a comparison of an international experience for nursing students in developed and developing...

A comparison of an international experience for nursingstudents in developed and developing countries

Kate Thompson, Jennifer Boore, Pat Deeny*

School of Health Sciences Ð Nursing, University of Ulster, Coleraine, Co. Londonderry, BT52 1SA, UK

Received 11 November 1999; received in revised form 18 January 2000; accepted 19 January 2000

Abstract

Theoretical perspectives and approaches to transcultural nursing have been developed and there are di�erentoptions for teaching transcultural care. The opportunity for nursing students to gain healthcare experience in

another country is one option. This article reports a study undertaken in Northern Ireland to evaluate outcomes ofa 3-month international experience for undergraduate nursing students (n = 74) and to assess di�erences betweenthe experiences in developed and developing countries. Data were collected by questionnaire. The ®ndings indicate a

high impact on students' international perspective and career development. Students' understanding of cultural andpolitical issues within Northern Ireland was enhanced. 7 2000 Elsevier Science Ltd. All rights reserved.

Keywords: International experience; Transcultural nursing; Multicultural understanding; Cross-cultural care; Developing countries

1. Introduction

The need for nursing students to have an acute

awareness of the in¯uence of cultural factors on health

and healthcare is central if they are to respond appro-

priately to the cultural diversity that exists in society.Understanding the in¯uence of culture on health,

awareness of the impact of one's own ethnic back-

ground on interaction with others and sensitivitytowards the ethnicity of others should be central con-

cepts in nursing curricula. While all this remains a

laudable objective, nurse educators are short of evalua-

tive empirical evidence on how to achieve these out-comes. There is a need for more evaluative research in

order to determine the best approach to achieving this.

The Nurses, Midwives and Health Visitors Act(1979) provides the basic framework for the nursing

curriculum. In addition, amendments made to the Actin 1989 in recognition of the Project 2000 courses sta-ted that all nurses should be able to demonstrate an

``appreciation of the in¯uence of social, political andcultural factors in relation to health care'' [Rule 18a(d)]. Few would contend that this additional learningoutcome is essential if nurses are to meet the individual

needs of all patients irrespective of their ethnic back-ground. However, there is much debate over the mostappropriate curriculum content and methods of teach-

ing to prepare nurses to best meet the health careneeds of an increasingly diverse society. Whilst theNational Boards for Nursing, Midwifery and Health

Visiting of the four countries of the UK have theresponsibility for ensuring that pre-registration coursesprovide students with the opportunity to achieve the

learning outcomes speci®ed by the UKCC, none ofthese organisations provide speci®c curriculum guide-

International Journal of Nursing Studies 37 (2000) 481±492

0020-7489/00/$ - see front matter 7 2000 Elsevier Science Ltd. All rights reserved.

PII: S0020-7489(00 )00027-4

www.elsevier.com/locate/ijnurstu

* Corresponding author. Tel.: +44-2870-324390; fax: +44-

2870 324951.

E-mail address: [email protected] (P. Deeny).

lines on this additional learning outcome. Thus, indi-

vidual institutions can determine the exact course con-tent and methods used to achieve this.For nursing students in Northern Ireland, the cul-

tural di�erences and political con¯ict in the region cre-ates an important dimension for learning. On the face

of it, the dominant culture in the region is Caucasianand English speaking and the ethnic mix of this groupis mainly Irish and Ulster±Scottish. Critically, how-

ever, the main division is along religious identi®cation,Protestant and Catholic. This mix partly explains thedescription of Northern Ireland as `a divided society'

(Hainsworth, 1998). While the society is changing andattitudes are less polarised due to the recent peace pro-

cess (Brewer and Dowds, 1996), it still remains dividedinto two main religious, political and cultural group-ings; Catholic±Irish and Protestant±British. As most

children are educated at segregated schools and adultsinteract largely in religion-speci®c social networks it isalways possible that students of nursing will not

encounter the challenge of getting to know individualsfrom the `other community' until they commence their

nursing education. Moreover, this type of situation isnot unique to Northern Ireland. It can be suggestedthat in any country or region where ethnic groups are

not integrated or where there is ethnic con¯ict, nurseeducators are presented with similar problems. Thenursing situation demands a close relationship with

patient and family, and the lack of previous experiencewith people of other cultures may make this relation-

ship di�cult and result in inappropriate or culturallyinsensitive care.In addition within Northern Ireland there are the

needs of the `hidden minorities' such as the Chinese,Indian, Pakistanis, Jews and Irish Travellers. Recentevidence points to the need for more attention to the

health needs of these groups and the need for greatersensitivity to the cultural factors in¯uencing health and

illness (Watson et al., 1996). Despite almost 20,000 eth-nic minority residents living in Northern Ireland(Hainsworth, 1998), it is highly probable that many

nursing students will not encounter an individual fromany of these groups during their entire undergraduateexperience. Certainly there would not be the numbers

or wide distribution of these groups throughout North-ern Ireland to guarantee that each nursing student

