The influence of international mobility programmes on nursing students ' personal and professional development : a descriptive research

Introduction: Student mobility programmes have become a valuable instrument in student education as they enable the acquisition of essential knowledge, skills and attitudes, and equip the individual more effectively to work in the globalised world. The aim of the study was to examine the impact of international exchange programmes on the personal and professional development of undergraduate nursing students. Methods: A quantitative secondary analysis was conducted. The primary data were collected in 2016 as part of the study entitled International Nursing Student Exchange – Comparison Between Slovene and Foreign Students. The sample in the secondary analysis consisted of 73 nursing students from Slovenia and other European countries. The questionnaire included 20 statements which were rated on a 5-point Likert scale (1-strongly disagree to 5-strongly agree). The data were described on the basis of calculated mean values and the Mann-Whitney U test. Results: On the personal level, students stressed that mobility can improve their self-confidence (Z = –2.088, p = 0.037) and acceptance of other cultures (Z = –3.116, p = 0.002). On the professional level, they highlighted the need to upgrade students' professional competencies (Z = –3.116, p = 0.002), particularly in the field of culturally competent nursing care (Z = –2.391, p = 0.017). Discussion and conclusion: The benefits reported by nursing students seem to show that it is sensible to continue to support and promote international student mobility programmes.


Introduction
Today, nurses work in culturally diverse settings, which is why the cultural competence has become key to ensuring quality nursing care. There is growing concern in both educational and healthcare institutions about the need to respond to different patient populations in order to ensure equity in health care (Memmott, et al., 2010;Kulbok, et al., 2012). In response to increasing globalisation, nursing courses have had to develop suitable learning opportunities for students (Siles Gonzalez, et al., 2016). Student mobility programmes which enable students to gain experience in another country have become a valuable way for students to acquire cultural competencies and intercultural sensitivity (Edmonds, 2010;Kelleher, 2013). Although a study placement abroad does not yet make student nurses culturally competent, it can help them recognise that there are multiple ways in which care can be provided to individuals, families and communities (Maltby, et al., 2016). Other benefits of international student mobility programmes highlighted in the literature include students' social, personal and professional development (Guedes, et al., 2018). Such international experience stimulates the exchange of best practices, ideas and values, and promotes a better understanding of various healthcare systems and practices which, in turn, contribute to one's personal and professional development (Memmott, et al., 2010). Furthermore, Siles Gonzalez and colleagues (2016) note that student mobility programmes help students increase their selfconfidence and independence. Finally, the experience of learning and working outside the borders of one's country of origin enriches students' curricula and consequently increases their employability at home and abroad (Marshall, 2017).
The Bologna process has had a significant impact on student mobility. The idea of cooperation between EU member states in the field of education is supported by Article 165(1) of the Treaty on the Functioning of the European Union (EU), which states that "the Union shall contribute to the development of quality education by encouraging cooperation between Member States" (European Parliament, 2020). Today, this cooperation is implemented through the European Region Action Scheme for the Mobility of University Students (Erasmus), which enables students to study or work abroad at a foreign university or other institution / organisation (e.g., in hospitals and other clinical settings for nursing students) as part of their degree programme. This includes participation in lectures and practical training in the host country (Marshall, 2017). In 2014, the Erasmus programme was renamed and extended to cover all areas of lifelong learning, including school education, further and higher education, adult education and the youth sector, and is now known as the Erasmus Plus programme.
This programme enables participants to study, work, volunteer, teach and train in other European countries. At present, there are 33 countries participating in the Erasmus programme, including some which are not part of the EU, e.g., Macedonia, Liechtenstein, Norway, Iceland and Turkey. The programme enables students to go abroad for a minimum of 12 weeks, which, in the case of purely theoretical degrees, can be extended to the entire academic year (European Commission, 2020).
The Conference of European Ministers Responsible for Higher Education in Leuven (2009) and the Education, Audiovisual and Culture Executive Agency [EACEA] (2012) set as its target that at least 20 % of all EU students should experience student mobility by 2020 (EACEA, 2012). However, the latest available data for 2012 are not so encouraging, as the share of intra-EU student mobility did not even reach 4 % that year. In Slovenia, the proportion of students participating in international mobility was also very low (2.6 %). The highest rates of student mobility was reached in Malta, Ireland and Slovakia, where the percentage ranged from 11.2 to 14.3 (Eurostat, 2020). Several authors (Brown, et al., 2016;Kelleher, et al., 2016;Marshall, 2017) believe the main reasons which may deter nursing students from undertaking a student placement abroad are related to personal safety and access to quality health care, difficulties associated with leaving their family behind, financial challenges and language barriers. Furthermore, when referring to undergraduate nursing programmes, Kelleher and colleagues (2016) also stress that such courses are relatively demanding in terms of academic commitments with very limited time available for study abroad. In fact, this might be another barrier preventing nursing students from engaging in such experiences. It should be noted that in nursing education the practice of studying abroad is a relatively new phenomenon (de Oliveira & Tuohy, 2015) despite the fact that it has been promoted since internationalisation was identified as a main strategy in nurse education in the 1980s (Myhre, 2011). Internationalisation of the nursing curriculum through offering nursing students the opportunity to study in another country is viewed by nursing regulatory bodies as a priority, as it will better position the nursing profession within the growing global health agenda (Zanchetta, et al., 2013).

