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Abstract

International student exchange has been enhanced by higher educational institutions, national governments and policy documents for the last two decades. Nevertheless, there is limited knowledge and research regarding nursing students’ experiences of going on study exchange to non-English countries like Norway. The study aimed to explore international nursing students’ experiences when studying abroad in a Norwegian Bachelor of Nursing program. The study used an interpretative qualitative design. Ten nursing students from Australia and the Netherlands participated in two focus groups, and provided their motivation letter, written prior to their exchange. The study followed the Standards for Reporting Qualitative Research (SRQR) checklist. The findings suggest that the students had several motives and expectations for studying abroad that went beyond nursing skills and competence. It was also of great importance to prepare for the exchange at multiple levels. Another important element central to the students’ development was their relations with the other international students. Their experiences in daily life and their participation in the courses that they took on campus were interconnected and contributed to both personal growth and professional development.

Keywords

intercultural internationalization at home nursing education student mobility studying abroad

Introduction

International student exchange has been enhanced by higher educational institutions, national governments and policy documents for the last two decades.^1–3 In an increasingly globalized and multicultural world, cultural awareness and sensitivity has become an invaluable skill.⁴ Student mobility can help individuals increase their professional, social and intercultural skills²; these skills are also of relevance within health care education and for health professionals, such as nurses. Nurses work in a multicultural environment at different levels: through international cooperation, with colleagues, and through patient encounters from various cultures.⁵ Nursing programs that offer study exchange in a foreign country are of importance given the capacity to promote students’ cultural competence and thus respond to the need of future nursing care.⁶

Studies have shown that nursing students’ engaging in a study mobility experience can provide advantages, such as professional and personal development, and intercultural competence.^7,8 Furthermore, experiences with international student mobility have been shown to facilitate personal and career development.⁶ Studies have also found that exchange positively influences skills for nurses such as communication and cultural competence,^9,10 and it can provide an increased awareness of the nursing role.¹⁰

In study exchange, there has been a shift towards looking beyond what students do in their study program to also address social networking and socialization.^11,12 Studies have identified social networking as an important part of a successful study-abroad experience.¹¹ The concept of learning associated with socialization is unfolded in Wenger's framework communities of practice (CoP).¹³ Connecting CoP to international students’ experience seems relevant and has been applied by others.^14,15 This conceptualization of learning is more than “learning by doing” in that learning is an integral and inseparable part of social practice. For example, participating in a team with students in a class or group is both action and belonging; it not only shapes what we do, but also influences who we are and how we interpret what we do. In this way, people create their shared identity through engaging in and contributing to the practices of their communities.¹³

Since the launch of the Erasmus program some 30 years ago, there has been an emphasis on mutual and equal exchange.² In Norway, the authorities have indeed stated that 50% of all students enrolled in higher education ought to participate in student mobility.¹⁶ However, Norway has traditionally sent more students abroad than it receives in exchange, and limited studies have been conducted on international students experience of going on study exchange to Norway.¹⁷ Moreover, little is known in regard to international students experiences in non-English speaking countries.^18,19 That is also the case for nursing education.²⁰ Knowledge about the international student experience can give important insights to academic institutions as well as the research field. This can in turn benefit both international and domestic students. Therefore, this study aimed to explore international nursing students’ experiences and perspectives of being on exchange in Norway and studying in a Bachelor of Nursing program.

Methods

This study used an interpretative qualitative design.²¹ Both motivation letters and focus group interviews were utilized as data sources. A motivation letter is a document written by the student that explains their motivations for applying for student exchange. This document is mandatory for all students applying to go on an exchange at the university, and, in some instances, can also be used in the selection process. A motivation letter was considered relevant for this study given its ability to disclose the reasons students applied for student exchange to Norway. Focus groups are suited to learning more about people's experiences, attitudes, views, goals and challenges in an environment where many people interact.^22,23 In focus group interviews, the participants can verbalize their experiences, perspectives and practical knowledge, which can prompt thoughts when participants have experienced similar situations to others in the group.²³ The study followed the Standards for Reporting Qualitative Research (SRQR) checklist.

