred to procedures that they considered to be old fashioned and routine, and perceived nursing to be very much more hierarchical than they were accustomed to. Healthcare Differences: Macro Callister & Cox (2006) refer to an increased understanding of global socio-political and health issues. Similarly participants in the study conducted by Keogh & Russel-Roberts (2009) were all engaged in comparing the German and Finnish health care systems and their relative strengths and weaknesses. There was a strong consensus that the Finnish system had a stronger component of public health than the German one. UK students in the study by Grant & McKenna (2003), who had already commented on a more hierarchical nursing structure, also felt that this extended to nurse-doctor relationships, with medical staff often coming across as intimidating and being feared. Participants in the Smith-Miller et al. (2010) study reported on healthcare in developing countries, with a noticeable lack of technology, a low nurse to patient ratio, reliance on lay carers, and a
Children’s Nurses and Overseas Placement
93
lack of patient rights. This led a number of students to question the disparities of global healthcare provision. Personal and Professional Growth Personal This primarily was concerned with issues around overcoming stress and mastering language barriers. Participants in the study by Green et al. (2008) talked about having to overcome homesickness as well as more practical issues such as problems with accommodation. Tackling these issues gave students confidence and engendered a sense of achievement. Participants in the study by Lee (2004) found they could overcome language barrier problems by being more attuned to nonverbal communication. All the respondents in the Keogh & Russel-Roberts (2009) study referred to personally benefitting from the exchange with an altered approach to their nursing care delivery. Participants in the study carried out by Ruddock & Turner (2007) all couched this aspect of their experience as making a transition from one culture to another. Although many reported feelings of uncertainty from the loss of a familiar environment, they were ultimately able to adjust, hence achieve personal development. A key theme that emerged from the study by Greatrex-White (2008) was that of leaving behind the familiar and embracing the new environment with its new routines. This initially led to a sense of detachment which the respondents were able to overcome, although for many this was not a linear process, and was characterized by periods of elation and depression. Professional This finding was mainly concerned with enhancing future career prospects as a result of the experience. Callister & Cox (2006) refer specifically to professional growth as a key finding. Participants in the study by Green et al. (2008) reported learning new insights into multi-disciplinary working, along with developing their technical, personal, and interpersonal skills. Many participants felt that their overseas experience had been a contributory factor in securing their first post-registration position. This finding was echoed by a student in the study by Lee (2004) who felt that her overseas experience had helped her during her stressful transition from student to qualified nurse.
94
R. Standage and D. Randall
Keogh & Russel-Roberts (2009) explored this issue in terms of the level of student supervision. While most students appreciated the level of supervision they received, there also was the feeling that it should ideally be pitched at a level that allowed them to develop and experience a degree of self-directed learning. This theme was picked up on by Lee (2004) where respondents reported there was often a degree of overprotection in domestic placements, with a readily available support network. Without this, students felt they had more freedom to develop assertiveness and problem solving skills. Respondents in the study by Grant & McKenna (2003) saw professional development in terms of having the confidence to engage and show initiative in their placement setting. This led many of them to realize that they had transferable clinical skills to be an effective nurse. Contributing to the Host Callister & Cox (2006) expressed this theme in terms of increasing the commitment to make a difference and contributing to professional development in the host country. Both Greatrex-White (2008) and Green et al. (2008) reported on participants establishing friendships which persisted once they had returned to their own country. Similarly participants in Hagen et al. (2009) spoke of a desire to learn from each other, recognizing that both host and guest could exchange skills and knowledge that would enhance each other’s practice. The findings of this literature review mirror to an extent the themes that were apparent in the earlier literature review by Button et al. (2005).The lack of information about children’s nursing in these studies of students experiences of overseas elective led us to review data collected in our previous student evaluation. STUDENT EVALUATION: METHOD A purposive sample was sought from children’s nursing students in one cohort (2007), who recently had returned from their overseas placement. The students were invited to share a lunch and participate in a group interview. All students were invited to the group which took place on an afternoon when no teaching activities were scheduled. The students were informed about the purpose of the group interview, assured of confidentiality with the proviso that any safeguarding issues would be acted upon. The group lasted for 80 minutes, one afternoon in the autumn of 2009. The team felt that as this was an evaluation of current practice it did not require ethical review. The activities undertaken by the students
Children’s Nurses and Overseas Placement
95
Table 2. Topic guide for overseas placement group interview
Where did you do your overseas placements? And how long were you there? Did the places you went to have philosophies of care? How were these philosophies enacted in the care of children? Were children’s rights recognized? How did nurses involve children in their care? Did nurses and parents negotiate the care of children? If so how was this done? What do you feel you have learned about children’s nursing from your overseas placement? Is there anything else you would like to add?
in the group interview were considered to be equal to those in which they participate in the classroom setting as part of the usual placement evaluation process and therefore did not present additional risks to the student. All students were asked and gave written consent and assured that they could withdraw at any time without penalty. Students were informed of the intention to publish the findings. A topic guide was used in the group to focus the conversation as suggested by Krueger (1994) (see Table 2). The students were aware that the group interview was recorded on audio tape and were asked to comment on the transcript of the interview. The authors analyzed the transcript separately using open coding (Parahoo, 2006). Once the transcript had been coded by each of the authors they met to agree on axial coding, where themes were created and data sections were ascribed to particular themes. Once coding was complete the authors reviewed the literature review reported above, some labels for themes were changed as on reflection they appeared to be essentially the same as those uncovered in the literature review. STUDENT EVALUATION: FINDINGS Although the cohort consisted of 23 students only 3 students attended the group (Participants P1–3). Attendance may have been poor as the group was held on an afternoon set aside for sport and other activities. Students may have been unable to attend due to other commitments which they regularly undertook at the time of the group. However, the students who did attend had visited different countries and different clinical areas. They had all gone overseas on their overseas placement, one to a majority (developing) country, India, and two to western, northern hemisphere countries (Canada and USA). They had worked in public hospitals, primary care, neonatal intensive care, and a hospice setting. All of the participants were female, White, British second year children’s nursing students. Although this sample is small and
R. Standage and D. Randall
96
homogenous in terms of the students’ cultural backgrounds with clear consequences for validity and reliability, the data from the interview showed diverse views of the overseas placement and insight into children’s nursing within different countries health systems and cultures. Developing Cultural Competence The participants recognized that they had learned about the host cultures, but they also felt that they could apply this new understanding to immigrant communities in the UK who had come from these cultural backgrounds. In the following excerpts, P1 ¼ Participant 1; I1 ¼ Investigator one, and so on. P1 I think I’m more culturally aware than I was. I have a greater understanding of the Indian culture and not just . . . to say that Indian culture would be naı¨ve, because it’s not just the one culture it’s got so many different cultures. And a greater understanding of why we need to do the things that we do, like gaining consent from a child, yeah we don’t need that consent but to gain that consent, is to have that child understand and agree with what you’re doing . . . I think I have a greater appreciation of what we actually do in terms of nursing here in contrast to other countries.
