Initiation of student participation in practice: An audio diary study of international clinical placements

Abstract

Background

Differences in professional practice might hinder initiation of student participation during international placements, and thereby limit workplace learning. This study explores how healthcare students overcome differences in professional practice during initiation of international placements.

Methods

Twelve first-year physiotherapy students recorded individual audio diaries during the first month of international clinical placement. Recordings were transcribed, anonymized, and analyzed following a template analysis approach. Team discussions focused on thematic interpretation of results.

Results

Students described tackling differences in professional practice via ongoing negotiations of practice between them, local professionals, and peers. Three themes were identified as the focus of students’ orientation and adjustment efforts: professional practice, educational context, and individual approaches to learning. Healthcare students’ initiation during international placements involved a cyclical process of orientation and adjustment, supported by active participation, professional dialogue, and self-regulated learning strategies.

Conclusions

Initiation of student participation during international placements can be supported by establishing a continuous dialogue between student and healthcare professionals. This dialogue helps align mutual expectations regarding scope of practice, and increase understanding of professional and educational practices. Better understanding, in turn, creates trust and favors meaningful students’ contribution to practice and patient care.

Keywords:

• Clinical workplace
• initiation
• international placement
• student participation
• undergraduate students

Introduction

Contemporary healthcare programs often provide international learning experiences, such as study exchange or placement abroad. International clinical placements may change not only students’ professional outlook, but also positively affect personal behaviors like proactivity and self-confidence (Atherley et al. 2019). Many healthcare students are challenged by the transition between pre-clinical and clinical training, feeling insecure about their role and participation in practice (Peters et al. 2017). Nevertheless, students should actively participate in practice to support their workplace learning (Dornan et al. 2014). For novices, participating may also be difficult due to notable differences in practice. In an international learning environment, there are several features that can be different from placement in their home country, such as team structure and hierarchy, protocols or treatment time (Steven et al. 2014). Furthermore, students are likely to experience difficulties in patient communication because of language and cultural barriers (Thomas et al. 2018). Besides, they might face challenges on more personal levels, related to traveling independently and living abroad. Available literature focuses mainly on creating favorable preconditions for international placements, through predeparture training and education on health and safety abroad, including ethical dilemmas (Wiskin et al. 2018).

Evidence on workplace learning indicates that recognizing and creating opportunities for active participation in patient-related care and team activities is crucial to stimulate students’ learning-by-doing (Dornan et al. 2014). While some students manage to participate in practice directly from the start, others need more time to familiarize themselves with the context of professional practice in order to feel supported and confident enough to engage (Wenger 2010, p. 125–144; Van der Zwet et al. 2011; Chen et al. 2014; Duvivier et al. 2014; Attrill et al. 2016). This could be especially true when students immerse themselves in an international learning environment, where their role and responsibilities as a learner within the healthcare system may differ from previous training experiences at home.

A model of healthcare students’ initiation of international clinical placements describes four different phases students are likely to experience when first arriving at a new workplace and looking for ways to learn in this new environment (Wijbenga et al. 2020). Via introduction into the clinical workplace, and alignment of learning goals and expectations, students learn how to actively participate in practice. In international workplaces, students can be even more challenged to find the right level of participation, as local practices, language and time pressure may affect their engagement in patient-related tasks or team activities (Wijbenga et al. 2020). Students’ contributions to practice become meaningful through social interactions with their supervisor, other healthcare professionals and peers, which supports their sense of belonging (Yardley et al. 2013; Newton et al. 2016). During clinical placements social relationships between student, healthcare team and peers are likely to generate additional learning opportunities and encourage student participation in patient care (Sheehan et al. 2012; Acharya et al. 2015; Atherley et al. 2021).

Little is known about which strategies for learning students use to familiarize themselves within the scope and context of professional practice during international placements (McKenna et al. 2017). Only a few articles specifically address international placements, leaving it unclear which differences are commonly experienced and must be overcome before students can actively participate in practice (Terry et al. 2020). Although key in support of workplace learning, the role their support network plays in facilitating students’ initiation of workplace learning remains unknown. Therefore, this paper aims to explore how first year physiotherapy students overcome challenges during initiation of international placements, in order to actively participate in practice.

