© 2008 The AuthorsJournal compilation © 2008 Blackwell Publishing Ltd.

Learning in Health and Social Care

,

7

, 2, 79–92

Original article

Blackwell Publishing Ltd

Enablers and challenges to international practice education: a case study

Elizabeth Anne Kinsella

PhD

,

1

* Ann Bossers

MEd

2

& Donna Ferreira

MSc (OT)

3

1

Assistant Professor, Faculty of Health Sciences, Elborn College, University of Western Ontario, 1201 Western Road, London, Ontario, Canada N6G 1H1

2

Associate Professor, School of Occupational Therapy, Faculty of Health Sciences, Elborn College, University of Western Ontario, 1201 Western Road, London, Ontario, Canada N6G 1H1

3

Community Occupational Therapist, WOTCH, Community Mental Health Services, 534 Queens Ave, London, Ontario, Canada, N6B 1Y6

Keywords

case study, health

professional education,

internationalization,

international education,

practice education

*Corresponding author. Tel.: (519) 661-2111 ext. 81396; fax: (519) 661-3894; e-mail: akinsell@uwo.ca; abossers@uwo.ca

Abstract

Internationalization is a growing priority for professions, universities and

governments around the globe. This has led to increased numbers of health and social

care students participating in international practice education experiences. This study

identifies enablers and challenges to participation in international practicum

education through a case study. The case involves one occupational therapy

programme and its international partners, and investigates the perspectives of

students, university personnel and preceptor stakeholders. Challenges included: lack

of financial support, limited placement availability, and procedural complexity.

Enablers included: external financial support, champions for the concept,

international connections, and access to the appropriate communication technology.

Practical insights that may be relevant for enabling student participation in

international education experiences are highlighted.

Introduction

We live in a global era that is influencing every

dimension of life, including the education of healthcare

practitioners (Westcott & Whitcombe 2003; Sinclair

2005; Whiteford 2005). In the context of a rapidly

changing and complex world, the need to educate

students to participate in, and contribute to a global

knowledge-based society, while maintaining apprecia-

tion and respect for difference, has never been

greater (UNESCO 1996; 2005). Internationalization

has become an organizational priority for universities

and colleges globally [Association of Universities

and Colleges of Canada (AUCC) 1995; International

Association of Universities (IAU) 2005], and has

garnered the attention of governments and groups

such as the United Nations Educational, Scientific

and Cultural Organization (UNESCO 2005). In

many countries, the new global context has prompted

universities to articulate their commitment to

80 E.A. Kinsella

et al.

© 2008 The AuthorsJournal compilation © 2008 Blackwell Publishing Ltd.

internationalization in their mission statements

[Association of Universities and Colleges of Canada

(AUCC) 1995] and to consider the question, ‘How

can institutions of higher education adequately

prepare graduates to live and participate as global

citizens and professionals?’ (Gacel-Avila 2005, p. 123).

Internationalization

Internationalization is distinct from globalization.

Internationalization claims to promote recognition

and respect between countries. In contrast, global-

ization has been said to promote de-nationalization

and homogenization (Gacel-Avila 2005), and is

frequently characterized by unequal power relations

(O’Shea 1997). Internationalization is recognized

as an important alternative to globalization and as

an educational priority [Association of Universities

and Colleges of Canada (AUCC) 1995]. Knight

(2004) defines internationalization in the context of

higher education as ‘the process of integrating an

international dimension into the purpose, functions

or delivery of postsecondary education’ (p. 11).

Activities fall into two categories, those that occur

on the home campus and those that happen abroad

or across borders (Knight 2004). The current study

focuses on international education activities that

occur in the second of these categories, those

activities that happen abroad.

International practice education

Allied health professional students receive a significant

portion of their professional preparation through

practicum education experiences. This is education

that occurs under the guidance of a preceptor, who

is a professional practitioner, in an actual practice

setting. At the Canadian university where this study

was initiated, occupational therapy students complete

a minimum of 1000 hours of

professional practice

education.

This is similar to other disciplines such as

physiotherapy, nursing, speech language pathology

and social work. In recent years, there has been a

growing interest by allied health students to

participate in international practice education

(Ewert & Knight 2007) and many universities have

witnessed increased investments of time and energy

by educators, administrations and students to arrange

such experiences. This is consistent with broader

trends that see universities and colleges around the

world promoting the development of international

partnerships and international knowledge exchange

networks as crucial for the next generation (Chan

2004).

