SUCCESSFUL STRATEGIES IN PROVIDING INTERNATIONAL SHORT·TERM RURAL CLINICAL PLACEMENTS

ABSTRACT


BACKGROUND
Realising the value of international academic experience, many universities allow their students opportunities for international experience through completing part of a degree overseas; at the same time allowing international students academic experience at their universities.Study exchanges have proven to be beneficial for students and educational institutions, Acquisition of a foreign language, improving knowledge of the host culture, and transfonning worldviews are some of these benefits (Lewis & Neisenbaum 2005).In addition, overseas exchanges are favoured highly by many employers (UniSA International Students, nd), This explains why the University of South Australia has arranged exchange destinations with more than 60 institutions in over 30 countries; one of these is the University of Worcester in England, During a lifelong learning conference, held in Queensland in 2004, the International Coordinator of the Institute of Health and Social Care at the University of Worcester and the author, a University of South Australia nursing lecturer at the Whyalla campus discussed the feasibility of student exchanges between the two universities and the expansion of the Adelaide placement for Worcester students to include rural experience.The lecturer gave the coordinator a confident recommendation on what the region could offer, specifically the rural and Aboriginal health option, which consisted of authentic learning experiences in small rural hospitals, community health centres, aged care facilities, Aboriginal health agencies and the regional university campus.After many communications with the coordinator and consultations with local health agencies, a customised program that would provide Worcester students with an opportunity to complete their practicum at Whyalla was finalised.So far, seven students (5 males and 2 males, ages between 20s -30s, 3rd year in their program) have undertaken the twoweek rural placement in differing study periods, in addition to the five-week placement at the Royal Adelaide Hospital in the capital.
Clinical placements are a significant component of the nursing program because these provide experiential learning, They are integral to the study of nursing because they provide real life experiences at the workplace and opportunities to become absorbed into the nursing culture.Contemporary nursing programs include a range of clinical courses providing students occasions to put theory into practice.The benefits of clinical placements can be further extended by locating them in health settings abroad where students have prospects of learning at first hand about people and communities, become immersed in different cultures and languages, and can be transformed by health challenges and realities.Scott and Faugler (2005) report on the lessons learnt on study tours by nurse leaders who travelled to Europe.They conclude that there is much to learn from the health care systems of other countries.In partnering with colleagues abroad, ideas are exchanged and alternatives are explored.A similar learning outcome was envisioned for the Worcester nursing students as they exchanged knowledge and skills with local students, faculty members, and staff working in various rural clinical venues.

THE LOCAL CONTEXT
This study occurred after a year of implementing the program desigued for the Worcester students.The short-term rural clinical placement, arranged by the faculty of the Nursing and Rural Health Unit at the Whyalla campus, was developed and implemented in close collaboration with local health agencies and the Worcester coordinator.
The aims of this study abroad rural clinical placement were to provide students with an understanding of nursing education in Australia, the varied roles of nurses, the Australian health care delivery system, and health promotion in rural Australia; to practise nursing skills; to work closely with local health professionals; and to become familiar with the host culture and cultural influences on health.Participating students identified their own objectives, which the program aimed at meeting satisfactorily as well.

THE PROGRAM
Following arrival, the students were helped to settle at the student village.The table below summarises the activities for the duration of the rural visit.Note that there were some variations of activities for each cohort of students.The program designed provided short experiences in a variety of clinical settings to give students an overview of the different areas of rural nursing and the varied roles of nurses in rural areas.Cowell is a small town 110 kilometres from Whyalla.Port Augusta is another regional city, about 45 minutes by road from Whyalla.
EV ALUA TION OF THE PROGRAM Evaluations were conducted at the end of placements.A questionnaire was used to determine the impact of the program on the students.Other sources of information from where student perceptions about the program were obtained were from interviews and anecdotal accounts.The students were invited to participate in the evaluation, emphasising that participation was voluntary and that information they were to provide would be used only for research purposes.Anonymity of individuals participating in the study was maintained.
A 23-item survey instrument, consisting of open-ended and closed questions, was employed.The first part of the questionnaire consisted of 12 statements where the students were to respond using a Likert scale from I to 5, I meaning 'strongly disagree', and 5 meaning 'strongly agree'.The students were asked about the general ambiance of the venues, the staff members, meeting of objectives, orientation to and preparedness for placement, confidence levels, and perceived benefit for other students.The second part of the evaluation explored perceptions relating to the adequacy of learning opportunities, positive and negative experiences, overall benefits and outcomes, and ways by which the activity could be improved.The qualitative data gathered from the survey were collated, tabulated and analysed.