Data collection

All students that were on a semester exchange in the nursing education program between August and December 2023 were invited to participate. Of the 12 exchange students, 10 participated in the study: four Australian students and six Dutch students. The Australian students were enrolled in both clinical placement and on campus theory courses; the Dutch students were enrolled in on campus theory courses. All the students had participated in interdisciplinary lectures, which meant studying together with social work students. The participants were all female and aged between 19–22 years. All students provided their motivation letter, which had been written prior to their exchange.

The focus groups consisted of four and six participants. They were grouped with students from the same university to create an environment where they could feel safe, since they knew each other and shared a mother tongue. Because the interviews were conducted in English, the students could also support each other in the event of language barriers.

The interviews were carried out shortly after their final course, following grade release at the end of the semester. The focus groups lasted between 60 and 90 min. Interview guide topics consisted of themes such as language and culture, subjects and learning, mastering the exchange and socializing and, finally, competence development and expectations (Table 1). The interviews were audio recorded and transcribed using the data program Autotekst (https://autotekst.uio.no), before being thoroughly checked and corrected by two members of the research team.

Table 1.

Examples from interview guide.

Introduction

Why did you choose to go abroad and to Norway?

To what extent did you prepare yourselves before you came?

Language and culture

How did you experience the culture, customs, and social norms in Norway?

How did you experience language barriers and cultural differences?

Subjects and learning

How did you experience the different teaching styles and academic expectations?

What was the difference between being an international student and a domestic student?

Mastering the exchange and socialization

What kind of network did you have during your exchange stay?

Tell us a little about what you did outside of your studies?

Tell us about how it was to get to know other people and students from the university?

Competence development and expectations

Was the experience abroad as you expected? What was the difference? What surprised you?

What did you learn as a student abroad?

How do you think you can use this competence/learning in your future work as nurse?

Analysis

Thematic analysis was applied to analyse the transcribed data and the motivation letters.^24,25 The analysis involved following six steps: becoming familiar with the whole data set, initial coding, searching for themes and patterns, reviewing the themes, deﬁne and giving name to the themes, and finally producing the report (Table 2). To become familiar with the data, the researchers read and reread the motivation letters and listened to the interviews several times. Three of the researchers connducted the initial coding and findings were discussed by the whole research team. In the beginning of the analysis process, the codes and categories were developed inductively, whereas, later in the process, they were increasingly organized under already established codes and categories. The analysis was far from a straightforward process, but rather a movement back and forward across the whole data set searching for patterns. When searching for themes, we were not looking for quantifiable measures, but rather to see meaningful patterns and whether they captured important aspects regarding the aim of the study.^24,25

Table 2.

Examples of the coding and analysis process for motivation letters and focus group interviews.

Unit meaning	Coding	Subthemes	Themes
From motivation letter I have chosen to pursue this minor abroad, because for me this is a major investment in the field of expertise. Norway is a country in which health care is well known and I am curious how it is arranged, and I would like to see it with my own eyes. It is also an investment for me personally, because I have never been away from my home, including my family and friends, for so long. I think that this minor will allow me to personally grow in my independence and to take care of myself. I am curious about the country, Norway; I have never been there myself. I am curious about Norwegian society and Norwegian education.	Norwegian health care Personally Being on my own Take care of myself Norwegian society and education	Professional motivation Independence Experience a different culture	Motivation and expectations for studying abroad
From interview When you're walking down the street [at home] you just say like, hello, how are you to everyone? But like here [in Norway] that doesn't happen. Well, unless you're in like the mountains …. then you say hello. But yeah, just like walking on the street. No one really says hello. It is a bit lonely sometimes.	Social norms Experiencing different culture	Navigating in a foreign country	Studying and living in a foreign country

Ethical considerations

The study was carried out following the Declaration of Helsinki. The Norwegian Centre for Research Data (Sikt) approved the study (ref. nr 139030). The participants were given written information and consent forms detailing their rights and the study's goals before taking part in the interviews. This was also reinforced through oral discussion and the offer to answer any participant questions.

Results

Ten students participated in this study: four Australian students and six Dutch students. Findings from the motivation letters identified the theme “motives and expectations for studying abroad”. Findings from the focus groups interviews revealed three themes: “preparations for going abroad”, “studying and living in a foreign country” and “lessons learned”. Table 3 illustrates the main and subthemes.