could gain experience in working with them in a hospi-tal setting. Equally, it would not be feasible to rotateall students through community settings with signi®-

cant representation from these minority groups. How-ever, following graduation a proportion of the nursesfrom the University of Ulster seek work in Great Brit-

ain where the mixed ethnic composition, especially inthe metropolitan areas, is much more visible and

diverse than in Northern Ireland.It was against this background that the University

of Ulster introduced a compulsory 3-month inter-national experience into the B.Sc. (Hons) Nursing

course leading to an initial nursing quali®cation. As awhole, the course emphasises the transcultural and in-ternational nature of nursing integrated within various

modules throughout the 4-year programme. The inter-national experience is undertaken at the end of thethird year. In planning this, it was envisaged that this

experience would make students more aware of thecultural, economic and political factors which help todetermine the level of health and ill health within the

population and which in¯uence the quantity and qual-ity of healthcare provision and uptake, and facilitatedevelopment of a global perspective. It was alsointended that the experience would stimulate re¯ection

on self and one's own ethnicity and interaction withothers.Students normally undertake this international ex-

perience in small groups within a particular country orregion, with approximately one-third choosing to tra-vel to a developing country and two-thirds to a devel-

oped country. Experiences are arranged mainly inareas where academic sta� at the University of Ulsterhave contacts and where a named individual in the

country concerned is prepared to take responsibilityfor oversight of the experience. A small number of stu-dents have organised their own international experi-ences in countries where they have contacts or are

particularly interested in working. All international ex-periences are ®nanced by the students either by assist-ance from grant awarding bodies, fund raising

activities or personal ®nance. The ®rst international ex-perience took place in the summer of 1995.Whilst a number of authors have cited the potential

value of international learning experiences for nursingstudents, many of the articles identi®ed discuss onlyanecdotal or personal experiences or simply describethe programme o�ered (e.g. Pashley, 1997; Cotroneo

et al., 1986). Due to the large amount of time and®nance committed to this experience it is imperativethat a thorough evaluation is carried out and the maxi-

mum potential is achieved for all concerned. Thisarticle reports on some of the data from such an evalu-ation and focuses speci®cally on the di�erences

between the experiences in developed and developingcountries, the overall impact of the experience for thepersonal and professional development of nursing stu-

dents, and the e�ect on their understanding of the situ-ation in Northern Ireland.

2. Literature review

Reports on the outcomes of international study fornon-nursing undergraduates have been published overthe past 40 years and summarised by Kau�man et al.

K. Thompson et al. / International Journal of Nursing Studies 37 (2000) 481±492482

(1992). They suggest that students who have underta-ken international experiences can develop in three

ways: intellectual development; increased global under-standing; and personal development. However, there isa paucity of nursing literature on the evaluation of in-

ternational experiences, although many anecdotalarticles describe the experiences as positive. In onesuch article, Pashley (1997) a UK nursing student

describes her own international experience and con-cludes that `` . . .I have learnt so much from this experi-ence. My nursing skills and thus my patients/clients

where I practice, in whatever area, will bene®t too'' (p.53). While this statement reinforces the value to the in-dividual, theoretical and research based evidence mayprovide additional justi®cation for the inclusion of an

international experience in nurse education pro-grammes.

2.1. Theoretical considerations

Traditionally, nursing care within a medical modelhas focused on providing care within a diagnostic andtreatment regime for patients, without consideration ofa cultural perspective. Today, however, nurses are

expected to be more holistic in perspective, respondappropriately to cultural diversity, and recognise thein¯uence of a range of factors on health and health-

care. Developments in the ®eld of transcultural nursinghave contributed to curriculum guidelines, and a num-ber of theoretical perspectives and approaches have

emerged regarding the curriculum content and themost appropriate way of teaching transcultural care(Lynam, 1992; McGee, 1992; Leininger, 1994;

Andrews, 1995; Newm, 1995; Lipson, 1996).Lynam (1992) discusses a number of challenges for

curriculum development in this area of study and prac-tice. One of these is to achieve a balance between cul-

tural/ethnic speci®c content and developing anunderstanding of concepts that are applicable withinand across di�erent cultural settings. Additionally, stu-

dents need to develop the ability to interact e�ectivelywith patients/clients from di�erent cultural back-grounds and ethnic groups, taking into account the in-

dividual patient's expectations of the healthcare serviceand involvement in decision making. In order toachieve this, nurses need to acquire an understandingof the inherent biases within themselves and the care

organisation and how these may limit the e�cacy ofcare provided.Leininger (Reynolds and Leininger, 1993) has con-

tributed to an enhanced understanding of factors in¯u-encing cultural care through her Sunrise Model whichdemonstrates her theory of Cultural Care Diversity

and Universality. This model identi®es a range ofissues which together create the context of environ-ment, language and cultural background which are

major in¯uences on patients, the expression of needand provision of care. All these contribute to the ex-

pression of holistic health which is expressed throughthe individuals, groups and institutions involved ininteracting systems of generic or folk care, professional

action and nursing care. Through nursing care de-cisions and actions, `culturally congruent care' is pro-vided (p. 27). This model can provide guidance for

development of an appropriate curriculum althoughthe time commitment which appears to be required isprobably greater than can be encompassed within an

initial nurse education programme.There would appear to be no ideal approach to the

teaching of transcultural care and McGee (1992) ident-i®es methods by which the necessary content can either

be integrated into the curriculum or taught as speci®cmodules or courses. Of particular relevance to thispaper, these include experiential learning associated

with exposure to those from ethnic minorities, butdoes not include consideration of an international ex-perience as such.

