Norwegian nursing students’ experiences of theoretical and clinical studies in Tanzania: A descriptive qualitative study

Abstract

Internationalization has been a priority in higher education for several decades. No studies reporting nursing students’ learning experiences from both theoretical and clinical studies in Africa were identified. The study aimed to describe learning experiences of Norwegian nursing students after participating in a study-abroad program that includes theoretical and clinical studies in Tanzania. A qualitative descriptive design was chosen. Five group interviews were carried out from 2013–2016. The students entered new ground; they were in a challenging learning process but most of all they experienced personal and professional growth. The students increased their cultural competence, enabling them to meet patients and relatives from foreign cultures more open-mindedly. Being part of a student group, sharing experiences and reflecting on these are crucial for personal and professional growth. Returning home and experiencing a kind of ‘reverse culture shock’ underlines the importance of debriefing shortly after return to their home university.

Introduction

Culturally competent nurses are needed in today’s multicultural society. ¹ Free movement for citizens within the European Union and worldwide underlines the need for skills related to cultural awareness and cultural competence.^2–5 Internationalization of student education has been a priority in higher education for several decades.^6,7 The Norwegian University of Science and Technology (NTNU) has ‘knowledge for a better world’ as a vision, and aims to offer 40% of students one semester of international experience as part of their study program. Thus, NTNU aims at doubling the aim set out in the Bologna Process that 20 percent of students in higher education should study abroad for at least three months. ⁸ The current study aimed to describe students’ learning experiences after participating in a study-abroad program that included both theoretical and clinical studies in an African country.

Background

Internationalization in education programs contributes to the relevance of the programs.^8–10 A recent review reports that global justice as a deeper human right needs to be discussed in nurse education, especially in practical contexts. ⁶ International programs contribute to increased cultural competence over several years^3–5,7,9,11 and to personal growth.^5,12 However, it is also described that ‘real experience’ is an underestimated resource.^2,13 Studies report that measuring and assessing cultural competence is challenging.^3,5,14

Up until 2020 Norwegian nursing education was based on General Plan and Regulation ¹⁵ and is a bachelor’s degree. Clinical practice is an important part of nursing education as in other countries outside Europe.^16–18 International experience for nursing students is mainly based on study-abroad programs for Norwegian, ⁹ for Swedish ¹⁹ and other European countries. ¹² The study-abroad programs have mostly consisted of clinical practice in the host countries. The periods of clinical practice in the host countries are rather short, typically three weeks,^5,19 four weeks^9,20 and eight to twelve weeks.^21,22 This seems to also be the case for some study-abroad programs in the USA^23,24 and Australia, ¹³ but a program lasting one semester is also described. ²⁵ A study-abroad program for more than three months including theoretical and clinical learning activities, may contribute to a deeper insight into a foreign healthcare system, a foreign education system and a foreign culture.

However, we have not identified studies reporting nursing students’ learning experiences from both theoretical and clinical studies in Africa by searching databases such as PubMed, Medline, Cinahl, and ERIC. Thus, the current study contributes to new knowledge by describing nursing students’ experiences of combining theoretical and practical studies in Tanzania.

The study-abroad program

Establishing a partnership takes time, and requires motivation and resources from both partners.^25,26 This was also the case for the current program, developed between 2010 (the initial contact) and 2012 when the agreements were signed. The partners developed a program where Norwegian students in the third and final year of their bachelor program have an option for three months’ stay in Tanzania. The Tanzanian students are in a three-year Bachelor of Science in Nursing (BScN) program based on a diploma in nursing, and they have varied clinical practice experiences in nursing. The Norwegian students are assessed and graded by host faculties. The foci in these theoretical courses are Community Nursing, Research Methodology, and Leadership and Management.