RESULTS OF THE EVALUATION
As shown in Table 2, student perceptions of the clinical placement were favourable, with none disagreeing with any of the positive statements, although there were several neutral responses for many questions.Six students completed and returned the questionnaire, with one student failing to complete the survey due to a shortened clinical placement.

DISCUSSION
The students' aims and expectations were very clear from the very outset.They wanted to learn about other cultures and wanted to expand their understanding of health care delivery systems and at the same time enrich their clinical experiences, and enhance their skills and practice.Their Adelaide placement experience, while informative and fulfilling, provided them with an experience no different from what Worcestershire could offer them, according to students.They desired something different, a real experience of what it was like to be a country nurse in Australia.They wanted to be challenged and were prepared to move out of their comfort zones as they confronted cultural and health issues affecting rural and remote areas and Aboriginal people.Two students wanted to extend their placements longer because they found rural and Aboriginal nursing to be a compelling area to focus on during their visit.
Rural nursing is crucial in effective health care delivery.Rural communities offer unique opportunities for independent nursing practice and community participation in health.The limitations in rural areas provide the drive for student learning (Van Hofwegen, Kirkham & Harwood 2005).'I think it's interesting how nurses in rural communities have to wear so many different hats in the course of their day to day jobs,' commented one student during an interview.'Visiting rural Australia has been great.I like rural communities.Worcester is a smaller town so I did find a few similarities which is part of the reason why I wanted to include a rural experience as part of my overall study abroad practicum' (Dewar 2005, p. 2).Developing and implementing a program was not as difficult as initially thought because rural areas have much to offer and the successful strategy in providing these clinical placements was mobilising local health agencies and universities to enhance the clinical learning experiences of the British students.
The majority of the students had positive experiences with the program, which was .encouraging.It provided a pleasant learning experience.There was adequate orientation and the staff members involved were very willing to assist students' learning.Other strengths of the program were meeting of students' objectives, facilitating leaming, supporting professional growth, and providing many learning opportunities.As a result of their experience, the majority of the students felt confident working in rural areas and thought that other students would benefit from the same experience.
The students met their expectations.They expected to gain knowledge about other cultures, rural health provision, and the practice of nursing in Australia.They wanted some awareness of the issues surrounding Aboriginal health and culture, and to gain more clinical skills and practice.The list of positive experiences, outcomes for students, and benefits of the program revealed that these expectations were met satisfactorily.
Students were able to compare and contrast the Australian health care system and nursing practice with the British system and practice.They gained an understanding of the problems faced in rural areas and by Aboriginal people and gained an insight into how health care providers overcame problems with culture, resources, and distance in order to maintain and promote health.
There were negative experiences reported as well.The lack of transport and access to the Internet, and the short duration of the placement were cited.The nursing home experience was very similar to their aged care placement and was not popular with two students.One student mentioned that the difference in a manual handling procedure practised in a local facility caused some tension because he was taught a different technique.The program could be improved further by addressing these issues.Mention was again made about the Port Augusta visit, which should be extended as many found this to be very interesting and educational.
How did the program impact on the students personally and professionally?The rural clinical placement provided an avenue for personal and professional growth.They gained awareness of other cultures and this is important for nurses in order to expand their understanding of their clients' cultures and values.The cultural component of the program helped developed cross-cultural awareness and hopefully cultural sensitivity and acceptance of diversity in students.The students gained not only an understanding of Australian and Aboriginal culture but also learned about themselves and their ability to work in different environments (Penman & Ellis 2004).
Undertaking clinical experience in Australia proved to be advantageous for the students in terms of increasing professional knowledge and nursing skills and broadening understanding of health care provisions and nursing roles and practice.Consider for instance the learning that transpired in a two-day placement at the Spencer Gulf Rural Health School.Students learnt about the latest developments in diet, exercise and fitness testing.They gained new skills such as performing anthropometric measurements, blood processing and administering surveys.The students were privileged to have been introduced to this as these opportunities are so rare.
The students were able to manage themselves effectively while on placement, recognising their abilities and limitations.They practised nursing in accordance with the ethical and legal framework that ensured the primacy of clients (Nursing and Midwifery Council 2004).They adapted their nursing skills to fit the envirorunent they were in.There were occasions to demonstrate nursing values such as respect, confidentiality, and fair and safe practice.The students profited from the sharing and exchanging knowledge, skills, and practice.Students' workplace readiness was also assisted.However, the most significant learning was examining one's own practice.Schon (1987) describes a process where uncertain practice situations are reconstructed and new understandings tested as reflective practice.It involves thinking about one's practice, deliberating on its appropriateness, making comparisons, weighing benefits and pitfalls, and evaluating its effectiveness (Armstrong & Courad 1994).The students were challenged to think critically about their practice.Their reflection allowed rethinking of experiences, to learn from them so as to cope with similar situations in the future (Hoban 2002).In forming new associations, previously taken for granted understandings of the world of practice are suspended, raising questions about how things are, initiating conversation and debate about practice and how practice may be further improved (Sachs 1999).This could contribute very well to self-analysis and selfknowledge.Cases in point were the reflections of two students who observed that the nurses they worked with were very knowledgeable and less reliant On doctors and this was because they had to work independently most of the time.They observed also the quality of care provided for people with diabetes by the community health nurses.Much time was spent on educating clients, including the impact of lifestyle on their condition.The students wanted to emulate these nurses.
Very close to professional growth is the opportunity to develop networks.In preparing the program, the lecturer liaised closely with rural health care facilities to provide appropriate clinical supervision.The collaborative partnerships between student and clinician and between student and academic were valuable for student support, knowledge transfer and problem solving (LeGris & Cote 1997).Successful clinical placements depend upon effective supervision (van Ooijen 2000).Moreover, the presentations delivered by the British students to local nursing students expanded the latter's international perspective of nursing as well as informing them about nursing education and practice in the United Kingdom.
The placement gave the students and academics the chance to engage in collaborative research, academic writing and presentation.A paper and recent conference presentation were a direct result of the networking that materialised from the program (Penman, Gorton, Darby & Jones 2006).Also, networking allowed institutions to complement each other, draw on each other's strengths, and advance each other's interests (Digby, Garton & Murdick 1993).Plans to write a book have been suggested by the Worcester coordinator.In sharing a vision, resources, and expertise, both institutions create a supportive environment that impact positively on the learning outcomes of students.