Methods

This audio diary study followed an interpretivist approach, applying an exploratory qualitative study design to capture personal learning experiences in the international workplace.

Setting and participants

At the European School of Physiotherapy (ESP) in Amsterdam, The Netherlands, around 220 students from different nationalities follow an intensive three-year bachelor program in Physiotherapy (BSc. Hons.), taught in English. The mission of ESP is to deliver ‘world-class physiotherapist’, incorporating not only an international classroom setting, yet also international placements as standard within the curriculum. Clinical training consists of four 10-week placements, only one of which may be conducted in the Netherlands, to ensure globally competent practitioners. All year 1 ESP students eligible to enter their first placement in June 2018 (n = 54) were invited via personal email to participate. Thirteen students (24%) volunteered to participate in this study. Twelve completed the audio diaries, whereas one did not submit any. Placement details (such as country and healthcare setting) were obtained from the online database of the Faculty of Health at the Amsterdam University of Applied Sciences (AUAS). Out of twelve participants, four completed a placement in their home country, and one non-Dutch student completed placement in The Netherlands (Table 1).

Table 1. Participant and placement details (n = 12).

Placement region	Europe (n = 9), North America (n = 2), Asia (n = 1)
Healthcare setting	Private practice (n = 7), hospital (n = 3), rehabilitation (n = 2)
Organization	Database vs. self-organized placement 4:8
Nationality	EU vs. non-EU students 9:3
Gender	F:M ratio 8:4
Age	20–41 years (range); 29 years (average)

The students were supervised one-on-one by professional physiotherapists, with their learning progress being monitored by their mentor (ESP staff) from a distance. Supervisors did not receive additional compensation for their participation. The first internship consists of 280 clinical hours and forms mainly an orientation to the field of physiotherapy, in which students have the opportunity to observe and experience daily routines in a healthcare facility. Students may perform evaluations and (parts of) physiotherapeutic treatments under direct supervision of the clinical supervisor. Their clinical performance is evaluated midway and end-term by their clinical supervisor. Learning goals and evaluation forms are described in a reflection report, which is assessed by the students’ mentor for final evaluation of placement.

Data collection

Students were asked to create personal audio recordings (Crozier and Cassell 2016) via a smartphone application (VoicePro or Easy Voice Recorder). By focusing on the first month of placement, we aimed to include enough time for initiation. Students followed instructions on a prompt sheet, which invited them to freely share their personal experiences:

• What have you been doing?

• Who did you work with? During what activities?

• What have you learned? Can you provide specific examples of this?

• Were there any difficulties?

• What did you like?

To structure information and check for technical aspects, we first completed a pilot study among year 2 students, adding the option to decide individually on the moment and amount of time spent on single entries.

All participants gave informed consent before data collection took place in June and July 2018. Privacy was ensured by direct upload of audio files onto the password-protected network-environment of the main researcher (MW), who encrypted all data for storage. Ethical approval was obtained from The Netherlands Association for Medical Education (NVMO-ERB no. 00995).

Data analysis

Audio recordings were transcribed verbatim and anonymized by the first author (MW) before being shared with the team. We applied a template analysis approach according to King (2010), which entails a step-wise thematic analysis based on evolving coding templates (Frambach et al. 2013).

A priori themes were formulated in relation to students’ support network, learning experiences and the initiation process, based on the four-phases model by Wijbenga et al. (2020) (Table 2).

Table 2. A priori themes for coding.