An assumption of international education is that

enabling students to participate has beneficial

outcomes for students, professional practice and

society at large. Outcomes of international education

frequently include personal and professional growth,

personal transformation and expansions in

world-views (Standeven 1988; Kauffman, Martin &

Weaver 1992; Whiteford 1998; Sawyer & Lopopolo

2004; Whiteford & McAllister 2006; Greatrex-White

2007). Additionally, students potentially have

opportunities to develop international relationships

and collaborations; experience different healthcare

systems; develop knowledge about international

perspectives, frameworks and models; reflect on their

role as global citizens and; become more comfortable

with the prospect of professional mobility and

knowledge exchange across borders (McAllister

et al

. 2006; Taylor 1995; O’Shea 1997; Westcott &

Whitcombe 2003; Van Hoff & Verbeeten 2005). At

another level, institutional cultures are informed

and potentially transformed by international

interactions over time.

In the Canadian university where this study

originated, student interest surpassed international

practicum availability, which stimulated interest in

researching enablers and barriers to international

practice education. It was difficult however, to find

research that addressed this topic directly. Some

general trends identified in the literature as enabling

international education and placement include:

linkages between international institutions (Chan

2004); a growing recognition of the need for health

professionals to be globally mobile (Westcott &

Whitcombe 2003); recognition of the need for health

professionals to be able to work with individuals

from culturally diverse backgrounds (Whiteford

& Wright St. Clair 2002; Rundstrom 2005), inter-

nationalization of accreditation, certification and

licensure within professional groups (Taylor 1995);

and the mandate of many health professionals to

International practice education 81

© 2008 The AuthorsJournal compilation © 2008 Blackwell Publishing Ltd.

contribute to broader social and political realms

(O’Shea 1997; Whiteford 2005).

Potential barriers include the difficulty of plan-

ning international education experiences (Greatrex-

White 2007), and issues around quality assurance

standards and concerns that other institutions

may not be able to satisfy requirements of home

universities (McBurnie 2000). Potential challenges

for students were identified as trouble with social/

psychological adjustment, communication prob-

lems, concerns about personal safety, worries about

achieving educational goals, cultural differences and

challenges with language (Daly & Barker 2005).

In addition, it has been noted that international

education is costly (Greatrex-White 2007). Barriers

for preceptors may include increased time commit-

ments, additional work-load, the pressures of

balancing clinical and teaching demands, and the

loss of patient contact that can occur when supervising

a student (Stevenson, Doorley, Moddemand &

Benson-Laundau 1995; Jung & Tryssenaar 1998).

Purpose of the study

Given the growing demand, the positive outcomes

for students reported in the literature (Kauffman,

Martin & Weaver 1992; Whiteford 1998; Sawyer &

Lopopola 2004; Whiteford & McAllister 2006), as

well as the increased emphasis on internationalization

at university, governmental and global levels

[Association of Universities and Colleges of Canada

(AUCC) 1995; International Association of

Universities (IAU) 2005; UNESCO 2005], the

purpose of this study was to identify the enablers

and challenges to international practicum education

as reported by stakeholders.

Research questions

Three questions framed this study:

• How do occupational therapy students experience

enablers and challenges to participation in interna-

tional fieldwork?

• How do stakeholder universities and preceptor/

fieldwork educators experience enablers and

challenges to international occupational therapy

fieldwork education?

• How can increased student participation in inter-

national fieldwork education be facilitated?

Method

Methodology

Case study research is defined as ‘a strategy for doing

research which involves an empirical investigation

of a particular contemporary phenomenon within

its real context using multiple sources of evidence’

(Robson 1993, p. 5). Case study methodology has a

number of advantages. It is an effective approach

when one has little control over the events being studied,

and when the object of study takes place in a real life

context. As well, case study is often used when the

boundaries between the phenomena and the context

are not clear, and when multiple sources of evidence

contribute to understanding the phenomena under

investigation (Yin 1989, 1999; Stake 2000, 2005).

Case study research tends to seek answers to how

or why questions which are of concern to the

researchers. How, for instance, do students experi-

ence challenges and enablers to participation in

international fieldwork? How do fieldwork pro-

fessors and clinical fieldwork preceptors experience

enablers and challenges to the process? Why are

some students able to participate in international

placements and others not? How can improved

student participation be facilitated, and what obstacles

are encountered in the process?

Context of the case

At the Canadian Master’s level entry educational

programme in occupational therapy where this

study was based, there has been an increase in

student interest in international fieldwork. In recent

years, there has been a consistent rise in par-

ticipation which currently stands at 15–20% of the

student enrolment (Ewert & Knight 2007). The

programme has a history of facilitating

international practice education.

Over the last five years, internationalization has

become an institutional priority. A review of the

vision statements of the university, the faculty and

the school, reveal an institutional commitment to

82 E.A. Kinsella

et al.

© 2008 The AuthorsJournal compilation © 2008 Blackwell Publishing Ltd.

international relationships, international research,

and to preparing students to become global citizens.

In the last year, a research office for international-

ization has been established, and the university has

increased initiatives to support international field-

work education.

