Due to globalization, there is a need for nurses with skills and competence in providing safe, competent and culturally appropriate care. The aim of the study was to investigate whether International Study Experiences (ISE) in other countries during basic nursing education had an impact on newly graduated nurses as regards to self-reported competence. Moreover, a second aim was to explore what background factors that facilitated or constituted a hindrance for nursing students to choose to conduct part of their basic nursing education abroad. At 11 Universities/University Colleges (henceforth called Higher Education Institutions [HEIs]) in Sweden, 565 nursing students responded to the Nurse Professional Competence (NPC) Scale. Students with ISE rated their competence significantly higher on three NPC competence areas—“Legislation in nursing and safety planning”, “Leadership and development of nursing” and “Education and supervision of staff/students”. Background factors that significantly seemed to enhance ISE were living alone, not having children or other commitments in relation to family, international focus at the HEI and previous international experience. Lack of financial means was reported to prevent students from choosing ISE. The study implies that several background factors are of importance whether students choose ISE or not. ISE during basic nursing education might result in better self-reported competence in leading and developing nursing care, including education of future nurses, and in providing safe care.
The International Council of Nurses [
International educational exchange programs between different countries during basic nursing education have been ongoing for more than 40 years [
The Swedish Act on Higher Education [
One example of how ISE can be structured is presented in
The main aim of the study was to investigate whether International Study Experiences in other countries during basic nursing education had an impact on newly graduated nurses as regards to self-reported competence. Moreover, a second aim was to explore what background factors that facilitated or constituted a hindrance for students to choose to conduct part of their basic nursing education abroad.
The Nurse Professional Competence (NPC) Scale [
The items comprise eight sub-scales of competence areas. The eight sub-scales have shown to constitute the two overarching themes “Patient-related nursing” (Theme 1) and “Nursing careorganization and development” (Theme 2) as follows:
Theme 1: Patient-related nursing:
● Nursing care;
● Value-based nursing care;
● Medical technical care;
● Teaching/learning and support;
● Documentation and information technology.
Theme 1: Patient-related nursing and Theme 2: Nursing careorganization and development:
● Legislation in nursing and safety planning.
Theme 2: Nursing care organization and development:
● Leadership in and development of nursing;
● Education and supervision of staff/students.
The scale has been evaluated for psychometric properties and has shown satisfactory data quality, reliability and validity. Cronbach’s α for the eight factors in the current sample ranged from 0.75 to 0.90, which indicates high reliability of the scale.
The items in the NPC Scale are formulated as questions, e.g. “Do you think you have the ability to meet patients’ basic physical care needs?” The responses are given on a four-point ordinal scale: To a very low degree = 1; To a relatively low degree = 2; To a relatively high degree = 3; To a very high degree = 4. The response alternative “Cannot take a standpoint” is also provided.
Semester | Course/Program | Country | Length |
---|---|---|---|
4 | Emergency Care/unilateral exchange1 | India | 5 weeks |
5 | Culture and Health/bilateral exchange2 | Japan | 4 weeks |
5 | Culture and Health/unilateral exchange | Any country | 4 weeks |
5 | Primary health-care and BSc thesis/bilateral exchange funded by the Linnaeus-Palme program | Ghana, Tanzania and Thailand | 12 weeks |
5 | Data collection and analysis for BSc thesis/unilateral exchange funded by the Minor Field Study program | Low-income countries | 8 weeks |
6 | Clinical practice/bilateral exchange within the EU funded Erasmus program | Eleven European countries | 13 weeks |
1With unilateral exchange is meant a one-way program sending students abroad but the HEI not receiving any student from the receiving HEI abroad; 2With bilateral exchange is meant a two-way program sending students abroad and also receiving students from the receiving HEI abroad.