Table 3.

Main themes and subthemes.

Main themes	Subthemes
Motives and expectations for studying abroad	Professional motivation
	Independence and self-development
	Experience a different culture
Preparations for going abroad	Practical organization
	Informal and formal meetings
	Social and emotional preparation
Studying and living in a foreign country	Mobility-inclusive curriculum
	Belonging and being like a family
	Navigating in another culture
Lessons learned	Personal development
	Being outside your comfort sone
	Competence for future nursing profession

Motives and expectations for studying abroad

In their motivation letters students shared several reasons to study abroad. Taken as a whole, the responses indicate a combination of personal and professional motivations. Professional motivations relate to the development opportunities arising from immersion in an unfamiliar health system. One student noted the benefits of seeing alternative approaches to care:

“By completing a part of my nursing studies in Norway, I will find out how the healthcare systems are arranged there. I can take the experience of living and studying abroad with me in the future.” (Motivation letter nr. 6)

Students also linked the opportunity to their development of competence in both nursing and, for the students from the Netherlands, improve their English competence:

“This seems like a great challenge to increase my knowledge of and insights into the nursing profession and to improve my English level.” (Motivation letter nr. 4)

Personal motivations for studying abroad reflected the opportunities building relational connections. Interestingly, students extended the experience to include exposure to new physical environments and another culture. This was particularly the case for students visiting Norway from Australia:

“On a more personal note, I love to hike and would love to explore some of Norway's beautiful sights, which are greatly different from Australia's. Of course, I would hope to do some of the more touristy things too, like seeing the Northern Lights and travelling (with great ease and access) to some of the surrounding countries in Europe. Moreover, I love to discover different foods and cuisines and am very intrigued to try those in Norway. I am also excited to build relationships with various people from over the world and find more opportunities for the future from those.” (Motivation letter nr. 10)

Lastly, many of the students were living with their parents. The exchange appealed to some because it offered an opportunity for independence and self-development. The students also expressed that it felt safer to go together with a friend. As one of the students expressed it in the motivation letter:

“It is also an investment for me personally, because I have never been away from my home, including my family and friends, for so long. I think that this minor will allow me to personally grow in my independence and take care of myself. I hope to develop myself personally, even though I still find it a bit exciting. I'm going there with another friend of mine and we're going to discover things together. The fact that we are going together makes me feel good and I hope we can make it a great time together going to a new school and meeting new people.” (Motivation letter nr. 2)

Preparations for going abroad

The students in the focus groups discussed their preparations and planning before coming to Norway. Both practical and emotional preparations were identified. Practical preparations range from bureaucratic obligations to shopping. Students commented on the amount of paperwork required for the exchange, including preparing applications for the exchange and organizing funding, visas and accommodation:

“We had to fill in a lot of information. A lot of paperwork.” (Focus group Netherland (FGN))

They also had to plan for differences in the cost of living, shopping for clothes and kitchen equipment. For some students, this practical issue was directly linked to their supportive relationships at home:

“We knew that Norway was more expensive than the Netherlands was. So we were like, okay, we need to get it here because it's cheaper in the Netherlands. And we get to buy them in Norway. So we were like, okay, get everything. And my mom just put everything in my suitcase. Take this with you.” (FGN)

The students participated in information meetings and received e-mail from the university but also met with Norwegian students who were in Australia on exchange. The combination of formal and informal sources of information proved helpful:

“We did meet some of the Norwegian students before coming here, which was nice. They did give us some advice and everything. So that was good.” (Focus group Australia (FGA))

This example illustrates an easily overlooked aspect of the exchange process: the value of informal communication and of the sharing of experiences between students that provides important information not easily captured in formal, impersonal contexts such as lectures of information sheets. A practical example of this relates to clothing needs. The Australian students brought clothing with them to wear in placement. They learned after they arrived that this is given to you by the home care service, and there is a different code for shoes than in Australia:

“I literally brought my placement pants, shoes. Because I had no idea what we were going to need for what. Like uniform. […] I have 30 kilos of luggage. I didn't wear these shoes once.” (FGA)