Parameters of the case

The current case study was framed around an

analysis of international practice education over

the course of one academic year. The case study

involved a document review, a curriculum content

review, and interviews with students, university

and clinical preceptor stakeholders. The document

and curriculum review provided contextual and

background information for the case, and revealed a

trend towards increasing attention to international-

ization at a university-wide level. The primary data

reported in this article involve a qualitative analysis

of interviews with the stakeholders who participated

in the process over a 1-year time frame.

Participants

An outline of participants is provided in Table 1.

Participants were provided with information about

the study and invited to participate based on their

relationship to the case and their availability during

the researchers’ trip to Europe. At the home

university, all six students who had completed an

international educational experience during the

year under investigation, as well as the two university

practice education professors, and the director of

the university programme were invited, and agreed,

to participate. In the European context, the four

partner universities assisted in the coordination of

interviews with preceptors and with university

personnel. In the course of 1 week, the researchers

visited four European universities and interviewed

6 practice professors, 4 university programme

directors and 10 additional faculty members. The

researchers also visited three European hospitals

and interviewed 8 European preceptors, 5 of whom

were supervisors of the Canadian students in the

study and 3 who were involved in the organization

of international student supervision.

Data collection

Three interview guides (one for students, one for

university personnel and one for preceptors/

fieldwork educators) were developed based on the

questions of the study, the pragmatic concerns of

the university, the document review and a review of

the literature. The student interview guides were the

first to be developed and pilot tested. These guides,

as well as the emerging themes from the student

interviews, informed the development of the

interview guides for university personnel and for

preceptors/fieldwork educators. In-depth, semi-

structured interviews were carried out with 37

participants at a private location selected by the

interviewees. One researcher facilitated and tape-

recorded the student interviews. Two researchers

Table 1 Study participants (N = 37)

Participants

Individual

interviews

Group

interview

Canadian student participants

Scotland fieldwork experience 5

Ireland fieldwork experience 1

University academic personnel:

Programme directors (PD)

Practice education professors (PP)

University faculty (UF)

Canada 1 (PD)

2 (PP)

Scotland 1 (PD)

2 (PP)

5 (UF)

Ireland 1 (PD)

2 (PP)

5 (UF)

Ireland 1 (PD)

1 (PP)

England 1 (PD)

1 (PP)

Preceptors/practice educators

Scotland 1

Scotland 2

Scotland 4

Ireland 1

International practice education 83

© 2008 The AuthorsJournal compilation © 2008 Blackwell Publishing Ltd.

were present at the preceptor and the university

personnel interviewers. Researchers kept reflexive

field notes (Finlay & Gough 2003) and debriefed

together after each interview. A mix of individual

and group interviews was conducted for a total of 16

interviews (See Table 1).

Data analysis

All of the interviews were tape-recorded and

transcribed. Participants were given pseudonyms to

preserve confidentiality. Transcriptions and tapes

were placed in a locked filing cabinet at the

university. Following transcription of the data, the

researchers coded the data and identified conceptual

themes. Concept maps were created to visually

represent the conceptual themes from each

interview (Daly 2004). The 16 concept maps were

then compared to one another and analysed for

consistency and for repetition of themes. A theme

was considered salient if identified by 20% or more

of the participants, although themes generally

reached much higher rates of saturation (70% or

more). A research assistant independently coded the

transcripts following the same analysis procedure as

the researchers. Themes were found to be consistent

between researcher coding, research assistant

coding and with the concept maps generated from

the data.

Results

A summary of the salient themes related to

challenges and enablers as conveyed by students,

university professors and preceptors is presented

below.

Challenges

Finances

The most consistent barrier identified by

stakeholders was financial strain. Five of the six

students identified money as the primary obstacle to

participation, and speculated that this would also be

the primary barrier for fellow students. In students’

words:

The only [barrier] I’d say is cost ...

Barrier? ... Money!!!

I’d definitely say that’s the main ... barrier to going ... if

you didn’t have the funds.

It was financial, the barrier, because it is a lot to commit

to because school’s so expensive and just trying to really

sit down and look at your finances and say ‘Do I have

enough to go?’

I really do think it’s just financial, that’s probably the

biggest barrier.

In addition, financial burden was identified in

many of the interviews with university personnel as

a barrier. In Europe, some students receive funding

through Erasmus; however, as one university faculty

member pointed out:

Not all of them are being given money because they have

to go through an interview. They have to do a sort of a

preparation as to why they want to go on placement and

what they will get out of it. It doesn’t mean that they couldn’t

go if they don’t get the money but they have to fund it

themselves ... so for some of our students, that is

obviously an issue.

A modest estimate of the cost of a 6- or 7-week

international practicum was identified by students

as $4000–$5000 Canadian dollars.