2.2. Empirical evidence Ð outside the UK

Lynam (1992) recognised that all students must begiven the opportunity to apply in practice the theoreti-cal knowledge and skills acquired to meet the health-

care needs of those from di�erent cultures. Similarly,Bartz et al. (1993) also considered that students mustbe given the opportunity to practice transcultural nur-

sing and not simply taught the theory underpinningcultural assessment. The literature identi®es variouspossible options for gaining experience with di�erent

cultural/ethnic groups, amongst which is the inclusionof an international experience for students undertakingtheir initial nurse training programme.Zorn et al. (1995) reported the results of a quantitat-

ive study evaluating the cognitive development ofsenior baccalaureate nursing students from the USAfollowing a 3-month international study program in

the UK. The authors concluded that cognitive develop-ment was signi®cantly enhanced in students who hadtravelled to the UK when compared to students who

had elected not to participate in the Study AbroadProgramme. This study showed comparable results tothose reported in a similar study undertaken by Frisch(1990) with students from a di�erent institution in the

USA. The design and data collection instrument in thetwo studies were similar, the only di�erence being thelocation of the international study. The students in

Frisch's (1990) study spent their international experi-ence in Mexico where both the language and culturedi�ered from their own. Students who had travelled to

either England or Mexico demonstrated more cognitivedevelopment than students who did not participate inthe Study Abroad programmes. Zorn et al. (1995)

K. Thompson et al. / International Journal of Nursing Studies 37 (2000) 481±492 483

suggested that cognitive development was enhanced bydiversity and the degree of diversity was of little im-

portance.Haloburdo and Thompson (1998) in a study to

evaluate the learning outcomes of an international ex-

perience for baccalaureate nursing students found thatstudents (n = 14) reported both personal and pro-fessional growth. All students experienced a greater ap-

preciation for cultural di�erences and became moresensitive to the feelings of minorities within a society.Haloburdo and Thompson (1998) also noted that

those students who had travelled to developingcountries devoid of the usual tools of Western health-care had developed an appreciation of caring as theessence of nursing. Students with experiences in both

developed and developing countries had gainedincreased empirical knowledge. The American basedstudents in this study had spent their 2-week inter-

national experience in the Dominican Republic, Nicar-agua or the Netherlands.The long-term e�ects of study abroad experiences

for American nursing students were investigated byZorn (1996). In this study, the impact of an inter-national experience of either 3±4 weeks or 3±4 months

was measured in relation to four dimensions, namelyprofessional career, intellectual development, globalunderstanding and personal development. Zornreported the highest impact in enhanced international

perspective and personal development with a lowerimpact reported in the professional nurse role and par-ticularly in intellectual development. The study abroad

programmes varied in their duration and students whohad participated in longer programmes reported agreater impact than those participating in shorter ex-

periences. The length of time that had elapsed sincethe international programme showed a negative corre-lation with the degree of impact but the longer experi-ence resulted in a greater long-term impact.

2.3. United Kingdom studies

The evidence suggests that the UK's healthcare sys-tem is failing to address the healthcare needs of

patients from ethnic communities (Murphy andMacLeod-Clark, 1993). Curricula innovations in the®eld of nurse education have sought to address thisproblem. The results of a study to examine the extent

to which nurses and midwives in the UK were pre-pared to work in a multi-ethnic society were describedby Gerrish (1997). The ®ndings indicated that in some

institutions that o�ered nursing and midwifery courses,topics relating to the health beliefs and health needs ofminority ethnic communities received little attention.

Gerrish et al. (1996) have also reported that, whilemost educators recognise the importance of studentsgaining experience with clients from other ethnic

groups, some students are never given the opportunityto care for ethnic minority patients as suitable practice

placements are limited in certain geographical locations(including Northern Ireland). As a result, some insti-tutions have introduced di�erent approaches in order

to facilitate students' contact with ethnic minoritycommunities, including the introduction of an inter-national experience.

Lee (1997) has reported on a pilot study introducingEuropean placements to UK students who wereenrolled on a programme leading to a pre-registration

diploma in nursing. Students gained in con®dence,communication and social skills, although Lee high-lighted the fact that language barriers could hinder thepotential involvement in Europe of nurses from the

UK. Nevertheless, the European experience hadenhanced the students' cultural awareness and madethem more aware of the need to assess healthcare

needs on an individual basis. As a result of the pilotstudy, European and international themes wereincluded throughout the course and an entire module

was designed and devoted to international nursing.The Department of Nursing at the University of

Ulster has had the opportunity to evaluate the impact

of its international experience and it is this, therefore,which is the focus of the present paper. It has providedthe impetus to develop the cultural content of the cur-riculum and this is discussed later.