Identifying Healthcare Differences Healthcare Differences: Micro Students often framed their experience of children’s nursing in other countries in terms of how nurses support the practice of medicine (Liaschenko, 1997), less obvious was how nurses facilitate people’s experience of healthcare or facilitate how children live with illness (Randall & Hallowell, 2012). P2 A lot of it was computer based. All the notes were on computer, all the drugs charts, everything was computer based, which was fine, all very good until the computer crashed. . . . but things like the pharmacy over there, the nurse don’t draw up the drugs and stuff. We were literally just handed the syringes with the drugs in. They were then checked on the computer and given to the patient.
However, the participants did also frame their experiences as case narratives. They told stories of particular cases to illustrate what had
Children’s Nurses and Overseas Placement
97
happened, sometimes returning to the same case to make further points. The data quoted below also shows how the students recognized the rights of children in health care in a cultural context. P1 Like for instance we had a child that came in, he was five or six and because there’s no safety measures for things like fans, the child had put two of his fingers in a fan, . . . luckily it had gone through the joint, one of these little joints and it was hanging off . . . and we told the parents the child has to have an operation now. ‘‘Oh no we’re going to take him home we don’t want to pay for that’’—but they could. So the doctor said look if you don’t pay for it now you are going to have to pay for it when it gets infected. ‘‘Ok. We’ll pay for it.’’ This child was terrified, screaming, crying trying to run away, trying to hide. And the doctors just literally just picked him up, told him be quiet . . . . . . they didn’t use general anesthetic .. . . So this child is terrified, he was literally hauled upstairs and put on the operating bed. He’s still screaming, still trying to drag his hand away. . . . There was no advocacy there, nobody thought to stand up and say hang on maybe we need to explain before we do this, and it might be a bit easier if we explained and he calms down.
Healthcare Differences: Macro Participants implicitly and explicitly compared nursing in Britain with their experiences in overseas placement. For some the comparison focused on differences in the practice of nursing. For example those who went to countries with health insurance funded systems felt uncomfortable with the way care was accounted for in financial terms. Comparisons were also made about how care is negotiated between children, parents, and nurses (and other healthcare professionals). I2 So there were set visiting times? P2 Yeah as long as the doctors’ rounds had finished they could visit whenever they wanted but it was sort of always after 12. . . . I hardly saw any parents while I was there. I was really surprised. I used to ask my mentor when do the parents come, ‘‘oh they just come when they want,’’ but in America as well even babies who aren’t special care are taken from their parents and put into nurseries.
One participant, who had been to a developing (majority world) country placed the UK and the host country on a time line, to compare nursing in the two contexts. With the host country practices being related
R. Standage and D. Randall
98
to British practice 50 years ago. The participants referred on a number of occasions to how the British nursing context was, for them fairer than that of host countries. P2 I certainly learned to appreciate the NHS. There were so many sort of roadblocks when it came to the insurance. So you can’t do this, you can’t do that .. . . You know we treat patients equally here, and sometime it just didn’t seem to happen there.
During their overseas placements the students had come to understand a lot about how host countries health systems operate. They were also able to make direct comparisons with the British health care system. P3 They’ve got a weird system in Canada. It’s based by Province, and you can have free health care in your Province but if you go out of your Province you need health insurance. And not everything’s provided on the Government’s, by the Province .. . . You’re entitled to a certain amount of respite, sort of dependent on . . . they have to fulfill certain criteria, so they had to be technology dependent, or medically fragile. There were long lists of guidelines . . . I think it was 14 days a year. P1 A lot of corruption like they were just going to use the ambulance to go shopping. And there was a massive train crash, 30 people died and there were about 15 children involved and the ambulance was over sort of near Nepal at the time so these children couldn’t get brought into the hospital, and so most of them died at that scene .. . . So this acceptance of prejudices and corruption, it’s not something that I’m used to coming across it’s not something that I’ve encountered.
Personal and Professional Growth The participants recognised that the overseas placement gave them access to clinical experiences which they had not had so far during their course in the UK. One participant was able to work in a hospice which, although a rotation available in the UK, on our program was not one to which the student had been allocated. The participants were also able to gain experience of skills and interventions which may not be facilitated in UK practice, although the participants seemed to stay within their UK scope of practice limitations. P2 They were willing to let me do so much. ‘‘Do you want to put a cannula in this baby.’’ This baby was born at 28 weeks and is now 2 weeks old,
Children’s Nurses and Overseas Placement
99
it’s still as big as my palm: ‘‘No we don’t do that until we’re qualified!’’, so I wouldn’t be happy doing that. No but they let me do pretty much anything else like suctioning down the ET tube.
Contributing to the Host There was an acknowledgement from the participants that the learning was a two way process, that as students they learned from their hosts, that they also were able to exchange ideas with nurses in the host clinical areas. P2 You just have to be sort of open minded and listen to what’s going on. I used to tell my mentor the sort of practices we have here as well and I think by the time I left she had kind of taken on some of that and she was talking to the parents more and encouraging the parents to be with them I1 So you can be a role model. P2 Yeah try and influence them in some of the good thing we’ve got going on over here. Leaving your mark.