Aims and objectives
Over the past few years, the participating faculty has expanded student exchanges as more and more nursing students choose to partake in Erasmus mobility abroad. In this context, our aim was to explore undergraduate students' attitudes regarding the impact of international mobility on their personal and professional development. The aim of the study was to define potential differences between those nursing students who have participated in a student mobility exchange and those who have not.

Methods
A quantitative secondary analysis was used. This method is defined as the use of existing data to find an answer to the research question which is different from that used in the primary analysis (Johnston, 2014). However, there must be a premise between the primary and secondary methodological approach. Secondary analysis of quantitative data provides an opportunity to maximize the usefulness of data, particularly that associated with populations which cannot be reached on a wide scale (Tate & Happ, 2018), as is the case in nursing students who have experienced international mobility. The primary data were collected in 2016 in the study entitled International Nursing Student Exchange -Comparison Between Slovene and Foreign Students (Krivičič, 2017).
The primary study addressed the broader concept of international mobility programmes for nursing students, such as their availability, student satisfaction with the organisation of exchange programmes at the home and host institutions, as well as the broader impact of mobility on students' personal and professional development. Before determining whether a secondary analysis of quantitative data was feasible, an assessment of the adequacy of the primary data was carried out, focussing in particular on their relevance and quality in relation to the new aim of the study.

Description of the research instrument
A questionnaire was developed based on a review of the relevant literature (Goodman, et al., 2008;Green, et al., 2008;Keogh & Russel-Roberts, 2009). The questionnaire consisted of three parts: i) demographic data of the participants (gender, age, year of study, marital status); ii) questions regarding the impact of international exchange on the student's personal development; and iii) questions regarding the impact of international exchange on the student's professional development. The questionnaire included 20 statements, which were to be rated on a 5-point Likert scale (1-strongly disagree to 5-strongly agree).
The linguistic equivalence of the questionnaire for Slovene students and students from other European countries was established via translation and back-translation by two independent, bilingual and professional translators. The translators were informed about the purpose of the instrument. Finally, the questionnaire was reviewed by a panel of experts consisting of a language teacher and two nursing lecturers to determine whether the concepts expressed in Slovene and English conveyed the same meaning.
A reliability analysis using Cronbach's alpha coefficient was performed to check the internal consistency of the questionnaire. The alpha value of the entire questionnaire was 0.967, which indicates very high degree of reliability (for the part of the questionnaire relating to students' attitudes towards the impact of international mobility on their personal development, Cronbach's alpha coefficient was 0.939; while for the part of the questionnaire addressing students' attitudes towards the effects of international mobility on their professional development, Cronbach's alpha coefficient was 0.955).

Description of the research sample
Convenience sampling was employed to collect the primary data. The study included undergraduate nursing students enrolled at a single Slovene educational institution in the 2015/16 academic year (N = 287). A response rate of 18.47 % (n = 53) was achieved. The study involved nursing students of all three years of study, as well as students who, on the day of the launch of the research, held the status of a diploma candidate (additional year of study). At the educational institution where the study took place, an average of four to five Slovene nursing students undertake an Erasmus mobility placement each year. The study also included undergraduate nursing students from other European educational institutions who attended the Florence Network meeting in April 2016. As the purpose of Florence Network meetings is to discuss exchange opportunities between the participating countries, we were able to include students from other European universities as well. The meeting was attended by 75 undergraduate nursing students from 18 European countries, with 20 students participating in the study (a response rate of 26.67 %). The final number of undergraduate nursing students participating in the study was 73.