3. Design of study

3.1. The experience

The purpose of this study was to evaluate the impactof an international experience on nursing students.Preparation for this experience consisted of identi®-

cation and limited consideration of relevant culturalissues within various modules in the programme and a2-week preparation period immediately before travel-

ling abroad towards the end of their third year.In addition students in their second year completed

a language module in which they studied either French

or Spanish applied to healthcare. Students were givenadvice and support in planning the detail of their inter-national experience and, in many instances, theygained advice from students who had visited the same

country previously or obtained contact names throughrelationships already developed between academic sta�at the University of Ulster and sta� in other countries.

During their 3-month experience students wererequired to achieve a set of objectives in which theydeveloped their understanding of how political, econ-

omic, religious and cultural factors in¯uenced the wayof life, health problems and health care provision.They investigated the extent to which WHO (1978)


and WHO/ICN (1988) strategies regarding health forall were being implemented in the country visited.

They examined the organisation and professional regu-lation of Nursing as a profession and gained an insightinto the practice of nursing. In addition, they investi-

gated the role and function of complimentary health-care systems in that country. In most cases they gainedhands-on experience of care and developed a keen

awareness of how the principles of nursing wereapplied in contexts very di�erent from that to whichthey were used. The assignment associated with this ex-

perience required students to complete a re¯ectiveanalysis of the experience and the achievement of theirobjectives.Following the experience, students gave presenta-

tions about their experience at a conference to whichall students, nursing and other sta� from within theUniversity and representatives from the health service

were invited. Furthermore, they drew upon this experi-ence in the seminars presented in one of the academicmodules on professional issues in year four of their

programme.

3.2. The study

The 89 fourth year students and graduates who hadundertaken the international experience during their

degree course within a 3-year period were invited toparticipate in the study. Information was collected bypostal questionnaire. As all approached had the free-

dom not to return the questionnaire, there were noethical implications of this study.The questionnaire was in two sections. Section 1 col-

lected demographic data including age when the ex-perience was undertaken and when the questionnairewas completed, religion, current employment (whenrelevant) and country visited. Section 2 aimed to evalu-

ate the international experience by using a modi®cationof an instrument previously used in an InternationalEducation Survey (Zorn, 1996).

The instrument designed by Zorn (1996) uses Likert-type seven point scales to assess the degree to whichthe international experience has in¯uenced four di�er-

ent dimensions; a low score indicates minimal impactand increasing scores up to a maximum of seven indi-cate increasing impact. The four dimensions are: pro-fessional career; world and cultural views; personal

and social issues; and intellectual development. Theprofessional career dimension is examined through ®vequestions that focus upon the e�ect on practice and

career development of the international experience.The world and cultural issues dimension consists often questions which examine changes in understanding

and behaviour related to international and transcul-tural issues which impact on nursing and healthcare.Personal and social issues are considered through

twelve questions which focus upon the in¯uence on theindividual within their social environment. Intellectual

development relates to the use of reading materialsand interest in foreign languages, as well as a generalquestion regarding `intellectual development'. This

dimension is covered by four questions. In this study,the questionnaire was modi®ed by including ®ve ad-ditional questions which dealt speci®cally with chan-

ging perceptions in relation to the cultural andpolitical con¯ict in Northern Ireland. Thus the ques-tionnaire dealt with ®ve speci®c dimensions and

included 36 individual items.In the development of the original questionnaire,

validity was assured through review by experts in bothcontent and measurement. The alpha coe�cient for the

whole questionnaire was 0.97 and varied between 0.85and 0.94 for the four sub-scales (Zorn, 1996). The re-liability of the Northern Ireland section of the ques-

tionnaire was not, however, subjected to extensive testsof validity and reliability. Content validity was assuredthrough discussion with a panel of four experts on the

situation in Northern Ireland. In order to gain someadditional insights into students' views on their inter-national experience, they were asked to add any com-

ments they wished to make about the experience at theend of the questionnaire.Data were analysed using the Statistical Package for

Social Sciences (SPSS-PC). In relation to calculating

the overall values for each dimension, questionnaireswere included only if all questions related to thatdimension were answered. This explains the variation

in number of responses for the di�erent dimensions.Descriptive statistics show the impact of the inter-national experience on all 36 individual items and

further analysis (t-tests) highlight the di�erencesbetween an international experience in developed (n =51) and developing countries (n= 23). Where relevant,students' open-ended comments are used to illuminate

the statistical information.