The participants also referred to ongoing relationships with their hosts, and some had made tentative plans to return to their hosts for post qualification experience. DISCUSSION The findings of this student evaluation appear to match closely those of the literature review. However, although the same themes emerged the preliminary data suggest that children’s nursing students were able to learn about cultural practice and health care provision for children in host countries. It is perhaps doubtful whether true cultural competence can be fully achieved, especially within a time constrained placement. Instead perhaps Jurez et al. (2006) concept of cultural humility may be more appropriate. The data presented here suggest that despite the short duration of placements, students were able to gain understanding of cultural practice in relation to children’s rights and healthcare. Our student experiences showed an emerging cultural competency. They were able to comment and reflect on issues around the perceived inequalities of insurance based healthcare systems and the noticeable lack of parental input in caring for their hospitalized children compared
100
R. Standage and D. Randall
with UK culture and practice. There was an overwhelming appreciation for the UK National Health Service. Comparison of healthcare systems and nursing practices was the second emergent theme. The students were able to articulate the differences between UK practice and their host countries. This process of challenging assumptions appeared to help student to appreciate the child rights stance promoted in the UK. Whether student’s overseas placements affect their host’s views of children or their healthcare is not addressed in these studies. The theme of personal and professional development as a result of the placement was evident in most of the studies. Children’s nurses appear to also benefit professionally from their overseas placement despite the fact that the host countries only allow specialization after graduation/ registration not at the undergraduate/pre registration level as in the UK. Organizing overseas placements can be time consuming and incurs a significant amount of expenditure which may be beyond students’ means, and this must be borne in mind when addressing equality of opportunity in nursing programmes. The ability to contribute to the host country and the forging of longer term relationships also were an important factor with students exchanging ideas about practice with their hosts (Frenk et al., 2010). What has not been demonstrated is whether the student’s presence in the host organisation affects the development of children’s nursing in that country. CONCLUSION There is evidence from this review and our own evaluation that an overseas experience gives students opportunities to develop personal and professional skills, and cultural awareness. Despite the differences in the organization of children’s healthcare and nursing, students were able to learn about cultural practice, children’s rights and children’s nursing in host cultures. Further research should focus on the long -term effects of overseas placement not only on student’s career progression and development of leadership skills, but also the effects on health care for children in the UK and host countries. DECLARATION OF INTEREST The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper.
Children’s Nurses and Overseas Placement
101
REFERENCES Arksey, H. & O’Malley L. (2005). Scoping studies: towards a methodological framework. International Journal of Social Research Methodology, 8, 19–32. doi:10.1080/1364557032000119616. Button, L., Green, B., Tengrah, C., Johansson, I., & Baker, C. (2005). The impact of international placements on nurses personal and professional lives: a literature review. Journal of Advanced Nursing, 50, 315–324. doi:10.1111/j.1365-2648.2005.03395.x. Callister, L. & Cox, A. (2006). Opening our hearts and minds: the meaning of international clinical nursing electives in the personal and professional lives of nurses. Nursing and Health Sciences, 8, 95–102. doi:10.1111/j.1442-2018.2006. 00259.x. Davis, R. (2008). The Bologna process: The quiet revolution in nursing higher education. Nurse Education Today, 28, 935–942. doi:10.1016/j.nedt.2008.05.008. Duffy, M., Farmer, S., Ravert, P., & Huittinen, L. (2005). International community health networking project: two year follow up of graduates. International Nursing Review, 52, 24–31. doi:10.1111 /j.1466-7657.2004.00252.x. Frenk, J., Chen, L., Bhutta, Z.A., Cohen, J., Crisp, N., Evans, T., Fineberg, H., Garcia, P., Ke, Y., Kelley, P., Kistnasamy, B., Meleis, A., Naylor, D., Pablos-Mendez, A., Reddy, S., Scrimshaw, S., Sepulveda, J., Serwadda, D., Zurayk, H. (2010). Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet, 376, 1923–1958. doi:10.1016/S01406736(10)61854-5. Grant, E. & McKenna, L. (2003). International clinical placements for undergraduate students. Journal of Clinical Nursing, 12, 529–536. doi: 10.1046/j.1365-2702.2003. 00717.x. Greatrex-White, S. (2008). Uncovering study abroad: foreignness and its relevance to nurse education and cultural competence. Nurse Education Today, 28, 530–538. doi:10.1016/j.nedt.2007.09.005. Green, B., Johansson, I., Rosser, M., Tengnah, C., & Segrott, J. (2008). Studying abroad: a multiple case study of nursing students, international experiences. Nurse Education Today, 28, 981–992. doi:10.1016/j.nedt.2008.06.003. Hagen, L., Munkhondya, B., & Myhre, K. (2009). Similarities and mutual understanding: exchange experiences in Malawi for host and guest students. International Nursing Review, 56, 476–482. doi:10.1111/j.1466-7657.2009.00744.x. Jurez, J., Marvel, K., Brezenski, K., Glazner, C., Towbin, M., & Lawton, S. (2006). Bridging the gap: a curriculum to teach residents cultural humility. Family Medicine, 38, 97–102. Keogh, J. & Russel-Roberts, E. (2009). Exchange programmes and student mobility: meeting students’ expectations or an expensive holiday? Nurse Education Today, 29, 108–116. doi:10.1016/j.nedt.2008.07.006 108–116. Krueger, R.A. (1994). Focus groups: A practical guide to applied research. Thousand Oaks, CA: Sage. Kulbok, P.A., Mitchell, E.M., Glick, D.F. & Greiner, D. (2012). International experiences in nursing education: a review of the literature. International Journal of Nursing Education Scholarship, 9, 1–21. doi:10.1515/1548-923X.2365.
102
R. Standage and D. Randall
Law, K. & Muir, N. (2006). The internationalisation of the nursing curriculum. Nurse Education in Practice, 6, 149–155. doi:10.1016/j.nepr.2005.11.004. Lee, N.J. (2004). The impact of international experience on student nurses’ personal and professional development. International Nursing Review, 15, 113–122. doi:10.1111/ j.1466-7657.2003.00200.x. Liaschenko, J. (1997). Ethics and the geography of the nurse-patient relationship: spatial vulnerabilities and gendered space. Scholarly Inquiry for Nursing Practice, 11, 45–59. McAuliffe, M. & Cohen, M. (2005). International nursing research and educational exchanges: a review of the literature. Nurse Outlook, 53, 21–25. doi:10.1016/ j.outlook.2004.10.004. Nursing and Midwifery Council (2010). Standards for pre-registration nursing education: Draft for consultation. London: Nursing and Midwifery Council. Parahoo, K. (2006). Nursing research: principles, process and issues. Basingstroke: Palgrave Macmilian. Randall, D. & Hallowell, L. (2012). ‘‘Making the bad things seem better’’: Coping in children receiving healthcare. Journal of Child Health Care, 16, 304–312. doi:10.1177/1367493512443907. Ruddock, H. & Turner, S. (2007). Developing cultural sensitivity: nursing experiences of a study abroad programme. Journal of Advance Nursing, 59, 361–369. doi:10.1111/ j.1365-2648.2007.04312.x. Shields, L. & Nixon, J. (2004). Hospital care of children in four countries. Journal of Advanced Nursing, 45, 475–486. doi:10.1046/j.1365-2648.2003.02930.x. Smith-Miller, C., Leak, A., Harlan, C., Dieckmann, J., & Sherwood, G. (2010). ‘‘Leaving the comfort of the familiar’’: fostering workplace cultural awareness through short term global experiences. Nursing Forum, 45, 18–28. doi:10.1111/j.17446198.2009.00163.x. Tabi, M. & Mukherjee, S. (2003). Nursing in global community: a study abroad programme. Journal of Transcultural Nursing, 14, 134–138. doi:10.1177/ 1043659602250637.