The courses are mandatory, taught in English, and mainly based on lectures with group discussions where Norwegian and Tanzanian students are mixed in the groups. The Norwegian students take school exams in line with the Tanzanian students at the end of the stay. The study-abroad period lasts for 12 weeks, of which six weeks are clinical studies and six weeks theoretical studies. The clinical part of the program includes learning situations in out-patient contexts and in a hospital context. All students had passed clinical studies in nursing homes, in medical, psychiatric and surgical nursing earlier in the study program. Clinical studies in medical nursing includes placement in a delivery ward. The students carry out five weeks of their clinical practice in home care in Norway before leaving, which gives them an opportunity to compare the Tanzanian out-patient experiences to the Norwegian ones. During the first group’s stay a need for a more structured and organized program was apparent. Consequently, the second group was presented with a structured program that was developed in cooperation between the visiting and hosting institutions. Due to unforeseen circumstances in Tanzania, the program could not be carried out as planned. The third group also experienced changes and a delayed start of the program due to a presidential election in Tanzania.

The aim of this study was to describe learning experiences of Norwegian nursing students after participating in a study-abroad program that includes theoretical as well as clinical studies in Tanzania.

Method

The study had qualitative descriptive design ²⁷ and is reported in line with the COREQ checklist.

Participants

The first group of students (n = 3) had their study-abroad period in fall (i.e. from September to December) 2013, the second group (n = 5) in fall 2014 and the third group (n = 5) in fall 2015. All students in the study-abroad program 2013–2015 (in total 13 students) participated in the study.

Data collection

Group interviews with three student groups (three, five and five students respectively) were carried out from October 2013 to January 2016. All student groups were interviewed shortly after returning to Norway. Additionally, two groups were interviewed during their stay in Tanzania. The second group (fall 2014) was not interviewed during their stay due to force majeure. The interviews (in total five) were performed by the first author (a female PhD) and took the form of a qualitative interview in line with Kvale’s description. ²⁸ The foci in the interviews were the students’ learning experiences – those which contributed to and those which restrained them from meeting the outcomes of the program, which were to 1) acquire insight into Tanzania’s healthcare system, 2) experience cultural adaption, 3) acquire professional as well as personal development, and 4) meet the requirements in the courses of the program. The semi-structured interviews lasted from 50 to 70 minutes, were all performed in a room with no disturbance and with no other person present.

Data analysis

All the interviews were carried out in Norwegian. They were digitally recorded, transcribed and checked for accuracy. The transcriptions were made by the first author. The files were uploaded to MAXQDA, ²⁹ a program for analyzing qualitative data. An inductive analysis process was carried out in line with Elo and Kyngäs’ ³⁰ description of the qualitative content analysis process. Firstly, the author group read and re-read the transcripts separately in order to make sense of the data as a whole. The transcripts were read several times; and the open coding (marking notes and headings) was done in MAXQDA. During the process, the codes were thoroughly discussed by the author group in order to group the codes. Creating categories implied discussions in the same group until agreement was obtained. The proposed categories, labelling of main categories, and subcategories were discussed with our Tanzanian partners; thus, the analysis was done in English from this phase.

The Tanzanian partners were also included in the abstraction phase. Although the analysis process is described in phases, this was not a linear process. At several times we returned to former phases in order to ensure that the findings-to-come were grounded in the data. Quotations are used to illustrate the findings.

Ethical considerations

The study was carried out according to the Declaration of Helsinki ³¹ and the Ethical guidelines for nursing research in the Nordic countries. ³² Norwegian Social Science Data Services assessed the project plan and concluded that there was no need for ethical approval (ref. 35526). Ethics considerations are continuously assessed throughout the research process. Eligible students were informed about the project including the right to withdraw from the study. All participating students gave their informed consent in writing.

During the interviews, we emphasized that the students had the confidence to reflect on both positive and negative experiences. Therefore, we considered it crucial that the first author, who conducted the interviews, had an objective relationship with the students without grading and evaluating them. Throughout the analysis process, analytical triangulation in the whole author group was emphasized to prevent bias. ³⁰ As described previously, the organization phase was repeated several times before reaching the categories in the reporting phase. The collaboration with our Tanzanian partners was a strength, as it contributed to a reflexive process that took into account both the Norwegian and Tanzanian context.

Findings

The output of the analysis is reported in three main categories, each of them consisting of two subcategories. The main categories are ‘Entering new ground’, ‘In a challenging learning process’ and ‘Personal and professional growth’ as shown in Figure 1.

Figure 1.

Overview of main categories and subcategories.

