The aim of the study is to develop knowledge about how qualified RNs in Norway use the experience gained from clinical placement in the Global South in their daily work.
Equal access to health and care services is a goal for the Norwegian welfare state (2). This means that services must be adapted and arranged to suit the needs of the individual patient (3). The barriers that impede equal access to healthcare services for patients from minority groups have been shown to include language barriers, a low level of health literacy among patients, a lack of trust in the health service, differences in illness and health aetiology, and a lack of knowledge about patients’ cultures among healthcare personnel (3).
A study by Alpers and Hanssen (21) found that qualified RNs in Norwaylack knowledge about the illness aetiology and medical traditions of non-Western cultures. This makes it difficult for healthcare personnel to understand the wishes, needs and behaviour of patients from minority groups and their families. Research also shows that a lack of intercultural competence impacts on patient care and exacerbates health inequalities (22).
The informants’ descriptions of how they apply their experience from clinical placements in Madagascar seem to indicate that they have acquired intercultural competence (6). In both the survey and the interviews, it was apparent that informants felt that they had become more aware that people’s experiences and perceptions can differ from their own. This demonstrates that they have gained insight into how a different set of beliefs, illness aetiology and perception of the role of the patient’s family can affect the nursing needs of the patient.
The feeling of being a foreigner and an outsider is something they are now able to use in contact with patients who have an immigrant background.
Several of the informants described how the feeling of being a foreigner and an outsider was something they were now able to use in their work with patients who have an immigrant background. This suggests that experiences from clinical placement make it easier for them to understand and show empathy for patients who have a different cultural background.
The informants explained that they employed different communication techniques, such as using interpreting services, to increase mutual understanding. This finding is in accordance with previous studies and it shows that clinical placement in the Global South can help break down some of the barriers to equal access to healthcare services for patients from minority groups (9, 11).
Our findings indicate that former nursing students who have completed a clinical placement period in the Global South can, ideally, take on the role of bridge-builder, as they are able to see the needs of minority group patients whilst also helping them adapt to the Norwegian context. On the basis of their experiences in Madagascar, the informants understand the value of being familiar with the background and culture of the patient, and they are able to make adjustments accordingly. This is in line with the key learning outcomes in the regulations on national guidelines for nursing education (5), as mentioned in the introduction.
Many of the informants in our study state that they have learned a great deal from their clinical placement in Madagascar. However, it is also clear that many of them find it difficult to express in words what they have learned and that they struggle to transfer their experience to working life in Norway, especially with regard to intercultural competence.
This is a well-known problem found in studies focusing on transforming learning experiences to sustainable knowledge for future practice (23). It may indicate that students undertaking clinical placement in the Global South have a greater need than other students for guidance and tools, both during and after completing their placement, as other studies also show (10–12).
The perspective of gratitude and social involvement
In the survey, many of the informants indicated that one of the greatest benefits of clinical placement in Madagascar was the sense of perspective they developed. This was particularly linked to the poverty they encountered as well as the lack of resources in the health service. Does the feeling of gratitude acknowledged by the informants have relevance in the workplace? In the interviews, the perspective of gratitude was linked to a stronger commitment to help minority groups and those on the margins of society in Norway.
Gratitude can serve an important purpose in providing a basis for solidarity with people less fortunate than ourselves. The government white paper on international student mobility in higher education (Meld. St. 7 (2020–2021)) (4), points to social involvement as a benefit for students who travel abroad and indicates that this is a skill and attribute that can be useful later in connection with work. The white paper suggests that this effect is more a result of staying in a foreign country than the content of the study programme or work placement. This indicates that for many of the informants, the perspective of gratitude has become a motivation for them to work towards the goal of equal access to health and care services.
The experience of gratitude has also been found in other studies of clinical placement experiences in low-income countries (9, 10). In contrast to the ethnocentric gratitude identified in the study by Hovland and Johannessen (10), where the informants show a condescending and critical attitude towards the health service and the competence of the healthcare personnel in the host country, the informants in our study are generally more positive towards the local health service.