Support network
a. Personal factors	b. Instrumental factors	c. Social network	d. Other support
Learning experiences
a. Expectations	b. Learning goals	c. Practice	d. Other experiences
Initiation process (4-phases model)
a. Orientation	b. Adjustment	c. Contribution	d. Belonging

Two researchers (MW and RD) independently applied initial coding, using qualitative data analysis software (Atlas.ti v8.3.1) to support thematic analysis. The four-phases model offered a logical starting point for the initial coding and analysis. The theme of participation, connected to the different phases of initiation, emerged through our data analysis and was incorporated in the template structure. A final template was developed by MW and RD upon reaching consensus with the team, after which MW applied this final template to the data. Preliminary interpretation of results was discussed with the team, to resolve potential conflicts in coding and interpretation. MW subsequently coded all transcripts focused on differences observed by the students during the first month of international placement and disconfirming evidence. Final results were interpreted in discussion within the research team.

Research team and reflexivity

MW instructed all participants prior to collecting their audio entries. Now an educator, MW is also a physiotherapist by training, who has worked abroad and has ample experience in supervising interns in the workplace. As clinical coordinator in the ESP program, MW knew all students personally, but was not involved in any pass/fail decisions regarding placement. This study forms part of her PhD research into international clinical placements. All team members are experienced in qualitative research methods. PT brought his experience as a medical education researcher and physician to the analysis. He also has personal experience of being a resident in training doing international placements. SR has personal experience living and working abroad as a physiotherapist. He is also a medical education researcher, involved in the analysis and writing process. ED has a background in educational sciences, with special interest in workplace learning and cross-cultural education. RD brought practical and research experience. During his medical studies, he went on international placement himself, and more recently he has supervised medical students on international placements.

Results

Twelve students reflected on their individual experiences twice a week, delivering 96 individual audio entries in total, during the first month of international placement. Individual audio entries ranged between 2 and 25 minutes, with an average recording length of eight minutes (3.5–14 minutes) per student. In total, 764 minutes of audio data were collected and analyzed, which showed that healthcare students’ participation in practice during initiation of international placements involves an ongoing process of orientation and adjustment. Three themes were identified at the focus of students’ orientation and adjustment efforts: professional practice, educational context, and approaches to learning.

Note: For purposes of enhanced coherence and legibility, student quotes have been subject to light editing before journal submission. The authors, however, based their analysis on the original, unedited transcriptions.

Differences in professional practice

At first, the audio entries reflected mainly how professional practice varied between host and home countries. After being introduced to the clinical environment and team, all students were quick to notice differences to what they had learned during preclinical training. Differences observed related to organization and quality of care, professional approaches or guidelines for practice, but also included team roles and responsibilities. Although students had anticipated some of these differences, for example in hierarchy or work schedule, the international clinical context also revealed different understandings of health, which would sometimes leave the students puzzled:

I really cannot understand the system here and I cannot cope with it […] also the patients how they don’t care about their bodies and how they feel like they are just going to do the exercise with us. (Student 3, entry 5)

On the other hand, many professional features in the clinical workplace were similar to the students’ training environment at home. Hence, most students quickly felt comfortable enough to participate in small tasks, such as patient instructions during therapeutic exercises. Yet, many students were confronted with unfamiliar interventions or therapeutic modalities, such as technical applications or training equipment:

This clinic likes to use the kind of modalities that we haven't been taught yet, but I guess [foreign] schools do. […] At the clinic they did show me how to use it, it's just that I don’t feel confident using it if I don’t really know what it is doing. (Student 8, entry 1)

Sometimes students did not yet feel safe or confident enough to voice their opinion about local clinical practices when first entering their placement. When practicing new approaches to care, students encountered uncomfortable situations when applying physiotherapeutic knowledge or skills that conflicted with their own standards of care:

I saw one [patient] that was questioning me on magneto-therapy. I feel that with all the research I’ve done about it I am very sceptical as to whether it is actually effective and I found it really hard to defend it and that got a bit awkward. (Student 11, entry 8)

Most students demonstrated a proactive response to these challenges by looking into evidence or available reading materials. Students found patient registration systems to be an accessible source of information in support of self-regulated learning:

Imagine physiotherapists running around all the time. They do not have a lot of time to do the filing, so we tried to help them out with that, which was very interesting because then all the time you can get to know the patients on file; see what kind of cases there are and what they have been treating them with. (Student 2, entry 2)

Note-taking, reflection on practice and additional background research further helped students to build confidence to question and discuss professional practice with other healthcare professionals.