Notice of Correction: A change has been made to the first author’s degree since this article’s original online publication date of February 4, 2014.
Copyright of Issues in Comprehensive Pediatric Nursing is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
THE BENEFITS FOR CHILDREN’S NURSES OF OVERSEAS PLACEMENTS: WHERE IS THE EVIDENCE?
Richard Standage, MSc1, and Duncan Randall, PhD2
Overseas placements are presumed to provide students with experiences to enhance their cultural competence and to give them insights into other healthcare systems. However, the literature has not focused on what students of children’s nursing might gain from an overseas placement. This paper is a report of a literature review (2003–2011) and our own student evaluation, both aimed at shedding new light on this important opportunity for learning for children’s nurses. The literature review indicates that current research does not address the learning from overseas placements for children’s nurses. Our student evaluation suggests children’s nursing students are able to explore the position of children in the host culture and to place this in a healthcare context. Students also reported that they adhered to UK scope of student practice when delivering care to children on overseas placement. These placements provide a valuable learning experience for children’s nurses. However, consideration in the shorter term is required to address issues of equity. Looking forward, further large scale studies are required to determine the long term effects of such experience on the health outcomes for children, and development of children’s nurses and children’s nursing globally.
20 14
1 School of Health and Population Sciences, Nursing, University of Birmingham, Edgbaston, Birmingham, United Kingdom and 2Family and Community Health University Research Group, University of Western Sydney, Penrith, Sydney, Austrails
Keywords: children’s nursing, cultural assimilation, elective placement, nursing education Received 27 August 2013; revised 7 December 2013; accepted 8 December 2013
Correspondence: Duncan Randall, Family and Community Health University Group, School of Nursing and Midwifery, University of Western Sydney, Campbelltown Campus, Locked Bag 1797, Penrith, NSW 2751. E-mail: [email protected]
87
88
R. Standage and D. Randall
INTRODUCTION While issues of comparative healthcare and globalisation can be taught in a classroom setting, there is a body of literature that suggests that immersion in another culture is more effective (Duffy et al., 2005). One of the presumed benefits for students of overseas placements is an increase in their cultural awareness (Kulbok et al., 2012; Law & Muir, 2006; Tabi & Mukherjee, 2003). This is important for students, and qualified nurses who are required to deliver culturally sensitive care to a range of communities. It is therefore imperative that as undergraduates, students are given exposure to cultural diversity to equip them both for clinical placements and for their future careers. In addition to cultural safe practice at home, there is an increasing blurring of international boundaries and the single employment market particularly within the European Union (EU) (Law & Muir, 2006) which makes knowledge of other healthcare systems a major asset for future career development and portability (Frenk et al., 2010). The Bologna Process in particular has the stated aim of increasing the mobility of graduate nurses within the EU via unification of pre-registration programs and reciprocal recognition of qualifications (Davis, 2008). The Bachelor of Nursing programme at our university requires students to undertake a 4-week self-organized experience to an area or institution that does not form part of our usual clinical placement circuit. Although there is no specific requirement to go overseas, the majority of students choose this option as demonstrated by statistics from recent cohorts: 66%, n ¼ 82 (of which 17 were child field of practice) in 2010, 71%, n ¼ 74 (of which 18 were child field of practice) in 2011. Students receive preparatory sessions that address issues around culture shock and how this can be recognized and dealt with. As the placement is for 4 weeks there is no requirement for the host organization to be audited or to have accredited assessors (NMC, 2010), nor would students be expected to be fluent in the host’s language. Placements are covered by the University’s indemnity insurance. Kulbok et al., 2012 provide a literature review of overseas placements. They note the two previous reviews of overseas placements, both published in 2005 (Button et al., 2005; McAuliffe & Cohen, 2005).These 2005 reviews reported on papers from 1980 and 1983 respectively up to 2003, and found that nursing students reported enhanced personal development, a wider perspective on practice, a wider appreciation of diverse healthcare systems and an increased sensitivity towards cultural issues. Kulbok et al., 2012 reviewed papers from 2003 to 2010.
Children’s Nurses and Overseas Placement
89
They found that only 2 of the 23 studies reported a program evaluation which went beyond student feedback. Few of the studies use a theoretical framework (3 of the 23) and the research had not addressed the recommendations of the previous reviews to evaluate programme over longer periods. However, none of these studies considered the specific issues in relation to children’s nursing. The lack of previous literature on children’s nursing students’ overseas placements can be explained by the fact that few countries have separate education programs for children’s nurses at undergraduate level, and by the lack of a trans-cultural focus in children’s nursing more generally (Shields & Nixon, 2004). REVIEW OF LITERATURE 2003–2011: METHODS The literature review presented here uses a scoping review methodology as suggested by Arksey & O’Malley (2005) to review the literature looking specifically at children’s nursing students’ experiences of overseas placements. A scoping method was used rather than a systematic or meta analysis approach because it was unclear whether the research included children’s nurses. Even in the studies involving UK students it was difficult to ascertain if the sample included students on child field of practice and to identify the data associated with these participants. The advantage of a scoping review is that instead of trying to synthesize disparate findings, a scoping review allows for a broader approach and attempts to capture all the literature irrespective of the quality of the data or method. The research question used was: What issues of children’s nursing have been addressed in the research literature between 2003 and 2011 relating to students learning from overseas placements? English language, published research relevant to the research question was included. The keywords used were adapted from Button et al. (2005): international exchange, international studies, international education, international placement and exchange programme, all combined with nurse* and education. The data bases used were CINAHL, British Nursing Index. and Medline. Twenty-one articles were retrieved, of which 11 were rejected as they were either personal accounts or descriptions of the overseas/exchange programs rather than methodologically based research. Two of the papers were reporting different findings from one study. These were combined and considered as one. The remaining nine studies (see Table 1) formed the basis for this review. The first author (RS) performed the search, both authors read all papers independently and then agreed on the analysis.