A final personal preparation involved the temporary farewells to home and family. Given the age of the students involved, the significance of this should not be under-stated. Some of the students identified the exchange represented a separation that was shared with both the students and their parents affected:

“And the last week before I came, I spent a lot of time with my family. My mom was acting like I was leaving forever …. And we went everywhere. It's like the five of us, my family. And we did everything and then just got away. Yeah, just mentally prepare yourself just to not see them for five months.” (FGN)

Studying and living in a foreign country

The students emphasized the importance of the curriculum being organized for domestic and international students enrolling in subjects together. This issue demonstrates the nexus of personal and professional concerns found in the data. Instructors can play a practical role in addressing this challenge by including activities in class that group exchange and domestic students together. Students expressed that it was challenging to get to know Norwegian students:

“Being in [clinical] placement and doing these assignments and meetings with the Norwegians [students] was the best, it gave [me] the best opportunity to make friends. And I think like …. because you're forced to be together ….You need to have something in common with the Norwegian [students] to get to know them … Like you're not just going to be friends for no reason … I remember somebody said this at the beginning of the semester … Norwegians are like an onion, like peeling the layers. And that really got us peeling the layers.” (FGA)

The students also had prior experience with inclusion of international and domestic students in the same courses from their home universities. That was important for the integration of international students. One student shared:

“Back in the Netherlands you have like an international course, and they just dump people from the Netherlands in one class and everyone talks English and you figure it out. So they don't split them from the Dutch people. They just integrate.” (FGN)

The students that did not have English as a first language found that they managed to study in a foreign language and that their skills improved during the semester. As one of the students expressed:

“Because we are used to [having] our class just in our own language and you can follow and you can read it very easily, very quickly. And we thought, well, let's do a good preparation and read all of the stuff. And I was like, oh, yeah, it's not [as] quick as I thought. But I think during the semester it gets better and you're more used to it.” (FGN)

The social and relational aspects of the exchange come to the fore in this theme, where the daily challenges of living in an unfamiliar country are explored by the students. The students expressed the importance of the roommates that they lived with during their time abroad, explaining that they became like a family. They also talked about the importance of discussing reflecting upon issues in their own language:

“It's easy to go to one another and yeah, you can talk about things. You can have deeper conversation because you can talk to each other in your own language …. it's a cute little family.” (FGN)

The students mentioned different aspects of living in a foreign country for the first time. These included experiencing differences in social norms, culture and behaviour. Moreover, some stated that Norwegians were more likely to talk to you when they were outdoors, hiking or jogging:

“When you're walking down the street [at home] you just say like, hello, how are you to everyone? But like here [in Norway] that doesn't happen. Well, unless you're in like the mountains …. then you say hello. But yeah, just like walking on the street. No one really says hello. It is a bit lonely sometimes.” (FGA)

The students also noted the practical challenges of living away for the first time in another country. For example, they noted the lack of variety in the Norwegian grocery shops and explained that they had to make adjustments in their everyday life when they went for groceries. Some students got visitors, such as family and friends, to bring food and snacks that were familiar for them from back home. As one student pointed out in the interview:

“The visitors from the Netherlands came with some good food. [My] family brought food and snacks … now we finally have like five bags of chips. But it's a lot of differences between the grocery stores in the Netherlands and Norway. So, that was something I had to adjust to.” (FGN)

The participants also discussed how climate conditions were challenging and influenced mood. One of the students said:

“Sometimes it's really like the sun really does affect your mood. I think for the past few days it was all right. But I think there was a period of like 20 days … the sun just didn't show, it's just so cloudy … just rains. It really does affect your mood.” (FGA)

The personal experience of exchange is inseparable from that most impersonal of factors – the weather.

Lessons learned

The students also expressed that they learned more about who they were as people during their semester abroad and experienced personal growth and development, and that this was relevant for them as future nurses. As one of the students said:

“Now, I think I know more who I am and what I want and what I don't want. So I can also use that in my nurse job.” (FGN)

They also talked about the importance of getting to know people from different parts of the world, being in dormitories with other international students. In many ways, that had also broadened their perspective.