Together with the NPC Scale, questions were also asked regarding background information such as demographic data, previous university studies determined by achieved credits according to the European Credit Transfer System (ECTS), and previous and current work experience in healthcare. One question was posed about ISE, i.e. whether or not the students had participated in ISE during their basic nursing education. Students who answered “yes” to this question also answered questions on the following: number of weeks of education in Europe, number of weeks of education outside Europe, countries chosen for ISE, during which semester (1 to 6) the ISE took place, whether they received the government and/or EU scholarships for ISE such as Linnaeus- Palme, Nordplus, Minor Field Studies and/or Erasmus. The newly graduated students answered also a question whether they experienced that the ISE had contributed to perceived competence development. The answers were given by the respondents on a four-point ordinal scale with To a very low degree = 1, To a low degree = 2, To a high degree = 3 and To a very high degree = 4.
The study was performed at 11 HEIs, purposively selected and located in cities throughout Sweden, which offer a nursing program. The 11 HEIs are named A, B C, D, etc. in this paper.
At each HEI, all students completing their final semester of the 3-year nursing program were asked to participate in the study by answering the NPC Scale questionnaire. Data for the study were collected during the students’ last week of their education directly prior to graduation. The students responded to the questionnaire anonymously, i.e. without providing any personal information, which would make it possible to trace the questionnaires back to any specific respondent. In total, 565 students participated in the study yielding a response rate of 66%.
One of the HEIs (F) carried out a further data collection using the NPC Scale with in-depth, additional background questions to explore factors influencing and/or preventing students to choose to conduct part of their education abroad. The rationale for choosing HEI F for the additional data collection was the knowledge of their high number of students who had conducted international studies. This sub-study included 59 students (response rate 72%); women n = 49 (83%), mean age 27.8 (SD = 6.28), upper secondary school (natural science 27%, nursing 9%, social science 42%, other programs 22%), experience of university studies prior (32%) and/or experience from working in health care (58%) before entering the basic nursing education.
A variety of countries were chosen by the students for their ISE (
Statistical analyses were conducted using SPSS for Windows, version 19 (SPSS Inc., Chicago, IL, USA). For each of the eight NPC competence areas, a summa score was calculated and then divided with the number of items. Likewise, for each of the two themes a summa score was calculated based on the included sub-scales and then divided by the number of competence areas. Thereafter the summarized scores for the competence areas and the themes were transformed into 1 to 100 scales, the higher the score, the better the perceived competence. Level of statistical significance (p) was set to 0.05. Descriptive analysis was performed using chi-square statistics. Independent t-test and one-way ANOVA were used to compare mean values between groups. Linear regression analysis was used for comparing sub-scales and themes between groups while controlling for age. Cronbach’s alpha was used to measure internal consistency on sub-scales and themes.
According to the current Swedish law of research ethics [
The principals of each HEI gave their permission to conduct the study, and oral and written information about participating in the study were given to the nursing students, emphasizing the voluntary notion of participation. Informed consent was obtained from all newly graduated students prior to filling in the questionnaire. The students gave their informed consent by leaving a completed questionnaire which was done anonymously.
A number of 565 students (mean age 27.6 years, SD = 6.28 years) participated in the study; 488 were women (86.5%) and 76 men (13.5%) (p = 0.383) (
In total, 56 (10%) nursing students had chosen to participate in ISE during their basic nursing education (
Regarding the funding of the ISE programs, the study showed that only six HEIs had students who had utilized any government scholarships. In total, 22/565 students (39%) were beneficiaries of government scholarships that enabled them to study abroad; the most frequently used was Nordplus Higher Education program (8 students at 4 HEIs), followed by Minor Field Study program (6 students at 3 HEIs), Erasmus (5 students at 2 HEIs) and Linnaeus-Palme bilateral exchange program (3 students at 3 HEIs).