Qualitative Qualitative
Qualitative Qualitative
UK
UK/Sweden
Norway/Malawi
German/UK
UK
USA
Denmark/ Australia
Greatrex-White (2008) Green et al (2008)
Hagen et al (2009)
Keogh & RusselRoberts (2009)
Lee (2004)
Smith-Miller et al (2010) Ruddock & Turner (2007)
Qualitative
Qualitative
Qualitative
Qualitative
Australia
Grant & McKenna (2003)
Qualitative
Method
USA
Country Based
Callister & Cox (2006)
Author
Interviews
Interviews and focus groups Reflection papers
Interviews
Interviews
Interviews and document analysis
Diaries
Journals and interviews
Interviews
Data Collection
Table 1. Selected papers in scoping literature review
5 students, 2 Norway to Malawi, 3 Malawi to Norway 7 students in a German to Finland exchange programme 4 module facilitators and 18 students 15 Baccalaureate or masters degree students 7 students exchange visit Denmark to Jamaica, Malta, Greenland and Australia
18 students UK to Sweden, 14 Sweden to UK
9 students. 3 interviewed only, 6 interviews and journals. 26 students UK to unknown
20 students, USA to Argentina, Guatemala, Jordan and Native Americans
Participants
Leaving behind the familiar, the experience of being a foreigner Increased self-reliance, professional knowledge and skills, awareness of different healthcare roles, change in attitude to others from different cultures Similarities and differences in practice, learning relational skills, developing cultural competence Diffusion of knowledge between different countries, education needs met despite language differences Personal development and enhanced transition from student to qualified nurse Personal growth and broader insight into multicultural care Development of cultural sensitivity and personal growth
Increased understanding of other cultures, increased understanding of global health issues, increased commitment to make a difference, personal and professional growth, contribution to professional growth in host countries, interpersonal connections, developing cultural competence Differences in nursing culture
Key Findings
90
R. Standage and D. Randall
Children’s Nurses and Overseas Placement
91
LITERATURE REVIEW UPDATED 2003–2011: FINDINGS The nine studies all used qualitative methodology incorporating interviews, focus groups, and diaries or reflective journals/writing. Five of the papers detail UK students’ overseas placements including exchange programmes. In these five papers it is not clear which field of practice students are undertaking. It is possible that children’s nursing students were included in these studies, but none of the papers refer explicitly to child field of practice. The four studies based outside the UK do not report aspects of children’s nursing. Thematic analysis of the data produced four axial themes: developing cultural competence, identifying health care differences, personal and professional growth, and contributing to the host. Developing Cultural Competence Cultural competence is a multi-faceted concept and is manifested in a variety of ways within the studies. Callister & Cox (2006) for instance use the term ‘‘opening our hearts and minds’’ and specifically refer to their study participants having an increased understanding of other cultures and peoples. Participants in the study by Greatrex-White (2008) described this concept in terms of them being the outsider or foreigner, which made them reflect on how this must feel for people who come from overseas and engage with healthcare provision. A key concept here was the participants looking on ‘‘we’’ as a sort of ‘‘they,’’ which she goes on to describe as an understanding of otherness and a clear development of cultural awareness and recognition of cultural diversity. Participants in the study by Green et al. (2008) spoke in similar terms about an increased awareness of other cultures, leading to a greater tolerance and empathy for minority ethnic groups. Similar ideas emerged in the study by Smith-Miller et al. (2010), where participants talked about their difficulties being in a non-English speaking country and how this enhanced their understanding of similar problems that face people in the UK for whom English is a second language, forcing them to review previously held opinions and assumptions. A key example was the participants’ desire to stay close together in a mutually supportive group, which increased their understanding of minority ethnic groups who form close community bonds in the UK. The importance of mutual social support was brought out in Ruddock & Turner’s (2007) study, who also reported on the experience of being a foreigner with a subsequently enhanced empathy, respect and understanding for immigrants in a similar position, along with the importance of being non-judgmental.
92
R. Standage and D. Randall
None of the studies discuss students learning about cultural practice in relation to children and childhood. Identifying Healthcare Differences Differences in children’s healthcare provision were not discussed in the literature. Findings under this heading can be usefully divided into micro factors relating to nursing roles and responsibilities, and macro factors, relating to wider healthcare systems and policies. Healthcare Differences: Micro Differences in technique were picked up on by students in the study by Keogh & Russel-Roberts (2009), who reported that they had observed disparities in technical skills and levels of autonomy between the two countries (Germany and Finland). Neither system was thought superior, and both groups felt that they had learned something from observing and participating in a different culture of practice. Similarly participants in the study by Lee (2004) compared and contrasted clinical procedures, roles and responsibilities, and also extended this to commenting on perceived differences in nurse education between their UK experience and the various host countries. Participants in the study by Grant & McKenna (2003), which looked at Australian students who travelled to a variety of overseas settings referred to procedures that they considered to be old fashioned and routine, and perceived nursing to be very much more hierarchical than they were accustomed to. Healthcare Differences: Macro Callister & Cox (2006) refer to an increased understanding of global socio-political and health issues. Similarly participants in the study conducted by Keogh & Russel-Roberts (2009) were all engaged in comparing the German and Finnish health care systems and their relative strengths and weaknesses. There was a strong consensus that the Finnish system had a stronger component of public health than the German one. UK students in the study by Grant & McKenna (2003), who had already commented on a more hierarchical nursing structure, also felt that this extended to nurse-doctor relationships, with medical staff often coming across as intimidating and being feared. Participants in the Smith-Miller et al. (2010) study reported on healthcare in developing countries, with a noticeable lack of technology, a low nurse to patient ratio, reliance on lay carers, and a
Children’s Nurses and Overseas Placement
93
lack of patient rights. This led a number of students to question the disparities of global healthcare provision. Personal and Professional Growth Personal This primarily was concerned with issues around overcoming stress and mastering language barriers. Participants in the study by Green et al. (2008) talked about having to overcome homesickness as well as more practical issues such as problems with accommodation. Tackling these issues gave students confidence and engendered a sense of achievement. Participants in the study by Lee (2004) found they could overcome language barrier problems by being more attuned to nonverbal communication. All the respondents in the Keogh & Russel-Roberts (2009) study referred to personally benefitting from the exchange with an altered approach to their nursing care delivery. Participants in the study carried out by Ruddock & Turner (2007) all couched this aspect of their experience as making a transition from one culture to another. Although many reported feelings of uncertainty from the loss of a familiar environment, they were ultimately able to adjust, hence achieve personal development. A key theme that emerged from the study by Greatrex-White (2008) was that of leaving behind the familiar and embracing the new environment with its new routines. This initially led to a sense of detachment which the respondents were able to overcome, although for many this was not a linear process, and was characterized by periods of elation and depression. Professional This finding was mainly concerned with enhancing future career prospects as a result of the experience. Callister & Cox (2006) refer specifically to professional growth as a key finding. Participants in the study by Green et al. (2008) reported learning new insights into multi-disciplinary working, along with developing their technical, personal, and interpersonal skills. Many participants felt that their overseas experience had been a contributory factor in securing their first post-registration position. This finding was echoed by a student in the study by Lee (2004) who felt that her overseas experience had helped her during her stressful transition from student to qualified nurse.