Going to Scotland and staying in residence and living

there was probably about half of the expense of like a year

of tuition. So it’s another good chunk and especially as a

student and you’ve been in school for 5 years and you

have this debt ...

In addition, unexpected expenses may arise:

One of the students was saying a first-aid course [required

for an international placement] costs one hundred pounds.

Well, you know that’s quite a lot of money for students.

There have traditionally been few financial resources

available to assist health and social care students from

Canada to travel abroad for educational purposes.

The institutional document review revealed, however,

that there have been modest supports implemented in

the form of student bursaries during the last few years.

Availability and timing of placements

Another challenge identified was the availability

and timing of the placements. Student education

84 E.A. Kinsella

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© 2008 The AuthorsJournal compilation © 2008 Blackwell Publishing Ltd.

placements were compared to ‘gold’ currency as they

were in limited supply for local students, prompting

some universities to hesitate about offering their

placements to international students. University

personnel and preceptors identified possible reasons

for this shortage: (i) some countries have a shortage

of occupational therapists; (ii) the increased pace

of therapeutic practice places greater demands on

therapists; (iii) changing funding structures such

that therapists frequently work in greater isolation,

with greater demands to account for their time

and efficiency; (iv) decreased goodwill within

organizations to absorb costs of educating future

practitioners; (v) increases in the number of

education programmes in Europe creating increased

demand; and (vi) therapists feeling inadequately

prepared to supervise students.

I think one of the major things here ... is that there is a

capacity problem ... So if we had entered into a separate

arrangement ... where we will send four over and they

place our four, then we would have trouble actually

placing people coming in to us.

Some practice educators reported additional

reluctance related to international students, who

are seen by some as requiring additional support

beyond the work-place.

Practitioners who had a ‘bad international student

experience’ voiced a hesitancy to offer future educa-

tional opportunities. ‘We’ve got clinicians that are

very reluctant [to supervise] international students.’

In addition, the arrangement of international

placements was seen to frequently require increased

work for the professional practice professors.

There’s actually a lot of background work that needs to go

in ... There’s the connections, the telephone calls or the

making the personal contact ... supporting the students to

making their preparations and plans to go. Then, when

they are there, it’s how to support them?

Another challenge related to the availability of

placements occurred when students wished to be

placed in a particular country, and a placement was

not available within a suitable time frame for the

student.

I think it depends on the availability of placements and

where they want to go. I know some other students in our

class couldn’t – it just didn’t work out. Like ‘I want to go

to New Zealand’ or wherever and the placements just

weren’t available.

Linked to availability of placements was the

challenge of living with uncertainty when there was

a short time frame between notifying students of an

available international placement and the time to

prepare for departure. The uncertainty and the

short preparation time to find living arrangements,

to arrange reasonable flights and to prepare psycho-

logically, created anxiety for a number of students:

The downfall I would say was the planning up to it.... I

wasn’t sure what was going on ... it was all just very all up

in the air.

I never felt that I knew exactly what was going on or if

there was any progress being made.

I think the initial uncertainty of not knowing what I was

doing, where I was living, what I was going to do. That’s

just a personal barrier that I had to deal with.

Initially, I was wanting to go in January/February to New

Zealand and I ended up in May/June in Ireland so ...

within a couple of months as you can see everything got

flipped upside down.

In addition, a number of preceptors noted that

the uncertainty of last-minute placements created

challenges for them as well:

It sort of feels just in the air somewhere, the student

appears from somewhere else and you’ve got different

forms to fill in and you don’t link or have an opportunity

to meet [the university liason] face to face.

Procedural issues

University stakeholders identified a number of

procedural issues as potentially contributing to

frustrations and challenges. Depending on the

country, various issues can arise regarding visas,

criminal record checks, immunizations, insurance

and educational fees.

Before we can take this further, we have to get this

contract signed and it’s a bit of a nightmare ... I forwarded

it on to the international office ... and they came back and

said there’s no way [the university is] signing this.

One of the big issues for us is indemnity because

obviously, it is a different system, particularly the States

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© 2008 The AuthorsJournal compilation © 2008 Blackwell Publishing Ltd.

compared to here. So that is one of the issues that we have

to be careful with, to make sure they’re covered.

Now we have no way of getting students to the States

because of this 9/11 and other visa arrangements.

Preceptors identified procedural challenges related

to the need to learn new evaluation procedures for

students, or when issues arose with students and

communication with the university was potentially

problematic.

One of the things that I struggled with ... due to my

unfamiliarity is the assessment form.

I think you get quite used to the way your [University]

does things, and most of our students come from there,

so it was a bit of a challenge coming to grips with different

forms and such.

One student identified a desire for a more formalized

approach to procedural issues:

A formal structure needs to be put in place of how the

process goes, and who[m] you contact and who you don’t

contact ... something needs to be more formal.