Entering new ground

Shortly after arriving in Tanzania, the students started their learning in clinical practice. Thus, these experiences from clinical practice constitute their descriptions of entering new ground. This main category entails two subcategories: Being acquainted with a foreign culture, and Meeting everyday situations in clinical practice.

Being acquainted with a foreign culture

When arriving in Moshi, the students were exposed to Tanzanian culture in terms of meeting with people in town, meeting Tanzanian students and teachers at the University, patients and relatives. The people were friendly and talked to them, and even invited them home, which was a positive experience, and quite different from how it is in Norway where strangers very seldom talk to you. On the other hand, the students sometimes were asked for kinds of support, for example financial help. To some degree such experiences dissuaded the students from further contact with people.

As Europeans in a Tanzanian community, the students reported being subject to attention due to, for example, having blue eyes, blond hair and wearing different clothing. However, when dressed in their uniforms in town they were ‘left in peace’ when walking the streets.

The students described an experience of unexpectedness in terms of lack of plans and change of plans. This was a source of frustration and very different from what they were used to in Norway, whereas, in some situations, the lack of preplanning also gave the students options to change the plans, described as a kind of flexibility. The students made good use of each other in the group to get through these frustrations. The reasons for changed plans were often outside the control of the hosting university; however, all three student groups faced such situations. If they received information about changes this was experienced as fine, but they said ‘not knowing is both strenuous and a waste of time’. Although they were used to having plans and sticking to them, the students became, in a relatively short time, accustomed to changes in many ways, which was expressed like this: ‘Being frustrated is not good – just take it as it is’.

Meeting everyday situations in clinical practice

The students experienced that all processes were slow, especially in the hospital practice. They described patients waiting from early morning until late afternoon, but they were surprised that there was no stress among the patients in the line. They also reported that while patients waited in the corridor the nurses were busy filling in the cards and greeting people coming to say hello. The varying number of patients in the clinics was a challenge for the students’ learning situations. Most of the patients attended the clinics during morning hours, and very few in the middle of the day, and the students found these hours more or less a waste of time.

The students had various experiences from the clinics regarding caring for and communicating with the patients, to knowledge and practical performance, hygiene, equipment, and how the nurses met the students. Doing things together with the nurses (i.e. nurses at different educational levels) improved their relationship with them. In some places the nurses greeted the students and asked for their names, which made them feel included. The students gave examples of good learning situations, such as ‘They sat down, took a new card, explained to me all about the card and translated from Swahili into English. Then I was allowed to fill in the card myself’. However, in other situations the students also reported that the nurses did not always trust them to perform the simplest procedures such as taking blood tests, expressed like ‘They don’t think we are able to do anything. Nothing’. At one place they were only allowed to observe, as they were not midwife students, while at other places they carried out blood tests and examinations of pregnant women. The students appreciated the rotation at three places as this gave experiences and insight into different clinics.

Lack of equipment, and even lack of water, was a frustrating experience for the students. Regarding equipment they observed that patients used their own ‘kanga’ (piece of cloth) as their bedsheet. They also described that the patients seemed more concerned about washing the delivery beds than the nurses. With respect to hygiene, the students in general thought it was quite good when taking the available resources into account. In some situations, they experienced a gap between what was taught in lectures and what they observed in clinical practice. On the other hand, they also reported practice in line theory taught in classes which created good learning experiences.

The students described various experiences when meeting patients and relatives, for example ‘less sympathy’ for women giving birth, but also that the women were taken good care of during delivery, ‘not too much cuddling, but still caring’. Positive experiences, such as ‘we were impressed; it was very satisfying to observe that nurses really took care of patients’ psycho-social needs’ were reported. The relatives were responsible for meals and for washing bed linen and clothes. The students experienced ethical challenges when patients and relatives were living at a distance from the clinic, for example a mother who had just delivered her baby was almost worn out. No relative was present and consequently she had not been offered any drink or food.

The students described uncomfortable situations when there was a large group of people around the patients, and the patients – to their knowledge – had not given their consent to this. It was acceptable to walk into patients’ rooms without minding if anybody else was there, for example ‘just walking in, sitting down, listening and asking questions, no matter whether other patients and relatives were in the room’.