“You make kind of friends [from] all over the world. So I think that's really cool.” (FGN)

The students expressed that living on their own also challenged them to get groceries, make dinner and clean their clothes. These were things they had gotten support from their family for in the beginning of their stay but then managed on their own and by themselves. As one of the students said:

“So yeah, first time living out of home. So I definitely learned lots of life skills like making dinner, doing laundry. At the start, I was like always on the phone with my mom and I'm like, I don't know how to make the washing machine work. But now I've got it.” (FGA)

The students shared that being in a country and community where they did not understand the language and having to adapt to a foreign culture, navigating ways to communicate, gave them important competence as future nurses.

“Being in a different setting than you're used to and not having your everyday around you. So I really feel like that will better me as a nurse in some ways. Yeah. I think having to adapt the way I communicated because the patient couldn't understand me the other way around. So I had to try and find other ways to communicate. And that could happen in Australia as well. Like sometimes I have had patients who didn't speak English there. But I think also being in the position where I struggle to understand, it helped me to understand how the patient could feel. Like, although maybe they understand the language, like the medical terminology they might find a bit difficult. So it kind of helped me to understand what it feels like to not understand.” (FGA)

They also mentioned the importance of learning to see the health care system from another part of the world; it gave them a different perspective that could be important in their work as nurses in the future. They also shared that managing a semester abroad had made them more resilient, and that being abroad could help in regard to employability:

“But I liked being able to have more awareness [of] how the system works because that's also somewhere that maybe I'd want to go into when I get back. So that's a specific thing about the course. But then in general as well, like employability, I think it'll really help because … it does show adaptability. Like resilience. You've seen, like experience, yeah, you've seen other parts of the world. So, yeah, just seeing it, like, it's interesting seeing how different people do things.” (FGA)

Discussion

Our study provides a timely reminder. We found in the study that the nursing students undertaking an exchange were doing so at a crucial and vulnerable time of their personal and physical growth: late adolescence. They experience in quick succession a range of developmental milestones without some of the protective factors most of their peers enjoy: supportive family in close proximity, familiar routines and linguistic environments. In addition to this, they are growing as individuals at the same time as they are participating in the work of professional development. As such, the design and management of successful international student exchanges needs to incorporate strategies to acknowledge the interaction of practical, professional and personal factors which characterize the experiences of the young people involved.

The study revealed that the nursing students had several motives and expectations for studying abroad. Their motives were related to the nursing profession and included learning more about the health care system in another country, developing intercultural competence, increasing employability and improving their language skills. However, they also had expectations that went beyond the learning outcomes in the nursing curriculum, such as travelling, living on their own, experiencing nature and becoming more independent. These findings are supported by others who also have found that nursing students reasons’ for going abroad are diverse.^26–29 Knowledge about the students’ motivation to participate in a study exchange gives an understanding of their rationale for going abroad.³⁰ These findings provide insight into students’ values and expectations and are thus of importance for meeting students’ expectations when developing study-abroad programs.³⁰ Moreover, they can also offer insights into how to advise and support students who are planning to go abroad.

Another factor that also influenced students’ decision to study abroad was inspiration from others. If the students knew someone who had been abroad earlier (e.g., family or friends), this was an inspiration for them to go abroad themselves. Another important factor in choosing to do an exchange was whether they had the chance to go with someone from their home university because this made it safer. This contributed to reducing the threshold for students to choose to go abroad, and the students also prepared together prior to their study exchange. The importance of peer support to promote internationalization is in line with other findings.³¹ These findings suggest the importance of facilitating students to travel together with others from the university, in addition to involving students that already have been abroad in the nursing program, because this can inspire future mobility and promote peer support in internationalization.

The findings also indicate the importance of thorough preparation before going on exchange. This is supported by Bohman and Borglin³² who stress the importance of providing information about the exchange opportunity early in the program. This makes it easier to recruit students to participate in exchange and, later in the process, to provide support to students who are preparing to be going abroad.³² Studies have indeed addressed the importance of preparing for cultural challenges.^33,34 However, we also found that it was for students to prepare both practically and socially before the exchange, as well as to meet host students. The importance of meeting host students before the exchange to discuss issues that could be problematic has also been highlighted by Chan et al.³³ The findings from our study address the need for educational programs to have structure for the information and preparations for students before studying abroad. They also draw attention to the significance of fruitful cooperation and communication between partner institutions to enhance support of students prior to exchange. This is also addressed by Green et al.³⁵