As shown in
– Legislation in nursing and safety planning (p < 0.05): items about legislation, patients’ rights, safety routines, management of violent and/or threatening situations, and knowledge of how to apply principles of disaster medicine;
– Leadership in and development of nursing (p < 0.01): items about systematic improvements in quality and safety issues, care environment, work environments, utilization and implementation of new knowledge for
Characteristics | With ISE n = 56 | Without ISE n = 509 | Total n = 565 | p-values |
---|---|---|---|---|
Age, mean (SD) | 25.3 (4.33) | 27.9 (6.45) | 27.6 (6.28) | 0.000 |
Women % (n) | 82.1 (46) | 87.0 (442) | 86.5 | 0.206 |
Men % (n) | 17.9 (10) | 13.0 (66) | 13.5 | |
Previous upper secondary school education % (n) | ||||
3-year natural science programme | 30.2 (16) | 22.3 (112) | 23.1 | 0.429 |
3-year social science programme | 32.1 (17) | 28.9 (145) | 29.2 | |
3-year auxiliary nursing programme | 11.3 (6) | 16.3 (82) | 16.1 | |
Other programmes | 26.4 (14) | 32.5 (163) | 31.9 | |
University studies prior to entering the basic nursing education % (n) | 41.1 (23) | 34.2 (174) | 34.9 | 0.189 |
Work experience in healthcare prior to the basic nursing education % (n) | 58.9 (33) | 58.0 (294) | 58.1 | 0.505 |
- as auxiliary nurse % (n) | 72.7 (24) | 56.1(165) | 57.8 | 0.048 |
- as assistant nurse % (n) | 27.3 (9) | 36.1 (106) | 35.2 | 0.211 |
- as personal assistant % (n) | 18.2 (6) | 20.4 (60) | 20.2 | 0.486 |
- other healthcare work (unspecified) % (n) | 6.1 (2) | 12.9 (38) | 12.2 | 0.199 |
Healthcare work experience in months, mean (SD) | 28.2 (64.2) | 45.8 (93.2) | 44.6 (91.2) | 0.300 |
Proportion of students who were working at the same time as studying during their basic nursing education % (n) | 73.2 (41) | 69.2 (352) | 69.6 | 0.323 |
Nursing Competences | With ISE1 (n = 56), mean (SD) | Without ISE1 (n = 509), mean (SD) | p-values2 |
---|---|---|---|
NPC competence areas | |||
Nursing care | 83.07 (9.12) | 81.19 (9.08) | 0.169 |
Value-based nursing care | 92.06 (7.09) | 90.24 (7.96) | 0.088 |
Medical technical care | 77.92 (7.56) | 75.65 (8.44) | 0.087 |
Teaching/learning and support | 80.60 (8.98) | 78.51 (8.70) | 0.075 |
Documentation and information technology | 88.42 (9.97) | 86.11 (11.36) | 0.261 |
Legislation in nursing & safety planning | 78.48 (8.97) | 75.73 (9.69) | 0.027 |
Leadership and development of nursing | 80.99 (7.43) | 77.19 (8.06) | 0.001 |
Education and supervision of staff/students | 76.11 (11.38) | 69.71 (12.32) | 0.000 |
NPC themes | |||
Patient-related nursing | 83.34 (5.99) | 81.78 (5.96) | 0.054 |
Nursing care organisation and development | 79.04 (6.92) | 75.07 (6.92) | 0.000 |
1The results of the NPC scale are presented with values ranging from 1 to 100, where a score of 100 indicates a very high self-reported competence; 2T-test significance values by regression controlled for age.
evidence-based nursing, initiation and participation in research, how to lead, develop and evaluate health staff teams, handle groups and manage conflicts, provide patient-focused care with an emphasis on quality and cost-effectiveness, lead and provide nursing care based on best knowledge, and participate in strategic planning and evaluation;
– Education and supervision of staff/students (p < 0.001): items about teaching, supervision and evaluation of staff/students.
A significantly higher score was also seen for the theme “Nursing care organization and development” (p < 0.001) (
On average, 80% of the nursing students with ISE reported that the clinical placement and/or theoretical education to a high/very high degree had contributed to improve their competence (
Among the 59 students participating in the sub-study data collection to explore factors that facilitated or constituted a hindrance for students to choose to conduct part of their education abroad, 20 had participated in ISE (
As shown in
The study showed that directly prior to their graduation, nursing students with International Study Experience (ISE) rated their own competence in nursing as significantly higher with regard to the following three competence areas: “legislation in nursing and safety planning”, “leadership and development of nursing” and “education and supervision”. Furthermore, the majority of the students who carried out part of their education abroad considered that this experience had contributed positively to their competence development. It was also found that few students had received government grants for ISE, although lack of financial means was reported to prevent nursing students from conducting ISE.