In a challenging learning process

This main category consists of two subcategories: The lack of common language, and An unknown view of learning.

The lack of a common language

The students described challenges due to not having access to the verbal communication between patients, relatives and nurses who all spoke Swahili. One of the students expressed, ‘We don’t understand when the patient talks. Hearing things directly from the patient is important’. Despite not understanding the words, they realized that it was about pain, but they missed the context. When the students spoke some Swahili words the patients ‘lit up and got a completely different facial expression’. All students regretted that they had not learnt more Swahili before arriving in Tanzania.

English was a common language when communicating with nurses – and nurses also translated from Swahili to English to facilitate the students’ learning process. In theoretical courses, fellow students underlined the need for speaking English to enable the Norwegian students’ active participation in group discussions. Even though lectures and discussions in classes were in English, they still reported challenges in understanding the content, expressed as, ‘I did not understand (the lecturer) in the beginning – s/he had this strange accent’.

An unknown view of learning

The students reported that the professional level of the lectures overall was good. The way of learning in most of the theoretical studies diverged from what the students were used to. As one of the students expressed it: ‘In Norway my focus is to obtain an understanding of the content I read and perhaps describe it in my own words. Here it was to learn definitions by heart and to respond immediately with a word-by-word definition when asked’. Another example of a different view of learning was that fellow students – and to some degree the lecturers – laughed when students raised their hand to ask or tell about something. Laughing at fellow students was an uncomfortable experience.

The students also described good learning situations in classes. This was especially when discussions between the students were facilitated by the lecturer. Both Tanzanian and Norwegian students were challenged to describe the health system in their countries in order to facilitate a ‘compare-and-contrast discussion’. These discussions gave the Norwegian students insight into the Tanzanian health system, and were described as, ‘interesting discussions in a good atmosphere’.

With respect to learning in clinical practice the students described being more or less left alone to find good learning situations; expressed in this way: ‘there were days when I did not know where to go or what was going to happen’. The hectic atmosphere in clinical practice was experienced as an obstacle for asking questions or raising discussions. The students recommended setting aside a fixed time for questions and discussion at all areas in their clinical practice. However, at the hospital a student coordinator gave the students access to various units or departments contributing to good learning situations. The coordinator asked for the students’ learning outcomes in order to facilitate good learning situations. She was used to having students in clinical practice, expressed like this: ‘She was really interested in our learning, ask us about reflections on activities – yes, she was really good’.

Personal and professional growth

This main category entails two subcategories: Returning home and The aftermath.

Returning home

Coming home was different from what students expected. It was good to be home with family, friends and for Christmas celebrations but it took some time to get back to everyday life. One challenge was to meet Norwegian patients complaining about ‘minor details’ compared to their African experiences. The students described that Norwegians should be inspired by Tanzanian attitudes, expressed like: ‘They are happy and satisfied all the time. While we – having lots and lots of everything – still are not satisfied.’

Before their departure from Norway they were prepared for life as students in Africa and meeting a new culture, but they were less prepared for reactions and emotions when returning home. One student expressed it in this way, ‘… Because when going down there I had expectations and I was clear that things would be different. But when coming home – I was not prepared for things to be different again – then everything was expected to be normal’. Entering the airport in Europe was described as a ‘grey’ and colorless experience compared to all the colors in Africa. They experienced that nobody noticed them, nobody greeted them, they were ‘nobody’.

The aftermath

Although the students described learning throughout the exchange period, they highlighted their reflections after returning home, which motivated their personal and professional growth. Students described a more conscious attitude to reflection, expressed like ‘I realize the reflection is more valuable now than before the study-abroad period’. The homecoming process was characterized by sorting all experiences into ‘some kind of order’. One student reported: ‘The more we are exposed to, the more we learn. The harder it is, the stronger one becomes. We learned very much about ourselves and about other people, almost to an extreme degree’.

Encountering a completely different culture was demanding; it was experienced differently with regard to pace, manners and everyday life.