4. Results

4.1. Pro®le of respondents

An overall response rate of 84.1% (n = 74) wasachieved. The majority of the respondents were female

(94.6%), and at the time of their international experi-ence were under 25 years of age (95.9%) and single(97.3%). All the respondents who had completed their

degree course were currently employed in nursing postsat Grade D level. The majority (95.6%) were employedas sta� nurses within an acute care setting. All but one

of the respondents (98.6%) classi®ed their nationalityas either British or Irish. The respondents had spenttheir international experience in a variety of di�erent


countries. Table 1 shows the developed and developing

countries visited by the respondents in this study.

4.2. Evaluation of international experience

The summative mean for each of the ®ve dimensionswas computed and the results are provided in Table 2.Whilst scores on all ®ve dimensions highlighted the

positive impact of the international experience,enhanced international perspective and career develop-ment scored highest. The mean of intellectual develop-ment was the lowest at 3.7. It is clear from Table 2

that students who had spent their international experi-ence in a developing country scored higher on all ®vedimensions than other students. These di�erences

achieved statistical signi®cance in the case of inter-national perspective, personal development and intel-lectual development.

The vast majority of students made positive com-ments about this experience:

it is an invaluable method to gain an insight into a

multicultural society. It highlights the di�erences inhealth care beliefs (i.e. unorthodox remedies usedby ethnic minorities). (It) re®nes personal and pro-

fessional skills such as communication (respondent067).

and

In conclusion, it is a fantastic, worthwhile experi-ence which not only increases our nursing experi-

ence but also increases our total experience of life(respondent 071).

One student commented:

after ®nishing my Nursing degree, I went to Bir-mingham to work. Without the con®dence and life-

skills gained as a result of the International Experi-ence, this move wouldn't have been an option forme personally (respondent 041).

This comment reinforces the importance of the ex-perience for these students many of whom have nevertravelled outside Northern Ireland before and are rela-

tively lacking in con®dence.

4.3. Professional career

In all ®ve individual items in the professional careerdimension the higher scores were recorded by respon-

dents whose experience had been in a developingcountry. Whilst a number of these di�erencesapproached statistical signi®cance, only one item, the

long term impact on their practice as a professionalnurse, achieved statistical signi®cance (see Table 3).Only those currently in professional practice were

asked to complete this section of the questionnaire andthe majority of respondents were still in junior pos-itions within the health service so career intentions,

rather than career development, determined their re-sponses to this questionnaire. While this sectionappears to have the lowest response rate (58%), in rea-lity, as some respondents had not yet completed their

degree, this is 100% of those eligible to respond.Some of the additional comments added to the pic-

ture of the value of this experience in this context. One

graduate had returned to Kenya, where she had spenther international experience, to work for a year.Another wrote:

For my part, the personal growth and developmentincurred throughout the experience has had a biggerimpact on my career path and career orientated de-

Table 1

The developing and developed countries visited for the inter-

national experience

Developed countries Developing countries

Australia Brazil

Canada Gambia

New Zealand India

Spain Kenya

Sweden Malawi

USA Tanzania

Uganda

Zambia

Table 2

The impact of international experience on the ®ve di�erent dimensions (mean scores; standard deviation in parentheses)

Developed countries Developing countries Total Signi®cance level No. of respondents

Professional career 4.8 (0.94) 5.4 (0.83) 5.0 (0.94) NS 43

International perspective 5.3 (0.78) 5.8 (0.50) 5.4 (0.74) p<0.01 74

Personal development 4.3 (0.95) 5.2 (0.98) 4.6 (1.03) p<0.001 69

Intellectual development 3.4 (1.11) 4.1 (1.13) 3.7 (1.15) p<0.05 74

NI perspective 4.7 (1.42) 4.8 (1.33) 4.7 (1.38) NS 73


cisions than has any professional or cultural aspectsof the experience (respondent 021).

The longer-term in¯uence of this experience ongraduates' professional career will only be judgedthrough additional follow-up studies.

4.4. International perspective

The mean scores for the individual items concerningworld and cultural issues are presented in Table 4. Asimilar pattern was observed with these individual

items Ð students who had undertaken their experience

in developing countries scored highest. Students whohad experience in a developing country scored signi®-

cantly higher when asked how the international experi-

ence had in¯uenced their evaluation of world issuesand if it had facilitated an international dimension in

their work activities.

Several students commented on increased under-

standing of the importance of culture in health careand the degree of variability in the countries they vis-

ited. One student wrote:

Undoubtedly, the opportunity to visit a country

with such diverse cultures, which are so di�erent

Table 3

Impact of international experience on professional career (mean scores; standard deviation in parentheses)

To what degree has your international experience as a

student at the University of Ulster . . .

Developed

countries

Developing

countries

Total Signi®cance

level

. . .had a long term impact on your practice as a

professional nurse?