Description of the research procedure and data analysis
The study was approved by the Institutional Review Board (University of Primorska, Faculty of Health Sciences). English and Slovene versions of the questionnaire were developed using the 1ka.si online application (2016). A Uniform Resource Locator (URL) to the online questionnaire was sent to students' email addresses, which had been obtained before the launch of the study. Access to both versions of the online questionnaire was restricted; students had to complete the questionnaire between 26 April and 13 June 2016. The questionnaire included a description of the study. Participation in the study was voluntary. To ensure the participants' anonymity and confidentiality, a database was created during data collection on the web server which contained the respondents' answers without their personal data and e-mail addresses. Data collection was the sole responsibility of one of the researchers, and data were stored in a passwordprotected 1KA (1ka.si, 2016) account.
In the secondary analysis, data were analysed using the Statistical Package for the Social Sciences, Version 25.0. (SPSS Inc., Chicago, Illinois). Descriptive univariate statistical tests (frequencies, percentages, mean values, standard deviation) were performed to obtain nursing students' attitudes regarding international mobility. The normality assumption was evaluated using normal probability plots and the Kolmogorov-Smirnov criterion. The Mann-Whitney U test was applied to identify any significant differences between the demographic characteristics of the sample in conjunction with students' experiences with international mobility and their perceptions on how international exchange programmes affected their personal and professional development. Statistical significance was set at p < 0.05.

Results
The study involved 24 male (32.9 %) and 49 female (67.1 %) nursing students. The foreign nursing students who attended the Florence Network meeting and participated in the study (n = 20) came from 11 different European countries, mainly Italy (n = 4), the Netherlands (n = 4), Norway (n = 2), Finland (n = 2), Sweden (n = 2), and one participant from each of the following countries: Czech Republic, Slovakia, Belgium, Portugal, Greece and Turkey. Further demographic data on the sample are presented in Table 1. Of the 73 students participating in the study, 17 (23.3 %) had already completed an international mobility programme (11 Slovene students and 6 students from other European countries). The main reasons given by the students who had not undertaken international exchange (n = 56, 76.6 %) for not participating in an exchange programme were "lack of financial resources" (n = 26), "poor knowledge of foreign languages" (n = 14) and "fear of the unknown" (n = 10). Only four participants stated that they were "not interested in international mobility", and two stated that they were "not satisfied with the list of host countries offered" by their institution.

Impact of international mobility on nursing students' personal development
On the whole, students believe that international mobility can have a positive impact on their personal development (Table 2). In this part of the questionnaire, the mean scores for a single statement ranged from 4.00 to 4.51 (an overall mean score of 4.35). The highest rated statement was "international experience encourages the creation of new friendships and acquaintances".
We also analysed the data to determine potential differences between the responses of students who had completed international mobility and those who had not. Through the five statements, students who had participated in a mobility exchange reported a greater impact of the international experience on their personal development. In broader terms, they believe an international exchange not only influences one's acceptance of other cultures, but also affects the understanding of one's own culture. Furthermore, it encourages one's self-reflection regarding life at home and improves one's personal relationships, for example with one's family or partner. In addition, students who had an international mobility experience also indicated that international mobility can improve an individual's level of self-confidence.
In this part of the questionnaire, no major differences in mean scores were detected between Slovene students and students from other European countries. The only statistically significant difference was observed for the statement that international mobility "encourages the creation of new friendships, acquaintances" (Z = -2.033, p = 0.042), with the latter being rated higher by the students from other European countries ( = 4.8, s = 0.41) than the Slovene students ( = 4.4, s = 0.91).

Impact of international mobility on nursing students' professional development
Students also indicated that international mobility can have a strong impact on their professional development ( Table 3). The overall mean score for this section of the questionnaire was 4.26 (with mean scores for individual statements ranging from 4.11 to 4.48). The highest rated statement in this section of the questionnaire  was that student mobility "can contribute to a broader understanding of nursing as a profession".