The students appreciated the opportunity to go abroad as part of their studies. They reported that these learning experiences contributed to cultural competence development, such as enabling them to meet patients and relatives from foreign cultures in a different and better way. One student stated:

… I work now at a hospital unit with patients who don’t speak Norwegian, and not even English. I have a kind of insight into how it may be being in that room not understanding anything. I think it (the African experience) has made me a better nurse.

The reciprocal support was described as an important contribution to the learning process and for their personal and professional growth throughout the exchange period. Students lived together in a house and spent more or less 24 hours a day together. When fellow students were frustrated, the student group took responsibility for ensuring that problems were brought up and addressed if needed. The students were exposed to challenging situations leading to reactions they were not used to at home. Reflections contributed to increased consciousness about one’s experiences, enabling students to see both positive and negative aspects of their experiences.

Discussion

This study aimed to describe learning experiences of Norwegian nursing students in Tanzania after participating in a study-abroad program that included theoretical as well as clinical studies. The Norwegian students described the lack of a common language, which indicates the importance of a common language when caring for patients and their relatives. Speaking some Swahili made the patients light up. Even though the nurses translated from Swahili to English for them, the students stressed the importance of direct contact with the patient. Similar experiences are reported for Norwegian students when caring for patients in Madagascar. ²² The language barrier is reported as important for students when caring for patients in foreign countries.^4,13,22 Both lack of a common language and different ways of communicating are described as barriers to an increased cultural knowledge base,^2,12,22,33 which was also the case for the students in the present study.

An agreement that clinical practice is essential in nursing education is apparent,^{2,15,16,18,33} and supervision from qualified nurses creates conditions for this.^18,34 The student coordinator at the hospital was used to supervising nursing students and was of great help; the students missed having a supervisor. It is reported that supervisors need training in supervision both in Africa, ³⁴ in Asia ¹⁷ and in Norway. ³⁵ Although the students reported good learning situations at the hospital, missing supervision was apparent in the dispensaries and clinics. Corresponding findings are reported in a study from Malawi, ³⁶ concluding that educational institutions need to ensure that a clinical supervisor is available for the students. Our findings support the Malawi findings.

Students were frustrated for several reasons, such as being exposed to having ‘no plans’, delays in planning, and change of plans. It is worth noticing that our findings show that some of the changed plans also gave options for changes in favor of the students. An experience of unanticipated situations is described as contributing to learning ‘beyond expectations’. ⁵ The importance of preparing the students for a kind of ‘unexpectedness’ before leaving their home country is also reported by Bohman and Borglin. ² Nevertheless, our study indicates that being in a student group was of great help to manage the ‘unexpectedness’ by supporting each other and thus reducing the frustrations.

An exchange period of three months may be considered as an extended period abroad, compared to previous studies.^9,19,24 In the current study, a relatively long exchange period gave the students the opportunity of forming new relationships and immersing themselves in a new culture and a new language. The students described their experience of growth and feeling more independent. Interestingly, our study shows that the students were prepared to adjust to a foreign culture when arriving in Tanzania but were not prepared for a new cultural adjustment when returning home. Returning home and experiencing a kind of ‘reverse culture shock’ underlines the importance of debriefing shortly after returning to their home university. The students tried to readjust to life at home without losing the ideas and values they formed while they were students in Tanzania, but it was challenging. They experienced a new way of seeing situations and culture at home, for example, ‘home’ was colorless, and they experienced that Norwegian culture was not as open-minded as Tanzanian culture. It is reported that the development of cultural competence continues after students return home. ²⁰ Similar findings are described in the current study. The students gave examples of meeting patients and relatives from other cultures with a new understanding and competence as nurses when returning home. Other studies also report that studying abroad may increase the students’ cultural competence, cultural awareness, and give them a new cultural insight.^1,2,33

Presbitero ³⁷ reported that students felt generally alienated when they returned home because the values and beliefs abroad were different from those at home. They found that families and friends were not interested in their experiences from abroad and described this as an experience of reverse culture shock. Findings in the present study that fellow students, family and others did not open up for these stories support Presberito’s ³⁷ findings.