4.9 (1.03) 5.8 (1.05) 5.2

(1.09)

p<0.05 n=43

. . .been relevant to your professional career? 4.9 (1.14) 5.2 (1.26) 5.0

(1.16)

NS n=43

. . .enhanced your e�ectiveness as a professional nurse? 4.8 (1.24) 5.4 (1.08) 5.0

(1.21)

NS n=43

. . . improved your e�ciency as a professional nurse? 4.6 (1.15) 4.9 (1.19) 4.7

(1.15)

NS n=43

. . .a�ected your progress as a professional nurse? 5.0 (1.22) 5.7 (0.78) 5.2

(1.15)

NS n=43

Table 4

The impact of their international experience on world and cultural issues (mean scores; standard deviation in parentheses)



Developed

countries

Developing

countries

Total Signi®cance

level

. . .shaped and in¯uenced how you evaluate world issues? 5.2 (1.29) 6.2 (0.81) 5.5

(1.26)

p<0.00 n=74

. . . in¯uenced your understanding of nursing and healthcare

in other countries?

6.1 (0.77) 6.5 (0.66) 6.2

(0.76)

NS n=74

. . . in¯uenced your discussion with other people about

international or transcultural issues?

5.9 (0.81) 6.2 (0.74) 6.0

(0.79)

NS n=74

. . .a�ected your interaction with people from other

cultures?

5.7 (1.22) 6.3 (1.18) 5.9

(1.22)

NS n=74

. . .a�ected your travel, work or study abroad since that

time?

4.4 (1.82) 4.7 (2.00) 4.5

(1.87)

NS n=74

. . .facilitated an international or intercultural dimension in

your work activities?

4.3 (1.74) 5.2 (1.30) 4.6

(1.65)

p<0.05 n=74

. . . in¯uenced how you deal with con¯ict at work? 3.8 (1.66) 4.4 (1.24) 4.0

(1.56)

NS n=74

. . . increased the likelihood that you would practice nursing

in another country?

5.5 (1.69) 5.9 (1.16) 5.6

(1.55)

NS n=74

. . . in¯uenced your practice of professional nursing? 5.2 (1.26) 5.6 (0.84) 5.3

(1.16)

NS n=74

To what degree would you encourage all university students

to participate in international education?

6.6 (0.94) 6.9 (0.34) 6.7

(0.81)

NS n=74


from our Western society, has changed my percep-tion of the world (respondent 038).

Clearly, this experience broadened the students' per-ceptions of international variations in culture and its

interaction with health. It is worth noting the veryhigh score recorded (6.7) when respondents were askedthe degree to which they would encourage all univer-sity students to participate in international education.

4.5. Personal and social issues

It is clear from Table 5 that high scores wereobtained on several of the individual items concerning

personal and social issues. The di�erence between stu-dents who had experience in developed and developingcountries achieved statistical signi®cance in the ma-

jority of individual items in this section. Followingtheir experiences in a developing country, studentsscored signi®cantly higher than other students when

asked to what degree it had made them reassess theiroutlook on life, had in¯uenced their career decisions,had contributed to their level of self con®dence, madethem more tolerant of others and had in¯uenced how

they judge themselves in relation to others. In addition,students who had their experience in a developing

country scored signi®cantly higher than other students

on all items concerned with facilitating an internationaldimension in their everyday lives.

Several of the respondents commented on the way inwhich this experience had changed their ways of think-

ing and their perception of self:

. . .basically changed my views on life for ever!!!

(respondent 022).

and

It also made me more aware of my own values and

beliefs and broadened my mind (respondent 071).

and

From a personal perspective it has given me con®-dence in myself, my capabilities and indicated

resources and strengths within myself, I didn'tknow I had (respondent 041).

One student commented that:

the process of arranging the international experi-ence was bene®cial in itself (respondent 007).

The results from this section, illustrated by the com-

Table 5

The impact of their international experience on personal and social issues (mean scores; standard deviation in parentheses)



Developed

countries

Developing

countries

Total Signi®cance

level

. . .made you reassess your outlook on life? 5.4 (1.14) 6.4 (0.59) 5.7

(1.10)

p<0.001 n=74

. . .a�ected your family decisions (spouse, partner,

parenting, living arrangements etc.)?

4.0 (1.92) 4.4 (2.03) 4.1

(1.95)

NS n=73

. . .a�ected your interpersonal relationships (friends, family,

partner, neighbours)?

4.2 (1.84) 4.8 (1.53) 4.4

(1.77)

NS n=73

. . . in¯uenced career decisions you have made/ or hope to

make following graduation?

5.0 (1.72) 5.9 (1.32) 5.2

(1.65)

p<0.05 n=74

. . .facilitated an international dimension in your volunteer

activities?

3.3 (1.59) 4.2 (1.82) 3.6

(1.71)

p<0.05 n=73

. . .facilitated an intercultural dimension in your volunteer

activities?

3.4 (1.62) 4.3 (1.88) 3.6

(1.74)

p<0.05 n=73

. . .facilitated an international dimension in your social or

religious activities?

3.7 (1.60) 5.1 (1.22) 4.2

(1.62)

p<0.001 n=74

. . .facilitated an intercultural dimension in your social or

religious activities?