CONCLUSION
This paper has described an international clinical placement of nursing students from the University of Worcester and has presented the findings of evaluations of their clinical experiences.The findings show that a placement of this type is profitable.Future programs would consider the recommendations, including attending to logistical difficulties.
The placement opened up more opportunities for engagement.Two students expressed their desire to come back to Australia either for leisure, study, and/or work.Another student is pursuing further study researching on 'The western influence on the AbOriginal culture -How will this affect my nursing different cultures in the future?' The same student wishes to practice in Australia in the future.All the students are hoping that there will be more visits, and that Whyalla nursing students will visit England as well.Whyalla is expecting another group of students early 2007.
The rural clinical placement provided rich and meaningful learning experiences for all involved.It presented students with a different view of the profession and role of nurses.The linkage between the universities was vital for academic and cultural understandings.The outcomes suggested that the students benefited personally and professionally from this academic experience, while the staff involved profited by gaining insight into study-abroad experiences and how to best meet the goals of participating universities.The statements of two students will be used to close: I hope it has made our universities more willing to exchange in the future as it has been an excellent learning experience.
Hopefully the exchange will continue both ways now that it has been successful.
. the clinical Elacement was a £leasant learning: eX2!::rience.staff members were very willing and available to assist my 0 a result of my eXEerience, I feel confident working in rural areas.were many learning of!f!ortunities for me in these venues.

Table 1 :
Program activities

Table 3
depicts the popular responses to eleven open-ended questions: Education in Rural Australia, Vol.16 (2)

Table 3 :
Program evaluation (n=6)13.Why did you apply for the academic exchange?