The findings in this study show that reciprocal support was an important presupposition for the students’ learning and for their personal and professional growth. They lived together in the same house on campus. Thus, despite being in different clinical settings throughout the day they had – and made use of – the opportunity to share experiences, support each other and reflect on their own as well as their fellow students’ experiences. The importance of a supportive clinical environment for learning processes is reported. ¹⁶ However, the present study underlines the importance of fellow students in this respect. Study-abroad programs may facilitate more and other learning opportunities than learning at the home campus, ²⁶ and are reported to increase cultural competence.^9,20 More specifically, nursing education institutions are advised to facilitate students’ interaction with different cultures to develop their cultural competence. ³ However, measuring cultural competence is difficult,^3,5,14 and there is a need for development of robust methods to assess cultural competence.^20,38 In the present study, the students entered new ground, they met challenging learning activities, and most importantly, they experienced personal and professional growth.

Personal and professional growth as an important aspect of the exchange experience, which was found in the present study, is also reported by others.^9,12,39 Knowledge of other cultures contributes to seeing the world with new eyes and understanding it from a different perspective.^5,39 Furthermore, studying abroad in a foreign country promotes a better understanding of various healthcare systems and practices stimulating reflection on best practice values and prerequisites. The current study shows that being confronted with new situations can be stressful for students, but that on the other hand, these situations gives them important experiences and contributes to their personal and professional growth, which is also reported by Karnjus et al. ³⁹

Methodological considerations

A qualitative design was deemed appropriate due to the number of eligible participants (n = 13) and a desire to acquire a deeper understanding of the students’ experiences. ²⁷ By using the four criteria, credibility, dependability, confirmability and transferability, the trustworthiness of the study is improved.^40,41 Credibility was ensured by including various aspects of learning experiences from all participating students. Three student groups – in all 13 students, both females and males – were included. The research group participated actively in the analysis, and the process is described. Additionally, quotations representing all student groups were used to illustrate the findings. An interview guide was used to ensure dependability throughout all five group interviews, and the first author performed them all. It is possible that the interviewer gained new insight during the interviews and that, because of this, follow-up-questions changed during data collection. To strengthen confirmability the analysis process is described to establish an ‘audit trail’. Faculties from the host university participated when discussing the categories and subcategories. In order to ensure transferability, the context, the participants, the data collection and analysis process is described. The first author as well as all co-authors were experienced members of faculties in nursing education at the cooperating institutions. Such descriptions enable readers to assess whether the findings are applicable to other contexts.

A possible limitation in the study is that data collection was carried out from 2013 and was accomplished in January 2016. Involving faculties at the host university has been important in order to increase our understanding of the Tanzanian context but required extra time. The extra time required for this involvement was necessary and has increased the quality of the study.

Conclusion

This study contributes to new knowledge by providing insight into Norwegian nursing students’ learning experiences during and after a study-abroad period in Tanzania, which included both theoretical and clinical studies. The students experienced personal and professional growth, exemplified by meeting patients and relatives from foreign cultures in a more open-minded way. The current study has identified the importance of being part of a student group. Sharing experiences and reflecting on these are crucial for personal and professional growth. Moreover, returning home and experiencing a kind of ‘reverse culture shock’ underlines the importance of debriefing shortly after returning to their home university.

The findings contribute to knowledge relevant to students going abroad for a shorter or longer period and may help universities in planning student exchange programs. This study provides insight into experiences from theoretical as well as clinical studies in Tanzania. Our findings are in line with earlier studies focusing on clinical studies, but further studies investigating experiences from theoretical studies in African countries is needed. Host universities’ experiences from both students’ and faculties’ perspectives are recommended included in studies. The returning home experiences in the present study are interesting and should constitute the focus of further studies.

Supplemental Material

sj-pdf-1-njn-10.1177_20571585211023240 - Supplemental material for Norwegian nursing students’ experiences of theoretical and clinical studies in Tanzania: A descriptive qualitative study

Supplemental material, sj-pdf-1-njn-10.1177_20571585211023240 for Norwegian nursing students’ experiences of theoretical and clinical studies in Tanzania: A descriptive qualitative study by Sigrid Wangensteen, Solveig Granseth, Marycelina Msuya and Kristin Haugen in Nordic Journal of Nursing Research