Since 2015 Birmingham City University has had links with the Lusaka College of Nursing in Zambia. Undergraduate nursing students in the adult nursing field, supervised by two lecturers, were given the opportunity to work alongside students at the Lusaka College of Nursing. The university-structured elective was supported by Birmingham City University's internationalisation agenda and provided an opportunity for undergraduate students to experience different healthcare environments, develop cultural competence and understand international nursing. It also allowed the faculty to build links with other partner organisations. This article will evaluate this experience, with the aim of raising the profile of international nursing and the impact of international electives on students, the wider faculty, the university and beyond.
Background
Undertaking an international elective has been identified as having a long-lasting effect far beyond the period of the actual stay overseas and has been widely acknowledged as having a positive impact on practice when individuals return to the UK (Carter, 2015; Simms, 2016). For qualified nurses the benefits of working internationally has been widely acknowledged. In 2015, 96% of 339 volunteers who had been working in the developing world self-reported or demonstrated improved clinical and leadership skills (Haines, 2016). In addition, electives help students develop resourcefulness, cultural competence and resilience (Crisp, 2007).
International electives often form part of undergraduate student nurse training programmes. These experiences have been shown to significantly benefit undergraduate student nurses in developing their cultural competence (Button et al, 2004; Ruddock and Turner, 2007; Bozinoff et al, 2014; Norton and Marks-Moran, 2014). Placements overseas give students the opportunity to experience unfamiliar cultures (Button et al, 2004), which can facilitate the critical appraisal of different healthcare systems and the effects on the delivery of health care. Although many elements of this topic can be explored in a classroom, being ‘in country’ bridges the theory–practice divide (Ruddock and Turner, 2007), and furthermore, provides an opportunity for educators to promote the development of life skills, behaviours and attitudes that enhance future employability and leadership skills, a key responsibility within higher education (Cole and Tibby, 2013). This in turn can help students to develop and build life skills, which are an advantage when competing for future employment (British Council, 2013).
Experiences may challenge students' existing values and cultural issues (Button et al, 2004); this is particularly important when considering their role in the UK with the increasing diversity of multicultural Britain. Experiencing a ‘minority status’, students are required to adjust to living and surviving in a foreign culture (Button et al, 2004; Ruddock and Turner, 2007). This may help them to develop empathy and respect for immigrants who find themselves in similar positions back in the UK (Standage and Randall, 2014).
Although international electives are seen as positive experiences, it is worth noting that this is not always the case, for either student or host. Ethically, the concept of students undertaking international electives in resource-constrained environments could be seen as ‘practising on the poor’, and the argument of why students feel the need to travel to other countries when opportunities to work with deprived and poor communities exist within the UK needs to be considered (Gilbert et al, 2013). Gilbert et al (2013) provided a frank insight into the realities for medical students undertaking an international elective in a developing country: not having the appropriate supervision to undertake tasks, not being prepared for their role and undertaking tasks beyond their competence.
For host staff and communities the impact can be even greater. Already working with limited resources and employees, local staff need to take time to translate, explain, and mentor international visitors, which results in them being distracted from providing care to patients or supporting their own students who will be required to continue to work in this environment long after the international student has gone (Gilbert et al, 2013; Biddle, 2014). These factors need to be considered not only by students but also the universities that include electives as part of their programmes (Royal College of Nursing, 2017).
Overview of elective
In 2015, the Faculty of Health, Education and Life Sciences at Birmingham City University (BCU) began developing a programme to build capacity in critical care nursing in Zambia, a low-to-middle income country in sub-Saharan Africa. This project provided an opportunity to establish an undergraduate elective for nursing students. In 2016 the university decided to provide a co-ordinated international elective opportunity for all undergraduate students within the faculty as part of their course. Students were invited to apply for grants to support travel and subsistence. Following discussion with partners at the Lusaka College of Nursing (LCN), based at the University Teaching Hospital in Lusaka (the capital), an opportunity arose for students to undertake an elective within this environment.
All students interested in undertaking the elective were required to submit applications and were interviewed in February 2017. Following selection students undertook a pre-departure programme to prepare them for their experience; this included clinical skills training and a cultural awareness seminar. The programme included external subject matter experts to discuss their experiences and share knowledge, and there was an opportunity to meet the Principal Nursing Education Officer and the Principal Tutor for the Critical Care Nursing programme at LCN (through the European Union Erasmus+ International Credit Mobility programme between BCU and LCN). Six students undertook the elective in August 2017, followed by a post-elective evaluation.