Adjusting to the educational context

Supervisors played an important role in students’ adjustment to the international setting of their learning environment. Students needed to balance their new and demanding work schedule with independent living in an unfamiliar environment, without close support of friends or family. Often, the clinical instructor would be the nearest contact in case of personal issues, work-related, or otherwise. Some students described how the team would involve them in activities outside working hours, which positively influenced the atmosphere at work:

We joined some colleagues for drinks yesterday evening (…). In the first week I had a lot of fun with the colleagues but I didn’t really feel like I had a good personal connection to them yet. Like they were rarely asking me personal questions and I had the feeling that they didn’t know me at all. But now, since yesterday it is getting way better and it also made the working vibe very good today. Also, they are starting to ask me way more things to assist them with; I feel that they are trusting me and they- I am actually helping them out often when it is busy. (Student 2, entry 4)

Students reflected on the importance of the social relationships with their supervisor and other professionals when talking about orientation and adjustment to practice. They described how mutual expectations toward student participation and goals were aligned based on continuous exploration, familiarization, and negotiation of practice, related to practices observed:

Today I had the opportunity to watch an exam of a student, [where] I saw a lot of similarities but also a lot of differences in the school system. (Student 12, entry 1)

Building social relationships within the workplace seemed crucial to open up opportunities for learning-by-doing, which increased self-confidence and mutual trust. The students that were invited to actively participate in patient-related tasks felt supported to explore new approaches or apply intervention techniques without being afraid to fail expectations:

The physiotherapists guided me and about half way through the exercise we switched over so that I could watch how they correctly did the movement and guided the patient to walk. (Student 4, entry 2)

These students also felt more confident posing critical questions about clinical decision-making or unfamiliar therapeutic interventions. Establishing an ongoing dialogue between students and local team members helped build mutual trust and understanding, which in turn broadened the scope of student participation in patient care. As a consequence, creating this professional dialogue often resulted in more autonomous practice, hence facilitating student adjustment:

I’m getting just more hands-on at the moment there. They’ve done well to progress me from initially observing, then taking on smaller stuff but I think that I’ve gained a little bit more of their trust to get into some more hands-on stuff. […] They’ve put me in my own little room, so it’s been awesome to get the experience. (Student 6, entry 5)

Students’ approaches to learning

Students reflected on how their individual goals and learning strategies at the start of a placement had to be adjusted to differences in organizational and educational practice. Initial expectations about the student’s position in the clinic and desired level of participation did not always meet local practice:

Although I feel I am able to do a bit more now, there is still not that much emphasis on the patient history taking and the assessment and I feel like that is something I would really like to see more of. (Student 11, entry 3)

This alignment of student expectations and learning goals was informed by the learning environment and educational context, revealing unanticipated opportunities for learning new knowledge and skills. At first, some students felt lost due to the many differences observed in the unfamiliar learning environment. This was especially true when initial learning goals did not align and students had to negotiate their position as a learner within the healthcare team. Yet, by displaying an open, inquisitive attitude many students managed to quickly orientate and adjust to the international learning environment:

I am not too sure what ultimately my goal is for the first internship. […] I am doing it because the more I practice and the more I do the better chance for when I come back [here] I can pass the board exams so that is my motivation. (Student 8, entry 6)

Although many students adjusted their individual learning goals to better suit the international setting, including new therapeutic interventions or patient registration systems, initial feelings of disengagement to practice became less evident. Instead, students recognized and welcomed many observed differences as learning opportunities, broadening their professional scope:

She also showed me the machines that are used in the clinic, which was really interesting for me because I haven’t seen any of these machines up close before and some of these I've never actually heard of. (Student 4, entry 1)