Enablers

Financial support for international initiatives

Financial support for students was the most

frequently identified enabler. As one student stated:

It would be nice if the school could provide some sort of

funding or support or something like that ... even just a

small amount ... even to get you over there ... because

it’s

a really, really great learning experience and

not everyone

can do it so ... if there was a little bit of help ... it would

be wonderful ... more people could do it.

In Europe, programmes such as Erasmus

(

a

programme to support academic mobility and

higher education within the European Union)

and others, offer potential funding for student

participation in international education. At the

Canadian university where this study was conducted,

new bursaries to assist with travel expenses have

recently been implemented; however, these are

small and cover only a portion of the airfare.

Additional funding through alumni donations

and endowment funds have also recently been

forthcoming. As two professors stated:

The University is starting to put a bit of money where

their mouth is.

As a school, if they could – if they could support students

financially in providing grants or I don’t know, some

money ... it would ease the uncertainty of students.

A number of students indicated that they received

financial support from their parents, or that they

were able to borrow money elsewhere. The capacity

to access resources and/or the willingness to accrue

debt were therefore seen as enablers for students in

this study:

It’s very expensive, very expensive. Um, my parents helped

me pay for it but it was worth every penny. Like I’ll pay it

off for a while, but it was completely worth it.

You kind of had to weigh, do I really want to go this much

more into debt to have this experience.

Champion for the cause

A major enabler appears to be the presence of a

‘champion for the cause.’ One professor, who has a

passion for international education and a commitment

to cultivating relationships with international practice

education professors and universities, can have a

tremendous impact. A ‘champion for the cause’ was

seen to create international networks, foster increased

availability of placements, support students and

preceptors engaged in international education, and

garner administrative support.

I think the biggest part of that is the work that [the

fieldwork professor] has done with the other universities

in making it mutually advantageous ... I think it’s that

process of open trust and follow-through that’s been the

biggest part.

I’d say the faculty here and staff were very [helpful] and

they found the placement for us and that sort of thing

which, we weren’t able to do on our own.

International connections

Another major enabler identified in the study is the

international contacts that faculty and professional

practice professors cultivate over time. Narratives

about the arrangement of international placements

frequently evoked stories in which previous

relationships and connections were recounted.

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© 2008 The AuthorsJournal compilation © 2008 Blackwell Publishing Ltd.

International connections included partner universities,

faculty at universities, family, friends or colleagues

in international contexts.

All the placements we have got so far have been because

of connections that we have.

And I guess we’ve gravitated towards the partner

relationship because of the ease and the smoothness with

which that process can go vs. the process of self-initiation.

Students wanting to do a placement in a country that

maybe doesn’t already have an affiliation with the school,

I think that would be really difficult. Because I think a lot

of things fall into place because of that affiliation.

International connections were also found to be

important enablers for students, some of whom

indicated they were more likely to travel to a location

where they had a connection. As one student stated,

‘Just the fact that we did know some friends over

there was a big help.’

Communication technology

Advances in communication technology were seen

as major enablers to both the planning and imple-

mentation of international education opportunities.

Students, preceptors, and university personnel each

commented repeatedly on how technology aided the

planning and the lived actuality of international

fieldwork. In particular, the internet was most

frequently used to arrange placements, communicate

with family, friends and the home university,

investigate housing, research local culture, download

maps, and to plan travel. In the words of one student:

We did a lot of internet research and that sort of thing.

Like the bus schedules and how much they were and we

tried to make a budget and determine where we wanted

to go on what weekends ... I think that really helped.

A global E-mail out through the university has produced

all these people responding back to say, sure you can give

my E-mail to the student and let them correspond with

me around housing, I’ve got a room in a house and that

sort of thing.

Supports

University administrative and policy supports were

identified as major enablers. As well, within the

university context, the general enthusiasm at all

levels of administration for international educational

opportunities was described as important. Support

from preceptors, including willingness to correspond

with students before their international placement,

appeared to assist students to prepare. A number of

students reported decreased anxiety as a result of

such support systems.

We managed to E-mail everything to her and ... we had

quite a lot of correspondence and we also sorted out her

accommodation.

I tell them what buses and yeah, the emails if you want

more details, stuff like that, you can contact us.

A number of preceptors felt additional respon-

sibility for students that extended beyond the work-

day. Preceptors or other team members frequently

arranged social activities, or participated in sight

seeing with students.

When students come from an international location, they

[the preceptors] feel a real sense of responsibility to sort

of help take care of that student beyond what a therapist

would for a student who’s here on their own.

If they come on their own you do feel a bit motherly

towards them, you know you feel that you want to know

that they’re okay.

So many people went out of their way to make it a special

visit for us.