At the request of BCU's partners, the faculty worked collaboratively to develop a series of learning outcomes that the students would complete during their clinical placements. This provided the nurses within the clinical areas with guidance on what the students were expected to complete and provide an opportunity to capture feedback. During the elective students had the opportunity of working in various departments within the hospital, including an acute medical ward and intensive care unit. They also attended classroom lectures together with fellow student nurses at LCN. Students on the elective were mentored by LCN nurse tutors and other students. During their time in Zambia, they were accommodated in student nurse hostels within the hospital grounds. This provided an opportunity to interact with their peers, experience student nurse life and the realities of working in a resource-limited environment. Students also volunteered at a local orphanage over a weekend.
During the elective students were encouraged to maintain a blog (online diary) as part of their reflective discussions to explore themes and topics that were of interest at the time. As these were personal to the students, containing information that they could choose not to share, the blogs were not included as part of the data presented, but students were encouraged to refer to them as an aide-memoir. Some students chose not to engage in the writing of blogs, despite being given the assurance that they did not need to share them because they were personal documents.
When off duty and during weekends students had the opportunity of experiencing Zambian culture; this included attending the local festivals, cultural villages and a trip to Victoria Falls. This provided an opportunity for students to experience life outside the capital city and to gain a deeper appreciation of life in Zambia.
Aims
This investigation aimed to examine the short-term impact of a faculty-structured international travel scholarship for an elective placement in Zambia for undergraduate UK nursing students. Specific objectives were to:
Methodology
The choice of descriptive phenomenology was influenced by the aims of the study because this methodological approach is concerned with discovering and exploring behaviour from the unique perspective of the individual (Van Manen, 2016). It allows the voice of the person, the participant's own subjective accounts, to be heard and offered the opportunity in this study to gain rich insight into the lived experience of undertaking an elective placement in Zambia. The methodology therefore needed to be flexible enough to allow the participants' agenda to predominate, so that their voices would be heard. The design for the study was also influenced by the lack of previous research in this field, which meant that limited baseline information was available.
In order to explore the lived experience of undergraduate nursing students who had taken part in a faculty-supported international elective to Zambia, all those who had undertaken this activity, 6 students in total, were invited to participate in a focus group interview. Focus group interviews appeared to be the most appropriate method of data collection: a strength of this method is that, rather than being individualistic, focus groups privilege the multiplicity of participants' beliefs, attitudes, opinions and experiences (Liamputtong, 2011). Focus groups also allow the participants' agenda to predominate rather than that of the researcher, and have the benefit of enabling those participating to probe each other's reasons for holding a particular view (Bryman, 2016). This often results in an increase in interaction between the individual participants and a decrease in the amount of input from the researcher, enabling participants to ask questions of each other and re-evaluate their own understanding of a particular experience (Freeman, 2006).
The focus group topic guide used was adapted from a previously published medical study conducted in Zambia, exploring international faculty experiences of teaching (Bould et al, 2015). Permission from the primary author and the Zambia postgraduate programme lead in that case was sought and granted to modify and use the topic guide for this study.
It was initially planned that the focus group discussion would be audio recorded. However, during the preliminary discussions, immediately prior to the focus group taking place, it became apparent that the participants would be more comfortable if their views were not captured in this way. The decision was therefore made by the researchers, with the explicit approval of the participants, to take notes on the responses rather than using audio recording. The flexibility of the methodological approach chosen facilitated this change in capturing the data, upholding the participants' autonomy in terms of how the research was carried out. The focus group was conducted by two researchers, who are experienced in facilitating and conducting focus groups but who were not directly involved in the elective, nor do they normally teach the students or have input in their assessments.
The sample
Six students who undertook the international elective placement agreed to participate in the focus group, 5 weeks after returning from the placement. The sample included both second-year and third-year nursing students representing the adult field of nursing. Two had previous experience of either visiting or living in a developing country. This was the first time any of the students had visited Zambia.
Data analysis
As Silverman (2016) and Miles et al (2014) suggested, central to data analysis in qualitative research is the process of making sense of what people have said, identifying patterns and understanding meanings. This was a key consideration for this study; therefore, data captured during the focus group were analysed using Braun and Clarke's (2006) model for thematic analysis. First, the two researchers examined both sets of notes independently to identify the emergent main themes and subthemes. Following this, they met to review the coded information, and to identify any new emerging themes.