Most students displayed self-regulated learning strategies, triggered by their curiosity in regards to differences noted. They learnt to overcome insecurities about participation and contribution to practice by means of proactive study behavior and additional background research. Once comfortably adjusted, students dared to critically question and discuss local practices with healthcare professionals and peers. This dialogue strengthened their position as a caregiver within the team. Although not yet fully belonging to the community of practice, all students were able to meaningfully contribute to patient care within their first month of placement:

I see that I am really lucky with my placement because I am so autonomous already and they trust me and I really put my theory classes into practice. (Student 12, entry 6)

Discussion

The international clinical context has allowed us to reveal a more cyclical nature of orientation and adjustment during initiation of placements, building upon the four-phases model by Wijbenga et al. (2020). This model described orientation and adjustment as separate phases leading toward active student’ participation in international clinical placements. Based on our findings, more detail was obtained on how these phases are actually feeding into one another, involving a more continuous alignment process to establish the right level of participation in an international clinical setting.

This audio diary study among first year physiotherapy students reflects how ongoing orientation and adjustment allows students to increasingly contribute to patient care, by means of negotiated professional, educational, and individual practices. Based on the time span indicated by individual entries (twice a week during the first month of placement), we deduced that the process of students’ orientation and adjustment to international practice generally takes up to two weeks (until entry 5). After one month of placement most participants indicated they were able to contribute to patient care, although they did not yet feel part of the healthcare team. This indicates that healthcare students must reserve time to orientate and adjust to differences in international professional practice before their actual contribution starts. To support students’ adjustment, educational institutions and workplaces should nurture an open, inquisitive study behavior among students and aim to ‘harness dialogue’ between students and professionals (Atherley et al. 2021). Based on the role of the clinical supervisor in international placements, assigning a personal support might help students discover and tackle professional differences during initiation of practice (Dornan et al. 2019; Matus et al. 2020).

Our study describes how students learnt to identify and negotiate differences in practice via ongoing orientation and adjustment to the professional and educational context. The results confirm the importance of creating social relationships with supervisors, healthcare professionals, and peers, to support student participation during placements (Yardley et al. 2013; Newton et al. 2016; Wijbenga et al. 2020). In an international learning environment, professional features such as team structure, clinical protocols, or treatment time can be different, and cultural or language barriers may apply (Steven et al. 2014; Thomas et al. 2018).

Even so, the participants did not perceive language or cultural issues as hindering their participation during initiation of international placements, similar to previous findings among culturally and linguistically diverse Australian nursing students (Jeong et al. 2011). The fact that we selected international students, likely to have experienced similar transition processes when first arriving in the Netherlands for study, may have affected difficulties perceived. Based on our findings, it seems that pre-departure training and workplace introduction alone does not prepare students for all elements of professional and educational practice that are different to previous training experiences at home (Balandin et al. 2007; Barrett et al. 2017; Duff et al. 2018). Social interactions within the workplace are key to help identify these differences in practice, whereas students’ adjustment can be further supported through ongoing dialogue with professionals and peers (Gower et al. 2017; Sheehan et al. 2017; Olmos-Vega et al. 2018; King et al. 2019). Effective student approaches during initiation of practice involved self-regulated learning strategies and proactive study behavior, as well as displaying an open, inquisitive attitude. Besides, the audio diaries indicated flexibility in adaptation of individual learning strategies and goals (Barrett et al. 2017; Sheehan et al. 2017). The students generally welcomed additional learning opportunities, and felt encouraged to participate in patient care because of social interactions in the workplace. Their audio diaries displayed an intrinsic motivation to take on challenges and explore unanticipated opportunities for learning, or self-regulated learning principles (Ten Cate et al. 2011). Active participation during initiation of international placements contributed to mutual trust and understanding between student and supervisory team (Sheehan et al. 2012; Acharya et al. 2015; Atherley et al. 2021).