Legend / Legenda: Yes -students who had experienced international exchange / študenti, ki so bili na mednarodni izmenjavi; Nostudents who had not experienced international exchange / študenti, ki niso bili na mednarodni izmenjavi; -average / povprečje; s -standard deviation / standardni odklon; Z -value / vrednost; p -statistical significance / statistična značilnost; n -number / število
Students who had participated in international exchanges expressed a stronger agreement with the statement that international mobility experiences enable students to upgrade their professional skills, in particular those associated with cultural competence. They also stated that participating in an international exchange enables students to compare their knowledge with that acquired through other education systems.
When comparing the scores of Slovene students and students from other European countries, two statements showed a statistically significant difference. Students from other European countries agreed more strongly with the statement that international exchange "can upgrade the competencies acquired during studies"

Discussion
Overall, nursing students believe that international mobility can positively influence their personal and professional development. However, the students who had already undertaken a mobility exchange programme assessed its impact as greater than those who had not had this experience. Previous studies (Myhre, 2011;Gower, et al., 2017) also demonstrate that students participating in international mobility programmes can gain greater cultural awareness and experience personal and professional development.
However, the proportion of students who had experienced international mobility in our sample was less than a third. The two main reasons given by both Slovene and international students for not participating in a mobility programme were lack of funding and poor language skills. When students undertake a placement abroad under the Erasmus programme, they receive financial support (Marshall, 2017). Through the Erasmus programme, a student can qualify for funding on condition that they spend at least three months abroad. Students receive an EU grant which compensates for their travel and accommodation costs in the host country. The amount is not the same for all countries participating in the programme and is defined by respective national agencies in agreement with the national authorities according to the costs of living in the host country (programme countries are divided into three groups) (European Commission, 2020). However, it often happens that these grants do not cover all the costs arising from the mobility exchange, and students need to secure additional funding themselves.
Students also pointed out the problem of poor fluency in foreign languages. Several authors describe the need for students to adequately prepare for a stay abroad, especially with regard to the language of the host country. De Oliveira and Tuohy (2015) note that students going abroad should be fluent in the language of the host country. In fact, some studies from countries where English is not used as an official language show that nursing mentors often feel insecure when they supervise international students in clinical settings and use English as a working language (Myhre, 2011). Proficiency in the language of the host country enables students to demonstrate their competence and enhances their learning process (Gower, et al., 2017;Guedes, et al., 2018). Effective communication in nursing is the cornerstone of students' professional growth, as it enables them to establish therapeutic relationships with patients and their families and with other health professionals (de Oliveira & Tuohy, 2015). However, in a study conducted by Keogh and Russel-Roberts (2009), German students who participated in an exchange programme in Finland stated that, despite language barriers, they always managed to find a way to communicate with patients, colleagues or lecturers, even though they occasionally had to use non-verbal communication. Nevertheless a certain level of English language proficiency is essential for students, teachers and clinical mentors to ensure a quality learning process.
Students believe that studying abroad stimulates their personal development. Gower and colleagues (2017) describe personal development as a transformation which enables a person to see the world from a different perspective which in turn broadens their worldview. During a stay abroad it is important for the individual to be open to new experiences in order to benefit from them. Guedes and colleagues (2018) emphasise that students can perceive an international experience to a large extent as an opportunity for personal as well as professional development. During an exchange programme, nursing students are likely to face numerous challenges on the personal, social and cultural levels (Myhre, 2011). Guedes and colleagues (2018) claim that the experience of studying abroad allows students to develop their autonomy, emotional control and self-confidence. Indeed, when staying in a foreign country, students are confronted with new situations and responsibilities, such as needing to plan their daily expenses, living with people outside the family environment and culture of origin, feeling homesick and missing their family members and friends etc. Although the beginning of this journey can be quite stressful for students, most of them return enthusiastic about their experience and express a notable increase in their personal confidence and maturity (Milne & Cowie, 2013). In our study, students who had already undertaken an international exchange emphasised that it had a positive effect on their ability of self-reflection and that it boosted their self-confidence. In a study by Green and colleagues (2008), nursing students reported that the experience of living and studying abroad had given them a sense of fulfilment. Milne and Cowie (2013) add that students who complete an exchange abroad learn to appreciate their own culture and other cultures more, which is also in line with our findings. The experience of spending a longer period abroad provides students with the opportunity to develop and heighten their awareness of different cultural values, which facilitates greater tolerance of others and gives them a better understanding of how challenging life can be for members of minority ethnic groups (Gower, et al., 2017). Maltby and colleagues (2016) investigated whether the international exchange experience in a low-income country versus a high-income country was reflected differently in nursing students' development of cultural awareness. According to their conclusions, one's cultural awareness changes regardless of the host country. In fact, the general experience students obtain through any mobility programme is that of being an outsider. Siles Gonzalez and colleagues (2016) find that to most students the personal experience of having been a member of a minority group represents the key precursor to the formation of new personal cultural awareness and tolerance. This also has a strong influence on the perception of the student as a nurse, as they have the opportunity to experience perspectives which will directly influence their future care and management practices (Kohlbry, 2016).