3.7 (1.61) 5.1 (1.32) 4.1

(1.66)

p<0.001 n=72

. . .contributed to your level of self-con®dence? 5.9 (0.98) 6.4 (0.66) 6.0

(0.92)

p<0.05 n=74

. . .made you more aware of your own culture? 5.9 (1.00) 6.2 (1.15) 6.0

(1.05)

NS n=74

. . .made you more tolerant of others? 5.1 (1.05) 6.2 (0.89) 5.4

(1.11)

p<0.001 n=74

. . . in¯uenced how you judge yourself in relation to others? 4.8 (1.12) 5.8 (0.85) 5.1

(1.14)

p<0.001 n=74


ments above, emphasise the value of this experienceand alone would be adequate reason for continuation

of the experience within the programme.

4.6. Intellectual development

Respondents were asked to what extent their inter-national experience had a�ected their intellectual devel-

opment and the results are shown in Table 6.Individual scores within this dimension were lowerthan for other dimensions, and in particular, the ability

to read/speak another language or the motivation todo so scored only 2.8 and 3.0 respectively.There were few comments which related speci®cally

to this area but one respondent wrote:

It ensures that the course produces thinking pro-fessionals not simply nursing clones (respondent

052).

The above statement re¯ects the aims of the degreeprogramme as stated in both the previous and recently

revalidated programme (University of Ulster, 1992,1999) and reinforces the value of the experience.

4.7. Northern Ireland dimension

The mean scores for each of the items pertaining tothe Northern Ireland dimension showed the positive

e�ects of an international experience and are shown inTable 7. In contrast to all other individual items, thosewith experience in developed countries scored higher

than the other respondents when asked how the inter-national experience had enhanced their understandingof both culture and politics in Northern Ireland. These

di�erences did not, however, achieve statistical signi®-cance. Students who had spent their time in a develop-ing country scored signi®cantly higher than other

students when asked how the experience had a�ectedtheir interaction with other cultures in Northern Ire-land.

Three respondents commented speci®cally on North-ern Ireland and the broadening in¯uence of going

abroad, for example:

As N.I. is very small, people tend to be narrow

minded. Going abroad widens your views about lifeand living, and makes you realise that there is aworld outside N.I. which is very di�erent (respon-dent 078).

Finally, given the positive results which haveemerged, it is perhaps not surprising that all but one

of the respondents (98.6%) felt that the internationalexperience should be continued as part of the B.Sc.(Hons) Nursing course.

5. Discussion

5.1. Bene®ts obtained

It is clear from the results that all students gained

considerably on all dimensions from their internationalexperience. However, it was demonstrated that thosestudents who had undertaken their international ex-

perience in developing countries had gained signi®-cantly more in relation to international perspectives,personal development and intellectual developmentthan those who visited developed countries. It appears

that the very considerable contrast from their owncountry in terms of living conditions, culture andvalues, common health problems, and the quality of

healthcare and nursing provided, stimulates a re-evalu-ation of the students' own circumstances and their per-sonal and professional values.

In the context of developing the transcultural aware-ness that is expected of all registered nurses, this ex-perience was obviously of great value. Within many

parts of the UK and other countries, student nurseswill interact with members of various cultural groupswithin their normal life and clinical experience. How-

Table 6

The impact of their international experience on intellectual development (mean scores; standard deviation in parentheses)



Developed

countries

Developing

countries

Total Signi®cance

level

. . .a�ected your selection of reading materials in the ®nal

year of the B.Sc. (Hons) Nursing?

3.9 (1.57) 4.0 (1.49) 4.0

(1.54)

NS n=74

. . .a�ected your ability to speak / read languages other

than English?

2.5 (1.62) 3.3 (1.80) 2.8

(1.71)

NS n=74

. . . in¯uenced your intellectual development? 4.7 (1.19) 5.3 (1.25) 4.8

(1.23)

NS n=74

. . .enhanced your motivation and/or ability to learn a

foreign language after returning to Northern Ireland?

2.6 (1.62) 3.9 (1.76) 3.0

(1.76)

p<0.01 n=74


ever, there are areas of this country and elsewhere in

the world, and Northern Ireland is one of these areas,

where student nurses are very unlikely to have contact

with members of ethnic minorities. In such situations,

an international experience of this type is particularly

valuable in enhancing an international and multicul-

tural perspective.

One of the major incentives behind introducing this

experience was to enhance students understanding of,

and permit a fresh perspective on, their own situation

within the con¯ict and divided culture of Northern Ire-

land. The results of this study demonstrate a high

degree of success in this, but with little variation

between developed and developing countries. In fact,

in relation to understanding culture and politics in

Northern Ireland, those who went to developed

countries scored slightly (although not signi®cantly)

higher than the other group. An explanation of this

may be that it is easier to make judgements about

one's own country from another that is at a compar-

able level of development, and thus provides appropri-

ate comparisons, than from a very di�erent country.

The extent of the di�erence in perspective from a

developing country may have little relevance to under-

standing the context of Northern Ireland.