94
R. Standage and D. Randall
Keogh & Russel-Roberts (2009) explored this issue in terms of the level of student supervision. While most students appreciated the level of supervision they received, there also was the feeling that it should ideally be pitched at a level that allowed them to develop and experience a degree of self-directed learning. This theme was picked up on by Lee (2004) where respondents reported there was often a degree of overprotection in domestic placements, with a readily available support network. Without this, students felt they had more freedom to develop assertiveness and problem solving skills. Respondents in the study by Grant & McKenna (2003) saw professional development in terms of having the confidence to engage and show initiative in their placement setting. This led many of them to realize that they had transferable clinical skills to be an effective nurse. Contributing to the Host Callister & Cox (2006) expressed this theme in terms of increasing the commitment to make a difference and contributing to professional development in the host country. Both Greatrex-White (2008) and Green et al. (2008) reported on participants establishing friendships which persisted once they had returned to their own country. Similarly participants in Hagen et al. (2009) spoke of a desire to learn from each other, recognizing that both host and guest could exchange skills and knowledge that would enhance each other’s practice. The findings of this literature review mirror to an extent the themes that were apparent in the earlier literature review by Button et al. (2005).The lack of information about children’s nursing in these studies of students experiences of overseas elective led us to review data collected in our previous student evaluation. STUDENT EVALUATION: METHOD A purposive sample was sought from children’s nursing students in one cohort (2007), who recently had returned from their overseas placement. The students were invited to share a lunch and participate in a group interview. All students were invited to the group which took place on an afternoon when no teaching activities were scheduled. The students were informed about the purpose of the group interview, assured of confidentiality with the proviso that any safeguarding issues would be acted upon. The group lasted for 80 minutes, one afternoon in the autumn of 2009. The team felt that as this was an evaluation of current practice it did not require ethical review. The activities undertaken by the students
Children’s Nurses and Overseas Placement
95
Table 2. Topic guide for overseas placement group interview
Where did you do your overseas placements? And how long were you there? Did the places you went to have philosophies of care? How were these philosophies enacted in the care of children? Were children’s rights recognized? How did nurses involve children in their care? Did nurses and parents negotiate the care of children? If so how was this done? What do you feel you have learned about children’s nursing from your overseas placement? Is there anything else you would like to add?
in the group interview were considered to be equal to those in which they participate in the classroom setting as part of the usual placement evaluation process and therefore did not present additional risks to the student. All students were asked and gave written consent and assured that they could withdraw at any time without penalty. Students were informed of the intention to publish the findings. A topic guide was used in the group to focus the conversation as suggested by Krueger (1994) (see Table 2). The students were aware that the group interview was recorded on audio tape and were asked to comment on the transcript of the interview. The authors analyzed the transcript separately using open coding (Parahoo, 2006). Once the transcript had been coded by each of the authors they met to agree on axial coding, where themes were created and data sections were ascribed to particular themes. Once coding was complete the authors reviewed the literature review reported above, some labels for themes were changed as on reflection they appeared to be essentially the same as those uncovered in the literature review. STUDENT EVALUATION: FINDINGS Although the cohort consisted of 23 students only 3 students attended the group (Participants P1–3). Attendance may have been poor as the group was held on an afternoon set aside for sport and other activities. Students may have been unable to attend due to other commitments which they regularly undertook at the time of the group. However, the students who did attend had visited different countries and different clinical areas. They had all gone overseas on their overseas placement, one to a majority (developing) country, India, and two to western, northern hemisphere countries (Canada and USA). They had worked in public hospitals, primary care, neonatal intensive care, and a hospice setting. All of the participants were female, White, British second year children’s nursing students. Although this sample is small and
R. Standage and D. Randall
96
homogenous in terms of the students’ cultural backgrounds with clear consequences for validity and reliability, the data from the interview showed diverse views of the overseas placement and insight into children’s nursing within different countries health systems and cultures. Developing Cultural Competence The participants recognized that they had learned about the host cultures, but they also felt that they could apply this new understanding to immigrant communities in the UK who had come from these cultural backgrounds. In the following excerpts, P1 ¼ Participant 1; I1 ¼ Investigator one, and so on. P1 I think I’m more culturally aware than I was. I have a greater understanding of the Indian culture and not just . . . to say that Indian culture would be naı¨ve, because it’s not just the one culture it’s got so many different cultures. And a greater understanding of why we need to do the things that we do, like gaining consent from a child, yeah we don’t need that consent but to gain that consent, is to have that child understand and agree with what you’re doing . . . I think I have a greater appreciation of what we actually do in terms of nursing here in contrast to other countries.
Identifying Healthcare Differences Healthcare Differences: Micro Students often framed their experience of children’s nursing in other countries in terms of how nurses support the practice of medicine (Liaschenko, 1997), less obvious was how nurses facilitate people’s experience of healthcare or facilitate how children live with illness (Randall & Hallowell, 2012). P2 A lot of it was computer based. All the notes were on computer, all the drugs charts, everything was computer based, which was fine, all very good until the computer crashed. . . . but things like the pharmacy over there, the nurse don’t draw up the drugs and stuff. We were literally just handed the syringes with the drugs in. They were then checked on the computer and given to the patient.