In terms of professional growth, students stated that spending some time abroad gave them a broader understanding of nursing as a profession. During longer placements abroad, students were able to obtain a more accurate overview of the healthcare system of the host country. They were able to discern the differences between the two systems and also identify the strengths and weaknesses of the system of their country of origin (Milne & Cowie, 2013;De Oliveira & Tuohy, 2015). Browne and colleagues (2015) state that the opportunity to experience another country's healthcare system and being immersed in its daily clinical practice is of far greater benefit to students than formal lectures on the care provided. In a study by Green and colleagues (2008), students from the United Kingdom and Sweden who had participated in a mobility programme stated that this experience not only expanded their knowledge and practical skills, but also raised their awareness of the differences in individual healthcare practices and nursing roles. Similar findings are reported in a study by Keogh and Russel-Roberts (2009), in which students from Germany were able to directly experience a significantly different nursing system compared to their own. Gower and colleagues (2017) emphasise that the experiences gained during an international mobility exchange serve to confirm the existing practices, while also encouraging students to review and change their practices.
Nursing students who had already experienced studying abroad agreed more strongly that international exchange has an impact on upgrading one's professional skills, especially in the field of intercultural nursing care. Although the curricula of most undergraduate nursing programmes address cultural topics and their relationship with patient care (Edmonds, 2010), several authors emphasise that registered nurses are still not sufficiently prepared to meet the needs of patients from different cultural backgrounds (Gower, et al., 2017;Guedes et al., 2018;Southgate & Wrench, 2020). At present, due to the growing ethnic diversity of people requiring nursing care, nursing students need multicultural experiences, and international mobility programmes can provide for this need. Studying abroad facilitates the development of cultural sensitivity in nursing students, which directly improves the quality of patient care (de Oliveira & Tuohy, 2015). Edmonds (2012) stresses that during a mobility placement, nursing student learn how to overcome ethnocentrism. In clinical placements, they come into contact with patients and families from various cultural backgrounds, beyond the level of a tourist. Nursing students can thus develop positive habits which will aid them in their future nursing practice and promote quality patient care (Edmonds, 2010).
Based on our sample, compared to Slovene students, students from other European countries seem to be more aware of the importance of intercultural care in nursing. One reason for this could be that Slovenia has a relatively small number of foreign citizens and could therefore be defined as a culturally homogenous state (Prosen, 2018). Consequently, Slovene students may be less sensitive to this aspect of nursing than students from other European countries. In our study, the latter came mostly from countries such as Italy, the Netherlands and Sweden, where the population structure is particularly diverse. As high-income countries they are more strongly exposed to migrant flows. However, over the past decade, Slovenia, as an EU member state, has also become an increasingly attractive destination for migrants (European Migration Network, 2019). Several authors (Brown, et al., 2016;Gower, et al., 2017;Southgate & Wrench, 2020) note that globalisation and increasing levels of migration make it necessary to increase nursing students' sensibility to the issues of cultural diversity and importance of intercultural nursing care, and international mobility seems to be an appropriate strategy to this end. In fact, the Slovene students who had taken part in mobility exchange programmes agreed more strongly that such an experience improves nursing students' understanding of intercultural competencies.
The results of our study are consistent with the results in the available literature. Nevertheless, certain limitations should be taken into account. The sample size of the study was relatively small and the number of Slovene and international students was not equal. Moreover, the Slovene nursing students participating in the study only came from one Slovene educational institution. For this reason, the results of this study should be interpreted with caution, as these limitations make it impossible to generalise them to all European nursing students. Moreover, the validity of the questionnaire was based only on Cronbach's value, which means that further psychometric tests should be performed. Caution should therefore be exercised when generalising the results and findings of this study. Further research could focus on external or actual constraints which might influence student mobility exchanges, such as financial issues, institutional support strategies, curriculum design, etc.

Conclusion
The results of the study suggest that international mobility programmes have a major impact on nursing students' personal and professional development. Students who had already experienced a mobility exchange programme rated the impact of such programmes more positively. Studying abroad brings new experiences into the lives of individuals and can thus help nursing students become more confident and able to provide better and culturally competent nursing care. It therefore seems worthwhile to continue to support and encourage students' international mobility opportunities. As enthusiastic role models, faculty members play an important role in promoting international student exchanges. Furthermore, the promotion of international mobility needs to start early in an academic programme and should include detailed information as well as provision of administrative support.