Students, preceptors and university personnel

noted that students who travelled with a ‘buddy’

tended to have an advantage in terms of support. A

number of preceptors reported worrying less about

students who travelled with a peer. These students

appeared to travel more and participate in additional

cultural events. Many students spoke of the advan-

tages of a friend to help them to process experiences.

And I remember waking up and just saying to [my

friend], I don’t know if I can do this. But I was lucky to

have someone there to talk to.

My last two came with a friend [so] they stayed together

and they obviously got on really well and they did loads

together so and they were staying with a fantastic host

who was, really looked after them so that was fine, that

was kinda taken care of.

Preceptors indicated that knowing the local host

university would provide support, contributed to

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© 2008 The AuthorsJournal compilation © 2008 Blackwell Publishing Ltd.

their willingness to participate. A number indicated

that phone calls or E-mail from the student’s home

site were valued forms of support.

The fact that you E-mail back so promptly and you know

it’s just hard to work out the time schedule sometimes

and E-mail works wondrously well.

Housing

Available affordable housing was identified as an

enabler of international experiences, particularly when

housing was (i) linked to the facility, such as student

or hospital residences; (ii) facilitated by a contact in

the host country; or (iii) when students had family

or friends to reside with, even temporarily, in the

host country.

We were also lucky in that um, through my supervisor she

was able to find us accommodation.

Experience and attitudes

Informants indicated that positive attitudes enabled

international experiences: enthusiasm, being

adventurous, positive, flexible and independent were

each identified.

You’d have to be the right person, like if you’re not

adventurous or wanting to do it, then it probably won’t

work out well.

I think a person who goes international needs to be

able to adapt very fast to new surroundings, new

healthcare – not worry, not stress – knowing that there are

people who will support you and help you and they do

understand that you are being thrown into a different

area.

It’s not likely that a lot of people are going to get

placements together, so you have to ... be a very

independent person and really want to do it.

Preceptors’ experiences and attitudes also con-

tributed to whether a placement would be offered

or not. Preceptors who had previously supervised

students who had struggled or failed, or students

who had not shared all relevant information (such

as a hidden disability), indicated that they would be

more cautious about taking students in the future.

Those who had positive experiences, and/or who

particularly valued offering international opportunities

indicated that they would be more likely to supervise

international students in the future.

Discussion: implications for practice

Three major factors that university health and social

care programmes interested in international

education may wish to explore in relation to the

findings include exploration of creative options for

financial support, cultivation of relationships with

international partners, and creation of supportive

cultures for international practice education.

Financial support

A key factor that participants in this study identified

as enabling participation in international education

is financial support. Interestingly, this is not a factor

frequently cited in the allied health literature on

international education, although some researchers

have acknowledged that international education is

costly (Greatrex-White 2007). As evidence of the

benefits of international educational continues to

grow (Kauffman, Martin & Weaver 1992; Standeven

1988; Whiteford 1998; McBurnie 2000; Sawyer &

Lopopola 2004; Gacel-Avila 2005; Van Hoff &

Verbeeten 2005; McAllister

et al

. 2006; Greatrex-

White 2007; Whiteford & McAllister 2006),

universities and governmental organizations may

wish to consider creative ways to offer additional

financial support. This might include exploring

ways to minimize costs for students, offering

bursaries and student assistance, and providing

support/incentives for preceptors. Raising awareness

of the need for financial support with administrative

officers at various levels in the host university has

fostered some new and creative funding initiatives

at the Canadian university where this study was

conducted. Advocating for government and

university financial support, as well as raising

awareness of the need with those who recruit alumni

support and sponsorship through endowment

funds, may contribute to the development of more

bursaries for student travel. Furthermore,

consideration of means to enable less expensive or

more convenient housing options, such as use of

residences or student housing exchanges may prove

88 E.A. Kinsella

et al.

© 2008 The AuthorsJournal compilation © 2008 Blackwell Publishing Ltd.

helpful in enabling international education. In

addition, financial support for preceptors may help

to offset the current shortage of available placements,

and provide recognition for the additional work

involved in supervising these students.

Cultivation of relationships with international partners

A second key consideration that emerged in this case

study was the potential for

sustained relationships

with international partners

to enable international

placements. This finding is consistent with literature

that suggests linkages between international institutions

can enhance opportunities for international

education (Chan 2004), and with the claim that

health professionals of the future will need to be

more globally mobile and contribute to broader

social and political realms (Taylor 1995; Whiteford

& Wright St. Clair 2002; O’Shea 1997; Westcott &

Whitcombe 2003; Whiteford 2005). International

relationships may create advantages for the

organization of placements. Over time, professional

practice professors can develop working relationships

with university personnel in other countries, as well

as develop knowledge about placement facilities,

housing options, health systems and local customs

and cultures. This knowledge may assist university

personnel to prepare students and to develop

resources for students relative to specific international

destinations. Placements arranged through univer-

sities potentially offer the advantage of local support

for students and preceptors, exchanges between

universities, and consistency in planning. Placements

may also be specifically designated for international

students so that there is more predictability and less

stress related to giving away placements ‘belonging

to’ the local student community. Such pre-planning

may also benefit preceptors by allowing more time

to prepare and to balance the pressures of clinical

and teaching demands (Jung & Tryssenaar 1998), as

well as to help alleviate the uncertainty (for all

stakeholders) that arises when placements become

available at the last minute.