Reliability and validity
The controversies surrounding the issue of rigour in interpretivist research have been highlighted in the literature (Morse, 2015). It is now well accepted that the positivistic concepts of reliability and validity are not appropriate for judging qualitative work because these criteria presuppose that there is one single true account of social reality. Instead, the criteria of reliability, dependability and transferability (Silverman, 2016) were considered to provide a useful assessment of the rigour of the ways in which data were collected and analysed.
Ethical approval
All research projects include some ethical issues and dilemmas and there is now a considerable body of literature on the ethics of research, which includes specific reference to researching those where there is an imbalance of power (De Haene et al, 2010; Zion et al, 2010). Jacobsen and Landau (2003) suggested that the question of whether the research is needed is too infrequently asked, which can seriously undermine the ethical position of a study.
The impetus for this study arose from the observation that, although growing in popularity, there appears to be little research that explores the reasons why undergraduate nursing students choose to apply for a travel scholarship for an international elective placement, their perceptions of the impact on them in terms of their personal and professional development and any lessons learnt that could inform future scholarship and elective activities. Thus, the research is a response to a direct concern to ensure that students are well prepared for international elective activities such as this one and what impact, if any, it has had in terms of their professional development.
Although designed for clinical studies, the ethical principles as outlined by Beauchamp and Childress (2009) proved helpful, as did work by Seedhouse (2009). Importantly in this study, because of the hierarchy in power between students and researchers, there was the need to ensure that all potential participants knew they had the option not to participate. It was also essential that all potential participants knew that there was no connection between this study and the services they received from the university and that non-participation would not affect access to services in any way. They were also reassured that all information provided would be used only for the purposes identified as appropriate to the study and that any data collected would be stored in accordance with the Data Protection Act (1998).
Ethical approval for the research was granted by the Faculty of Health, Education and Life Sciences Academic Ethics Committee.
Findings
During the focus groups the following themes were identified:
Importance of preparing for the elective
Participants reported the value of the pre-elective training pathway as important in preparing them for their elective. Except for the brief from the tutors from LCN, all other sessions were all delivered ‘out of hours’ at weekends or in the evenings to accommodate the students' timetables. The purpose of this was twofold: not only to prepare students for their experience but also for students to get to know each other and to bond, because they came from different year groups. Other than the self-development aspects there was no formal acknowledgement for the students completing this pathway. Students reported that they welcomed this opportunity to meet each other and actively engaged in the small group activities such as quizzes related to cultural awareness. Students also valued hearing about the experiences of the staff delivering the programme, something they were clearly passionate about.
The pre-departure programme exposed the students to experiences that they would not normally be able to access, such as an introduction to tropical medicine, outlining areas such as looking after yourself and keeping well, and learning about diseases not commonly seen in a UK context. Students reported that these sessions were valuable, but that they found preparing and attending for sessions in addition to their normal studies tiring. It is acknowledged that students preparing for an international elective should not only access training but also recognise the need to engage with extracurricular independent learning (Bohman and Borglin, 2014).
Other universities incorporate pre-elective training as part of a module or as recognised stand-alone training (Johns and Thompson, 2010; Latta et al, 2011). This could lead to increased motivation in students to engage in activities and help them understand the relevance to their course and future professional role. With the new regulatory standards relating to the pre-registration education curriculum there is an opportunity to consider a university module in the new course (Nursing and Midwifery Council, 2018).
Different nursing cultures, realities and patient safety concerns
During the pre-departure workshops, students were encouraged to explore the realities of working in a resource-constrained environment. Case studies and discussions provided an opportunity to identify the challenges; however, it was not until the students were faced with these realities that they could appreciate the impact on them emotionally and professionally:
‘We couldn't get over the size of the hospital and overcrowding on the wards.’
‘On the medical ward was certainly an eye opener … some shifts consisted of only 2 nurses to care for over 40 patients … in different bays and side rooms.’
‘Diagnosis ranged from diabetes, leukaemia, tuberculosis, heart failure, sepsis and we even saw a case of leprosy.’
Similar experiences have been reported in other studies (Bould et al, 2015; Brown et al, 2016). Of particular concern to the students in the focus group was the reuse of disposable equipment, the lack of early warning scoring tools to identify the acutely ill patient on wards, and lack of access to basic equipment. These experiences provided students with both moral and ethical dilemmas because they felt powerless to intervene given their own lack of experience, nor did they understand how they should respond and what their role should be in this situation.