As the political climate in Northern Ireland

improves, and it has been recently described in a cur-

rent a�airs programme on television as `a society mov-

ing out of con¯ict', the importance of this Northern

Ireland dimension in the international experience

becomes rather less important. However, other

countries where such divisive situations exist may be

able to use a similar approach in the development of

nurses with enhanced understanding of the various cul-

tures within their own country. The ®ndings in this

study suggest that obtaining international experience in

a country of a comparable level of development may

be of slightly greater value in enhancing understanding

of the divisions within a society than time spent in acountry at a di�erent level of development. However,experience in a developing country may be of greater

value in terms of enhancing interaction with other cul-tures within a society.Within these results, the in¯uence on language devel-

opment of the international experience in any country

is small, with the lowest scores in the questionnairefound on the two items related to this area. In general,those living in the UK are not linguistically skilled and

many students elect to visit a country where English isreadily understood. At present these students studyFrench or Spanish in year two, but may not choose to

visit a country where the language studied is of value.It appears likely that ensuring that any language studyis related to their planned international experiencemight enhance the acceptability of language study and

lead to di�erent results on this section of the question-naire.

5.2. Modi®cations to the programme

This study, and other feedback, has led to somemodi®cations in the B.Sc. (Hons) Nursing programme.The language module is being replaced with a 100-

hour (including individual study) module on Cultureand Communication. As part of this, students willdevelop an appreciation of the in¯uence of culture andlanguage on health and illness and will re¯ect on their

own ethnic background and how this fuses or con¯ictswith other cultures. In addition, they will identify thecommunication skills, in the broadest sense, that they

need to develop in relation to the particular culturethey will visit, and will be provided with guidance ondeveloping those skills, including relevant language

skills (when appropriate) through use of the languagelaboratory facilities. A considerably greater selection oflanguages will be available than previously. It is hoped

Table 7

The impact of their international experience on understanding of Northern Ireland issues (mean scores; standard deviation in par-

entheses)



Developed

countries

Developing

countries

Total Signi®cance

level

. . .enhanced your understanding of culture in Northern

Ireland?

5.8 (4.53) 5.0 (1.67) 5.5

(3.88)

NS n=74

. . .enhanced your understanding of politics in Northern

Ireland?

4.1 (1.60) 4.0 (1.87) 4.0

(1.68)

NS n=74

. . .enhanced your understanding of the con¯ict in Northern

Ireland?

3.9 (1.47) 4.2 (1.72) 4.0

(1.55)

NS n=73

. . .enhanced your interaction with other cultures in

Northern Ireland?

4.4 (1.45) 5.3 (1.53) 4.7

(1.54)

p<0.01 n=74

. . .changed how you think the rest of the world perceive

the con¯ict in Northern Ireland?

5.3 (1.62) 5.5 (1.41) 5.4

(1.55)

NS n=74


that this will enhance future students' interest in devel-oping their language skills.

The preparation for the international experience isalso being modi®ed somewhat, with an increasedtheoretical content for understanding transcultural nur-

sing being provided through a second 100-hour moduleon Global Dimensions on Health. In this module theydevelop their understanding of health care systems in

the country they are to visit in order to compare itwith that of Northern Ireland. They also considerwhat information they will need to collect in order to

understand the in¯uences on health care delivery andthe strategies they will use to gather that data. A sub-stantial part of this module is focused on individualstudy related to the particular country to be visited.

At present students are o�ered a wide choice in re-lation to the country they wish to visit, with no specialemphasis placed on visiting the developing world. The

mix of countries visited provides a valuable diversitythat adds to the richness of discussion in seminars anddebates in the ®nal year of the course. However, one

of the implications of this study will be an alterationin focus of the international experience. While studentswill still be o�ered a wide choice, a greater emphasis

will be placed on encouraging them to select a develop-ing country for this experience with the intention ofmoving to a more equal distribution of students acrossdeveloped and developing countries.

5.3. Conclusions

A number of conclusions can be drawn from thisstudy. Firstly, it is clear that the inclusion of this ex-

perience as an integral part of the degree programmeis worthwhile. The results demonstrate clearly that thevalue of this experience to the students and, now,graduates has been considerable in the short-term. It

has facilitated both personal and professional develop-ment and enhanced students' understanding of the in-¯uence of cultural factors on health and healthcare.

This study considerably enhances the literature inthis area. It contributes to the empirical knowledgeavailable to nurse educators when reaching decisions

regarding an international experience within initialnurse education programmes. It is particularly valuablebecause the number of respondents in this study islarge compared to other studies in this ®eld. For

example, Zorn's (1996) study consisted of 27 partici-pants with a response rate of 88%, compared to 74respondents with a response rate of 84% in this study.

The survey method used resulted in a very good re-sponse rate and provided appropriate data to evaluatethe international experience. The major shortcoming in

the study is that the longer-term in¯uence of this ex-perience has not been studied and this limitation canonly be overcome with time. As yet the ®rst of those

who gained such experience have only been RegisteredNurses for 3 years. It will be interesting to compare

the in¯uence of this experience over a longer time-spanwith that reported by Zorn (1996) who found thatimpact decreased over time. It is hoped to repeat this

study in 5 years time.

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