A number of faculty members in this study

indicated that international exchange of faculty

could be beneficial and contribute to the cultivation

of international relationships, as well as potentially

create additional incentives for offering international

placements. Certainly, the researchers/educators in

this study found the opportunity to visit sites, meet

with preceptors, visit international universities and

meet with faculty contributed to more collaborative

working relationships; a better understanding of what

was involved for various stakeholders; appreciation

for different cultures; and increased enthusiasm for

enabling international education opportunities.

Faculty exchanges may also contribute to the

advancement of internationalization of accreditation,

certification and licensure that many professional

groups are striving for (Taylor 1995), as well as

increased knowledge and opportunities for interna-

tional research collaboration. Educators and univer-

sities interested in fostering international education

may find it useful to cultivate long-term relation-

ships with international partners through exchange

agreements and memoranda of understanding.

Creating a supportive culture for international practice education

Support before, during and after placements

appeared to be important to student participants

in this study. Students who travel internationally

with a fellow classmate reported benefits. Students

indicated that they valued having someone to talk to

while encountering a new environment, and many

of those who travelled independently stated that

they wished they had someone to debrief with about

experiences while away. Such supports appear to

mediate some of the challenges identified in the

literature such as trouble with social and psychological

adjustment, and concerns about personal safety

when travelling alone (Daly & Barker 2005).

A number of preceptors indicated that they felt

less pressure when they knew the student was

travelling with a friend or classmate, or had other

contacts. Some preceptors indicated that they would

be more inclined to take an international student

who was travelling with a ‘buddy’ as they would not

feel as much responsibility for providing social

support after work hours. University programmes

might consider sending students to international

destinations in pairs, as a way to support students,

International practice education 89

© 2008 The AuthorsJournal compilation © 2008 Blackwell Publishing Ltd.

preceptors and host universities during international

education.

Various approaches that universities might

consider to support students to process and share

experiences include providing links on university

websites regarding international placement experi-

ences; offering opportunities for student presenta-

tions or informal discussion; facilitating invitations

to debrief with placement professors and peers who

have travelled internationally; and enabling oppor-

tunities to support international learning within

classroom activities or course requirements. Students

in this study indicated that they appreciated regular

contact through phone calls and E-mail from their

home university during international placements.

Preceptors also voiced appreciation for opportunities

to connect with universities, and many indicated

they were more likely to take future students if they

felt supported. Home universities might consider

ways in which they use communication technologies

to support students and preceptors and to maintain

contact with universities during international

education.

The importance of practice education professors

who are ‘champions for the cause’ also emerged as

an enabler in this case study. A positive and supportive

attitude, a willingness to work through obstacles

and procedural issues, and a capacity to cultivate

long-distance relationships, were seen to enable

international education by many in this study.

Consideration of ways to facilitate such attitudes in

one’s own organization, and the provision of admin-

istrative and organizational support for practice

education professors who ‘champion’ international

education may be worthwhile undertakings.

Enabling international education: student, university and preceptor suggestions

In addition to the three major areas identified

above, a number of specific suggestions for enabling

international education were identified by students,

university faculty and preceptors in this study. These

are summarized in Tables 2 and 3. Educators and

universities may find these ideas useful to consider

in the design of international practice education

programmes.

Conclusion

This research gathered data about the perceptions

of occupational therapy students, preceptors and

academics in order to foster greater understanding

of the enablers and challenges of international

practice education. The context for the study

included one Canadian university programme and

its European connections, over the course of 1 year.

This study documents the challenges and enablers

reported by stakeholders. Returning to one of the

questions posed at the outset of the study: ‘How

can increased student participation in international

fieldwork education be facilitated?’, our discussion

has focused on three, out of many possible

Table 2 Enabling international fieldwork education: student

suggestions

Student suggestions

‘More financial support please!’

Travel details:

• Finalize destination as early as possible

• Research host country in advance i.e. Google maps

• Contact preceptor in advance

Support:

• Arrange to go with ‘buddy’

• Investigate contacts in host country

• Arrange for internet access

• Phone calls and E-mail from home universities

Facilitate opportunities for students to share experiences:

• Brown bag lunches

• Buddy system

• Chat room

• Networking

Facilitate opportunities for students to research a

destination healthcare system, perhaps integrated into a

course.