‘We have observed patients sadly deteriorating and becoming seriously ill when this could have been prevented or managed.’
This feeling of being overwhelmed and helpless is of concern. One student described how one member of the family remains at the bedside and assists in the care of patients—for example, fundamentals of care—something that she felt would not happen in the UK. This provided students with a different insight into the role of the nurse and the caring environment.
‘We are very impressed with how families are very involved with their relatives' needs.’
Another area that the students found challenging was the hierarchical nature of the Zambian healthcare system, with nurses being subservient to doctors:
‘With no escalation process for deteriorating patients … nurses would wait for doctors to review the patient … before any nursing care could be provided.’
In addition, with a lack of nurses, they had to prioritise patient care and this resulted in few opportunities for bedside teaching or mentorship. The nursing students provided the majority of direct care with the registered nurses supervising them. Care tended to follow a series of tasks that need to be completed at particular times of the day and then reported to the nurse in charge. The supporting structure for students is through the clinical instructors. These nurses undertake assessments in practice and bedside teaching. The students spoke about the difference in the role of the nurse and the type of care delivered between the wards and the intensive care unit (ICU):
‘Our experiences of the [ICU] were much more Westernised compared to the medical ward … with around one nurse to two patients.’
The students noticed the hierarchies were not as visible and the ICU environment was more familiar to them. With more staff there were more opportunities for learning and bedside teaching. The students reported that the nursing culture was similar to that in the UK, with nurses taking more responsibility for the fundamentals of care and escalating concerns. However, the students noticed the realities of working in a constrained ICU, including low staffing levels and challenges with resources.
The students recognised the importance of resource management and felt that this would change their practice when they returned to the UK. During one care episode a central venous catheter was being inserted. The students observed that the doctors and nurses only opened equipment as required, to conserve the supplies. The students reflected that often, in the UK, packets of gauze, syringes, needles etc are opened for procedures, not used and then disposed of:
‘Above all, exposure to clinical areas that have limited medical supplies has made us all feel very fortunate of how lucky we are in the UK and made us very appreciative of the health care offered to us.’
Students had the opportunity to attend lectures alongside their Zambian peers. LCN offers a diploma (level 5) for pre-service courses and advanced diploma for in-service courses. The registered nurse-midwifery course is a 3.5 year diploma, with students completing midwifery training during their final year, and on qualification they have dual registration (both nurse and midwife). The students on the elective attended second-year nursing student lectures and found the content of lectures to be similar to that in the UK. From their discussions with local students they learnt that, in Zambia, nurse training is often didactic and students expect to be taught content from the lecturers. The UK students recognised that Zambian students were more practically focused, and more skilled at practical procedures. Reflecting on time spent with the Zambian students, they said:
‘We all feel humbled to have had such a warm welcome from the student nurses who were very intrigued to find out more about UK nursing practice.’
The students felt there were advantages and disadvantages to both the UK and Zambian nurse education systems. They felt they had a greater understanding of conditions and evidence-based nursing but lacked the same amount of confidence in their clinical skills. They were all in agreement that the elective to Zambia had a significant impact on them both emotionally and professionally:
‘We will never forget our time in Zambia and it has made us better prepared for our future roles as qualified nurses.’
Recommendations
Several recommendations arise from this investigation of the students' experiences. First, higher education institutions should seek opportunities to embed global health and international nursing electives in undergraduate nursing curriculums. Second, programmes should promote independent learning ahead of the elective and opportunities to use the learning as part of the university programme should be explored. Third, pre-departure training is essential in preparing students for their elective.
Limitations
Only one group of students who participated in an elective were included in the focus group. This provided a small sample size and may not be representative of the other students who undertook electives to other resource-constrained environments. This makes it difficult to generalise the results. In addition, due to their university timetables, only a short placement was possible. Had students had the opportunity for a longer placement their experiences and views might have been different.
Finally, because this study did not seek the perspectives of the Zambian hosts in relation to what they gained from having our students on placement, there is a need for follow-up research to investigate the hosts' experiences. This caveat also applies to the UK lecturers who were involved in the elective.
Conclusion
Findings from the focus group suggest that international electives for undergraduate nursing students are a positive experience. Electives, such as the one reported here, provide opportunities for shared learning, in an environment and culture where resources may be extremely limited. It is clear that pre-departure preparation is essential to the success of the elective both for the individual and the hosts.
Overall, the undergraduate nursing students who participated in this elective had a positive and transformative experience.