A recent review of 26 studies has identified the following six areas where newly graduated nurse students lacked competence: communication, leadership, organization, critical thinking, specific situations, and stress management [
Factors | With ISE (n = 20) | Without ISE (n = 39) | p-values |
---|---|---|---|
Age1 | |||
22 - 26 years | 65.0 | 46.2 | 0.136 |
27 - 44 years | 35.0 | 53.8 | |
Sex | |||
Women | 95.0 | 76.9 | 0.078 |
Men | 5.0 | 23.1 | |
Living situation | |||
Living alone | 40.0 | 20.5 | |
Living in a relation | 45.0 | 76.9 | 0.032 |
Living with other adults | 15.0 | 2.6 | |
Having children | |||
Yes | 0 | 35.9 | 0.001 |
No | 100.0 | 64.1 | |
Commitments beside the nursing studies2 | |||
Yes | 10.0 | 46.2 | 0.005 |
No | 90.0 | 53.8 | |
Ill health | |||
Yes | 0 | 0 | |
No | 100.0 | 100.0 | |
Lack of finances | |||
Yes | 0 | 48.7 | |
No | 100.0 | 51.3 | 0.000 |
Perceiving that the HEI had an international focus | |||
Yes | 55.0 | 20.5 | 0.009 |
No | 45.0 | 79.5 | |
Previous studies/work abroad | |||
Yes | 65.0 | 35.9 | 0.032 |
No | 35.0 | 64.1 | |
Perception that the ISE can negatively affect the ability to learn necessary skills for the Swedish health care | |||
Yes | 10.0 | 23.1 | 0.195 |
No | 90.0 | 76.9 | |
Other reasons3 | |||
Yes | 20.0 | 53.0 | 0.012 |
No | 80.0 | 46.2 |
1Categorization of age is based on median value; 2Responsibility for other family members, such as parents and/or siblings; 3E.g. responsible for own pet/s, not wanting to be away from home for such a long period.
safe care. The reasons why the nursing students with ISE rated their competence higher on the three competence areas cannot be explained by this study. However, it can assumed that being exposed to health-care systems in low-income countries where patients’ rights are not always obvious [
Several key documents stress the importance of internationalization in higher education, in order to promote understanding of other countries and international conditions, and encourage student mobility [
The utilization of government-sponsored scholarships among the group of students with ISE was low. This might reflect negative or reserved attitudes towards internationalization among the decision-makers and teachers at the HEIs, as the scholarships are applied for and obtained based on applications from teachers at the HEIs. Previous research has shown that nursing teachers have had difficulties in integrating internationalization in their teaching [
It is possible to enhance students to participate in ISE as shown by the results for the HEI labeled F. At this HEI almost 30% of the students had performed part of their education abroad. The HEI had at the time of the data collection undergone an intense internationalization program. This included international preparatory courses given to both students and teachers, which resulted in an increase in government-funded grants for ISE activities. However, to benefit from the ISE experience both individually and for the HEI it is crucial with a structured preparatory course and follow-ups once the student returns from the ISE in the form of clinical placement and/or theoretical courses. The study demonstrated a difference regarding how satisfied the nursing students were with their ISE depending on which HEI they had studied at. Potential factors influencing students’ experience of satisfaction with their ISE could be related to the kind of preparation received prior to studying abroad, the characteristics and quality of the host HEI, and post-ISE follow-up among nursing students. Based on our international experience we clearly see the value of well organized and structured program activities to support internationalization. This will enable students to make the most out of their international exposure and lead to good quality of care for patients including cultural appropriate care.
International Study Experience (ISE) during the basic nursing education has a positive impact on newly graduated nurses’ self-reported competence, especially legislation in nursing and safety planning, leadership and developing of nursing and education and supervision of staff and students. Measures should be taken to actively offer as many nursing students as possible the opportunity to do part of their clinical and/or theoretical education in other countries.
We are grateful to the nursing students for their participation in this study, Hilary Hocking, Östersund, Sweden for language revision, and JariAppelgren, Karlstad University, Sweden for statistical advice.