Self-directed research through internet before departure:

• Accommodation

• Clinical site

• Local culture

• Events

• Travel

• Tourism

International student card to obtain discounts.

‘Keep an open mind: be willing to experience different

things!’

90 E.A. Kinsella

et al.

© 2008 The AuthorsJournal compilation © 2008 Blackwell Publishing Ltd.

approaches, which those who organize international

education may wish to explore. These include the

exploration of creative options for financial support,

cultivation of relationships with international

partners, and creation of supportive cultures for

international practice education.

This study is a contextually bound, situated case

study. A criterion for judging quality in case study

method is that the veracity of the case is recognized

beyond the borders of the case. It is hoped that the

findings will resonate with those who are responsible

for similar undertakings. Further research to con-

firm the findings in other contexts, and to consider

enablers and challenges that occur in different

health and social care contexts may be needed. A

dimension of the study which may be seen as both a

strength and a limitation was that a collective

analysis of student, preceptor, and university faculty

perspectives was undertaken. This allowed for a

breadth of issues to surface; however, differences in

perspectives and cross-analysis of findings among

these groups would perhaps make for interesting

future investigation. One limitation of this study is

that the perspectives of students who initially

expressed interest, but were not able to participate,

were not included. This would be an interesting

topic for future research, as the results may contribute

deeper insight into the barriers that prevent student

participation. Also, all of the countries involved

were English speaking, and well developed in terms

of their healthcare systems. Studies in resource-poor

countries, or where cultural differences are extreme,

may well raise significant issues beyond the scope of

what was considered here.

A major assumption of the study is that the goal

of enabling international educational experiences is

a worthwhile endeavour (Greatrex-White 2007).

Whether this is indeed the case is an important topic

for ongoing investigation. Although numerous studies

suggest that students benefit from such experience,

the issues surrounding whether student benefits out-

weigh hidden costs, particularly in terms of utilization

of limited resources for supervision in resource-poor

countries (Whiteford & McAllister 2006), highlight

significant topics for future critically minded research.

Given the finding that financial resources appeared

to contribute to participation, another issue which

arises from the study is whether international educa-

tional opportunities may be perceived as elitist as

they are really only available to those who can afford

to pay. This is certainly an issue worthy of attention,

and one that may underline the importance of

enhanced financial supports for such programmes.

Table 3 Enabling international fieldwork education:

university faculty and preceptor suggestions

University and preceptor suggestions

Financial support:

• Students – travel & accommodation

• Preceptors – payment to supervise students

• Professors – time to arrange placements, international

exchange

• Administrative support to arrange placements

University and administrative support of international

education:

• Travel bursaries

• Endowments

• Alumni funds

• Support and recognition for professors/preceptors who

‘Champion’ the cause

Partnerships/relationships with international universities:

• Allows more lead time for student and supervisor

preparation

• Foster peer information sharing year to year

• Fosters resources about destination at home university

• Promotes information sharing about housing options

• Arrangement of placements through universities fosters

improved support for preceptor and student

Supportive culture for students:

• Before, during and after placement

Support for preceptors during placements:

• Phone call, E-mail communication appreciated

• Local university trouble-shooting in case of challenges

Select and prepare students carefully

• Students struggling on an international placement can

be a ‘nightmare’

• Students are ambassador’s for host country & university

International faculty exchanges

• Strength of partnerships

• Appreciation of different cultures and healthcare

systems

• Contribution to international knowledge exchange

• Knowledge of student exchange destinations

• Motivation and enthusiasm

International practice education 91

© 2008 The AuthorsJournal compilation © 2008 Blackwell Publishing Ltd.

Case study research is beneficial in that it elucidates

and documents situated findings with respect to a

particular phenomenon as it is actually lived. Case

study research is limited in that generalizability

of the findings cannot be claimed, although the

findings may be practically transferable. The

findings of this study offer practical insights that

may be relevant to stakeholders from health and

social care disciplines interested in enabling student

participation in international education. Finally,

this study opens avenues for future research into the

increasing trends towards internationalization in

health and social care, the challenges and possibilities

posed by international practice education, and the

curricular implications of calls to educate responsive

global citizens in health and social care.

Acknowledgements

The authors gratefully acknowledge financial support

for this research from the University of Western Ontario,

through an International Curriculum Fund Grant.

We extend appreciation to our international colleagues

who welcomed us into their universities and clinical

sites, and to the 6 students who participated in this

study. Thanks to those who offered research assistance

and support for this work: Lynda Rolleman, Theresa

Nielson, Heather Evans and Saumiya Srivigneswaran.

Finally, our thanks to two blind reviewers who

provided thoughtful feedback on the original

manuscript.

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