However, the participants did also frame their experiences as case narratives. They told stories of particular cases to illustrate what had
Children’s Nurses and Overseas Placement
97
happened, sometimes returning to the same case to make further points. The data quoted below also shows how the students recognized the rights of children in health care in a cultural context. P1 Like for instance we had a child that came in, he was five or six and because there’s no safety measures for things like fans, the child had put two of his fingers in a fan, . . . luckily it had gone through the joint, one of these little joints and it was hanging off . . . and we told the parents the child has to have an operation now. ‘‘Oh no we’re going to take him home we don’t want to pay for that’’—but they could. So the doctor said look if you don’t pay for it now you are going to have to pay for it when it gets infected. ‘‘Ok. We’ll pay for it.’’ This child was terrified, screaming, crying trying to run away, trying to hide. And the doctors just literally just picked him up, told him be quiet . . . . . . they didn’t use general anesthetic .. . . So this child is terrified, he was literally hauled upstairs and put on the operating bed. He’s still screaming, still trying to drag his hand away. . . . There was no advocacy there, nobody thought to stand up and say hang on maybe we need to explain before we do this, and it might be a bit easier if we explained and he calms down.
Healthcare Differences: Macro Participants implicitly and explicitly compared nursing in Britain with their experiences in overseas placement. For some the comparison focused on differences in the practice of nursing. For example those who went to countries with health insurance funded systems felt uncomfortable with the way care was accounted for in financial terms. Comparisons were also made about how care is negotiated between children, parents, and nurses (and other healthcare professionals). I2 So there were set visiting times? P2 Yeah as long as the doctors’ rounds had finished they could visit whenever they wanted but it was sort of always after 12. . . . I hardly saw any parents while I was there. I was really surprised. I used to ask my mentor when do the parents come, ‘‘oh they just come when they want,’’ but in America as well even babies who aren’t special care are taken from their parents and put into nurseries.
One participant, who had been to a developing (majority world) country placed the UK and the host country on a time line, to compare nursing in the two contexts. With the host country practices being related
R. Standage and D. Randall
98
to British practice 50 years ago. The participants referred on a number of occasions to how the British nursing context was, for them fairer than that of host countries. P2 I certainly learned to appreciate the NHS. There were so many sort of roadblocks when it came to the insurance. So you can’t do this, you can’t do that .. . . You know we treat patients equally here, and sometime it just didn’t seem to happen there.
During their overseas placements the students had come to understand a lot about how host countries health systems operate. They were also able to make direct comparisons with the British health care system. P3 They’ve got a weird system in Canada. It’s based by Province, and you can have free health care in your Province but if you go out of your Province you need health insurance. And not everything’s provided on the Government’s, by the Province .. . . You’re entitled to a certain amount of respite, sort of dependent on . . . they have to fulfill certain criteria, so they had to be technology dependent, or medically fragile. There were long lists of guidelines . . . I think it was 14 days a year. P1 A lot of corruption like they were just going to use the ambulance to go shopping. And there was a massive train crash, 30 people died and there were about 15 children involved and the ambulance was over sort of near Nepal at the time so these children couldn’t get brought into the hospital, and so most of them died at that scene .. . . So this acceptance of prejudices and corruption, it’s not something that I’m used to coming across it’s not something that I’ve encountered.
Personal and Professional Growth The participants recognised that the overseas placement gave them access to clinical experiences which they had not had so far during their course in the UK. One participant was able to work in a hospice which, although a rotation available in the UK, on our program was not one to which the student had been allocated. The participants were also able to gain experience of skills and interventions which may not be facilitated in UK practice, although the participants seemed to stay within their UK scope of practice limitations. P2 They were willing to let me do so much. ‘‘Do you want to put a cannula in this baby.’’ This baby was born at 28 weeks and is now 2 weeks old,
Children’s Nurses and Overseas Placement
99
it’s still as big as my palm: ‘‘No we don’t do that until we’re qualified!’’, so I wouldn’t be happy doing that. No but they let me do pretty much anything else like suctioning down the ET tube.
Contributing to the Host There was an acknowledgement from the participants that the learning was a two way process, that as students they learned from their hosts, that they also were able to exchange ideas with nurses in the host clinical areas. P2 You just have to be sort of open minded and listen to what’s going on. I used to tell my mentor the sort of practices we have here as well and I think by the time I left she had kind of taken on some of that and she was talking to the parents more and encouraging the parents to be with them I1 So you can be a role model. P2 Yeah try and influence them in some of the good thing we’ve got going on over here. Leaving your mark.
The participants also referred to ongoing relationships with their hosts, and some had made tentative plans to return to their hosts for post qualification experience. DISCUSSION The findings of this student evaluation appear to match closely those of the literature review. However, although the same themes emerged the preliminary data suggest that children’s nursing students were able to learn about cultural practice and health care provision for children in host countries. It is perhaps doubtful whether true cultural competence can be fully achieved, especially within a time constrained placement. Instead perhaps Jurez et al. (2006) concept of cultural humility may be more appropriate. The data presented here suggest that despite the short duration of placements, students were able to gain understanding of cultural practice in relation to children’s rights and healthcare. Our student experiences showed an emerging cultural competency. They were able to comment and reflect on issues around the perceived inequalities of insurance based healthcare systems and the noticeable lack of parental input in caring for their hospitalized children compared
100
R. Standage and D. Randall
with UK culture and practice. There was an overwhelming appreciation for the UK National Health Service. Comparison of healthcare systems and nursing practices was the second emergent theme. The students were able to articulate the differences between UK practice and their host countries. This process of challenging assumptions appeared to help student to appreciate the child rights stance promoted in the UK. Whether student’s overseas placements affect their host’s views of children or their healthcare is not addressed in these studies. The theme of personal and professional development as a result of the placement was evident in most of the studies. Children’s nurses appear to also benefit professionally from their overseas placement despite the fact that the host countries only allow specialization after graduation/ registration not at the undergraduate/pre registration level as in the UK. Organizing overseas placements can be time consuming and incurs a significant amount of expenditure which may be beyond students’ means, and this must be borne in mind when addressing equality of opportunity in nursing programmes. The ability to contribute to the host country and the forging of longer term relationships also were an important factor with students exchanging ideas about practice with their hosts (Frenk et al., 2010). What has not been demonstrated is whether the student’s presence in the host organisation affects the development of children’s nursing in that country. CONCLUSION There is evidence from this review and our own evaluation that an overseas experience gives students opportunities to develop personal and professional skills, and cultural awareness. Despite the differences in the organization of children’s healthcare and nursing, students were able to learn about cultural practice, children’s rights and children’s nursing in host cultures. Further research should focus on the long -term effects of overseas placement not only on student’s career progression and development of leadership skills, but also the effects on health care for children in the UK and host countries. DECLARATION OF INTEREST The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper.