It is possible to find similar attitudes among some of our informants, but the majority of the participants in our study expressed admiration over how much the local healthcare personnel were able to accomplish with so few resources.
The differing attitudes do not necessarily mean that the informants in our study are more culturally sensitive than those in the study by Hovland and Johannessen (10), but may be because a longer space of time had elapsed between the informants’ clinical placement and the interview in our study. However, the ability of students to participate in self-reflection, and the supervision and guidance they receive during the clinical placement can also contribute to forming these attitudes, as Hovland and Johannessen point out.
In line with the previous national guidelines for nursing education (24) and the new regulations (5), it is a primary aim to educate independent, responsible and innovation-oriented professionals. The informants’ responses show that although many of the experiences they had in clinical placement were ‘unpleasant’, they had still managed to have a valuable learning experience. An example of such learning is the increased development of insight into their own competence.
Both personal and professional growth are topics that recur in many studies that address the benefits of student exchange programmes (8, 9, 15, 16). In our study, we discuss how these forms of growth can be useful when working as a qualified RN.
Participants described how they had developed their creativity, and how they felt they had become more robust and dared to ‘stick it out’ in challenging situations.
One study (9) found that nursing students who had carried out a clinical placement abroad had developed individual skills and gained cultural competence that they were able to use later in working life. This corresponds with our results, in which participants explained that they had developed their creativity and felt that they had become more robust and ‘dared to stick it out’ in difficult situations. These are important qualities for a capable nursing professional facing a challenging working day in Norway.
Gained professional knowledge despite barriers
One study comparing students on international exchanges in high-income countries and low-income countries found that it was more difficult for the latter group to develop professionally (7).
In our study, several informants felt that they had gained cultural and personal insight as a result of clinical placement, in addition to professional knowledge. Increased knowledge about anatomy and physiology, training in developing the clinical eye and repetition were areas that the informants mentioned specifically. Previous studies have mainly focused on learning outcomes in the form of intercultural competence and personal development, and have had little focus on the professional knowledge gained through clinical placement in the Global South (8, 10, 11).
This article shows that Norwegian students can also obtain professional knowledge from these types of placements, despite significant socioeconomic differences and cultural barriers. However, this is conditional on the students being well-prepared, having clear course requirements for the clinical placement and having supervisors that follow up the students’ reflections during the placement period (8, 9).
Implications for nursing education and further research
Our findings show that informants achieved learning outcomes as a consequence of clinical placement in the Global South, but that it can be difficult for them to translate this competence into actual words and actions. This suggests that students who carry out clinical placement in the Global South have a greater need for guidance.
Emphasis should be placed on giving students guidance in how to use their experiences and learn from them, so that they are able to use the competence gained in a Norwegian context. There is also a need for more research to follow up the long-term benefits of international clinical placement and its relevance for work in the Norwegian health service.
Strengths and weaknesses
One strength of the study is that it provides knowledge about the experience of clinical placement, via in-depth interviews and written responses to the survey. However, only four in-depth interviews were conducted and some of the free-text responses were rather brief. Moreover, we do not know if the 40 odd people who did not respond to the survey felt that they had learnt anything.
A weakness of the study is that it only features informants who have been in Madagascar, and we cannot therefore generalise the findings to clinical placements in other countries. However, we have included a broad selection of former students from different educational institutions in Norway who carried out clinical placement in Madagascar over a time span of several years.
In our study, we did not examine whether there were systematic differences between the experiences of students in four-week placements and those in twelve-week placements, but our review of the data did not reveal any obvious differences. This is an area that requires further research.
The study shows that RNs acquired intercultural competence as a consequence of clinical placement in Madagascar, which they report using actively in working with patients from other cultures. Many of the informants said it is now easier to address patients from another culture than it was before the clinical placement, and indicated that they benefitted from the exchange both from a professional and personal perspective.
Our findings indicate that former international exchange students can take on the role of bridge-builder, as they are able to see the needs of minority group patients whilst also helping them adapt to the Norwegian context. This suggests that clinical placement in the Global South should also have a key place in Norwegian nursing education in the future.