Limitations

This study has some limitations, such as the fact that our results were deduced from self-generated accounts of student learning instead of observations of practice. The findings concern a single institute study, involving international students based at the AUAS. Moreover, the study participants went to different healthcare settings in Europe and North America mainly. Only one student visited a clinic in Asia, whereas other continents were not included in the results. The four students that completed a placement in their home country could communicate in their native language with patients and co-workers. All other participants used English as their local language. As a result, students did not encounter language challenges. It is also likely that these students have perceived less cultural differences than expected, based on their international backgrounds.

All participants in this study were self-selected volunteers who did not have any previous placement experiences. These students may have been more susceptible to first impressions in the workplace due to lack of comparison. Future research could explore the possibilities of generating peer support within the international workplace, as this might create mutual trust and understanding (Gower et al. 2017; Olmos-Vega et al. 2018). Additionally, it would be of interest to research the roles and responsibilities of students during international placements, compared to clinical training at home.

Conclusions

During international placements, healthcare students come to understand professional and educational practices by means of a continuous orientation and adjustment process. Students learn to accommodate individual approaches to workplace learning by means of active participation, professional dialogue, and self-regulated learning strategies. This negotiation of differences in practice is supported by establishing ongoing dialogue between the student, supervisor, healthcare team, and peers. This dialogue helps align mutual expectations regarding scope of practice, and increase understanding of professional and educational practices. Better understanding, in turn, creates trust and favors meaningful students’ contribution to practice and patient care.

Author contributions

MW, RD and PT conceptualized the study. MW, RD, PT and ED were involved in the design of the study. MW was responsible for data collection. MW and RD were involved in coding and data analysis. MW, RD, SR, PT and ED were involved in the interpretation of data. MW produced the first draft of the paper but all authors (MW, RD, SR, PT and ED) contributed to iterative drafting and refinement of the manuscript. All authors (MW, RD, SR, PT and ED) approved the final version of the manuscript for submission.

Acknowledgements

Special thank you to Sunny Virk for contribution to data transcription, and Lesley-Ann Menzies of the Maastricht University Language Centre for her support in editing the manuscript.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

Additional information

Notes on contributors

Miriam H. Wijbenga

Miriam H. Wijbenga, PT, MSc, is a senior lecturer and clinical coordinator at the European School of Physiotherapy, Faculty of Health, at the Amsterdam University of Applied Sciences, and PhD student at the School of Health Professions Education at Maastricht University, both in The Netherlands.

Pim W. Teunissen

Pim W. Teunissen, PhD, MD, is the Scientific Director of the School of Health Professions Education at the Faculty of Health, Medicine and Life Sciences at Maastricht University, and gynaecologist at Maastricht University Medical Center, both in Maastricht, The Netherlands.

Stephan P. J. Ramaekers

Stephan P. J. Ramaekers, PhD, is an Associate Professor with the Center of Expertise Urban Vitality at the Amsterdam University of Applied Sciences, The Netherlands.

Erik W. Driessen

Erik W. Driessen, PhD, is a Professor at the Department of Educational Development and Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.

Robbert J. Duvivier

Robbert J. Duvivier, MD, PhD, MBA, is a senior researcher at the Center for Educational Development and Research in health sciences (CEDAR), Groningen University, and resident in psychiatry at Parnassia Psychiatric Institute, The Hague, The Netherlands, besides being a Conjoint Associate Professor in Medical Education at the University of Newcastle, Australia.

 

Appendix. Final template

1. Information	1a. Before arrival	1b. In the workplace
2. Expectations	2a. Observation	2b. Invitation to participate
3. Learning experiences	3a. Patient interaction	3b. Responsibility	3c. Disagreement	3d. Team discussion
4. Approach to practice	4a. Healthcare system	4b. Communication and language	4c. Personal factors	4d. Instrumental factors
5. Orientation	5a. Basic conditions and introduction	5b. Getting to know the team	5c. Working culture
6. Adjustment	6a. Participation in practice	6b. Patient-related activities
7. Contribution	7a. Social participation and patient care	7b. Team activities
8. Belonging	8a. Legitimate practice