Children’s Nurses and Overseas Placement
101
REFERENCES Arksey, H. & O’Malley L. (2005). Scoping studies: towards a methodological framework. International Journal of Social Research Methodology, 8, 19–32. doi:10.1080/1364557032000119616. Button, L., Green, B., Tengrah, C., Johansson, I., & Baker, C. (2005). The impact of international placements on nurses personal and professional lives: a literature review. Journal of Advanced Nursing, 50, 315–324. doi:10.1111/j.1365-2648.2005.03395.x. Callister, L. & Cox, A. (2006). Opening our hearts and minds: the meaning of international clinical nursing electives in the personal and professional lives of nurses. Nursing and Health Sciences, 8, 95–102. doi:10.1111/j.1442-2018.2006. 00259.x. Davis, R. (2008). The Bologna process: The quiet revolution in nursing higher education. Nurse Education Today, 28, 935–942. doi:10.1016/j.nedt.2008.05.008. Duffy, M., Farmer, S., Ravert, P., & Huittinen, L. (2005). International community health networking project: two year follow up of graduates. International Nursing Review, 52, 24–31. doi:10.1111 /j.1466-7657.2004.00252.x. Frenk, J., Chen, L., Bhutta, Z.A., Cohen, J., Crisp, N., Evans, T., Fineberg, H., Garcia, P., Ke, Y., Kelley, P., Kistnasamy, B., Meleis, A., Naylor, D., Pablos-Mendez, A., Reddy, S., Scrimshaw, S., Sepulveda, J., Serwadda, D., Zurayk, H. (2010). Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet, 376, 1923–1958. doi:10.1016/S01406736(10)61854-5. Grant, E. & McKenna, L. (2003). International clinical placements for undergraduate students. Journal of Clinical Nursing, 12, 529–536. doi: 10.1046/j.1365-2702.2003. 00717.x. Greatrex-White, S. (2008). Uncovering study abroad: foreignness and its relevance to nurse education and cultural competence. Nurse Education Today, 28, 530–538. doi:10.1016/j.nedt.2007.09.005. Green, B., Johansson, I., Rosser, M., Tengnah, C., & Segrott, J. (2008). Studying abroad: a multiple case study of nursing students, international experiences. Nurse Education Today, 28, 981–992. doi:10.1016/j.nedt.2008.06.003. Hagen, L., Munkhondya, B., & Myhre, K. (2009). Similarities and mutual understanding: exchange experiences in Malawi for host and guest students. International Nursing Review, 56, 476–482. doi:10.1111/j.1466-7657.2009.00744.x. Jurez, J., Marvel, K., Brezenski, K., Glazner, C., Towbin, M., & Lawton, S. (2006). Bridging the gap: a curriculum to teach residents cultural humility. Family Medicine, 38, 97–102. Keogh, J. & Russel-Roberts, E. (2009). Exchange programmes and student mobility: meeting students’ expectations or an expensive holiday? Nurse Education Today, 29, 108–116. doi:10.1016/j.nedt.2008.07.006 108–116. Krueger, R.A. (1994). Focus groups: A practical guide to applied research. Thousand Oaks, CA: Sage. Kulbok, P.A., Mitchell, E.M., Glick, D.F. & Greiner, D. (2012). International experiences in nursing education: a review of the literature. International Journal of Nursing Education Scholarship, 9, 1–21. doi:10.1515/1548-923X.2365.
102
R. Standage and D. Randall
Law, K. & Muir, N. (2006). The internationalisation of the nursing curriculum. Nurse Education in Practice, 6, 149–155. doi:10.1016/j.nepr.2005.11.004. Lee, N.J. (2004). The impact of international experience on student nurses’ personal and professional development. International Nursing Review, 15, 113–122. doi:10.1111/ j.1466-7657.2003.00200.x. Liaschenko, J. (1997). Ethics and the geography of the nurse-patient relationship: spatial vulnerabilities and gendered space. Scholarly Inquiry for Nursing Practice, 11, 45–59. McAuliffe, M. & Cohen, M. (2005). International nursing research and educational exchanges: a review of the literature. Nurse Outlook, 53, 21–25. doi:10.1016/ j.outlook.2004.10.004. Nursing and Midwifery Council (2010). Standards for pre-registration nursing education: Draft for consultation. London: Nursing and Midwifery Council. Parahoo, K. (2006). Nursing research: principles, process and issues. Basingstroke: Palgrave Macmilian. Randall, D. & Hallowell, L. (2012). ‘‘Making the bad things seem better’’: Coping in children receiving healthcare. Journal of Child Health Care, 16, 304–312. doi:10.1177/1367493512443907. Ruddock, H. & Turner, S. (2007). Developing cultural sensitivity: nursing experiences of a study abroad programme. Journal of Advance Nursing, 59, 361–369. doi:10.1111/ j.1365-2648.2007.04312.x. Shields, L. & Nixon, J. (2004). Hospital care of children in four countries. Journal of Advanced Nursing, 45, 475–486. doi:10.1046/j.1365-2648.2003.02930.x. Smith-Miller, C., Leak, A., Harlan, C., Dieckmann, J., & Sherwood, G. (2010). ‘‘Leaving the comfort of the familiar’’: fostering workplace cultural awareness through short term global experiences. Nursing Forum, 45, 18–28. doi:10.1111/j.17446198.2009.00163.x. Tabi, M. & Mukherjee, S. (2003). Nursing in global community: a study abroad programme. Journal of Transcultural Nursing, 14, 134–138. doi:10.1177/ 1043659602250637.
Notice of Correction: A change has been made to the first author’s degree since this article’s original online publication date of February 4, 2014.
Copyright of Issues in Comprehensive Pediatric Nursing is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