How courses were structured and organized was also important. The students found the curriculum overwhelming at the start of the semester. This might be a result of challenges at the administrative level with translating the curriculum for international students, or teachers giving lectures in English, or the need for students to adapt to a new system. Some of the courses were only for international students, whereas other courses were taken together with domestic students. Another finding from the study was that the students found it challenging to get to know Norwegian students unless the courses were tailored to both international and Norwegian students. That finding indicates the importance of tailoring the curriculum for both international and domestic students. As such, this could benefit both students and staff and support internationalization at home and in the curriculum. Internationalization at home can be seen as a variety of activities “at home” in a domestic context, the aim of which is to develop intercultural competence for all the students.³⁶ Although some argue that internationalization at home does not need to include international students, it is in fact beneficial.³⁶ International students could be a catalyst to filling the gap when it comes to internationalization at home and in the curriculum and to promoting intercultural competence for all. This has also been highlighted by others.^33,37

Another important finding was that that participation in international exchange programs helped nursing students develop intercultural and professional competencies that are important for future nursing care. This observation is not new^35,38 and is one of the main reasons to develop study exchange programs for nursing students. However, it seemed like both their experiences in daily life and in the courses they took in the nursing curriculum, contributed to both personal and professional development. Green³⁵ has also emphasized that personal and professional development is interconnected and interrelated. The students appeared to learn from daily life and the experience of being a foreigner and not understanding all the customs, having to navigate while grocery shopping or hiking in the forest, and experiencing cultural barriers and differences in several situations. According to Wenger,¹³ the students are newcomers in the society and being at the periphery, negotiating their meaning through daily life and as international nursing students. The students also experienced different weather conditions than what they were familiar with, and they became more aware of how the weather and climate can influence their own health and well-being. Thus, studying abroad can make students more aware the importance of planetary health. This creates the potential for exchange students to learn more about this essential area. It has been suggested that nursing programs play a valuable role in promoting and supporting nurses’ influence on climate change and planetary health.³⁹

Another key finding is that the students supported each other during the exchange, and they were like a family looking after one another, making meals together and sharing thoughts and reflections about the exchange and cultural barriers. The fact that international students often form a strong social network of support for each other has also been addressed by others.⁴⁰ Indeed, the students’ relationships with other international students were key to their learning and development. Discussions and support among student peers contributed to and created knowledge. Others have addressed the value of peer support for international nursing students’ development,⁴¹ including Wenger,¹³ who emphasizes learning through mutual engagement. Despite being at the periphery¹³ the students formed their own community, learning from one another through experiences and reflections. This seemed to enhance their self-awareness and resilience and their ability to deal with new situations in another culture.

Strength and limitation

One strength of this study comprises the rich descriptions from both focus groups interviews and the motivation letters. As the interviews were conducted in English, the students from the Netherlands could support each other in their mother tongue when they could not express themselves in English and help each other talk about their experiences in English. The students were familiar with the topic discussed in the focus groups, which might have contributed for them to elaborate on the topics. In the process of analysing, all the interviews and motivation letters were read by three of the researchers before discussing the codes, themes and findings. The findings were discussed by the whole research team, which may have contributed to strengthening of the study's validity. A final strength is that the motivation letters were read before the focus group discussions, which gave the researchers an opportunity to select subjects and guide the discussion towards what the students had reflected on in their letters. One of the limitations was the small number of countries represented. More participants from various countries might have given more nuanced findings.

Conclusion and future recommendations

The findings support the claim that nursing students who participate in study abroad programs develop intercultural and professional competencies of importance for future nursing care. The students had several motives and expectations for study exchange that went beyond nursing skills and competence. Their experiences in daily life and the nursing curriculum were interconnected and contributed to both personal growth and professional development. The students’ relations with other international students were also key to their learning and development. These findings suggest that the perspectives of social learning theories can be fruitful and relevant for understanding students’ professional development while on exchange. Moreover, the development of intercultural competence among nursing students can be enriched by facilitating the internationalization of the curriculum, which likely also benefits local students. A next step would be to look into internationalization at home, both how the curriculum and curriculum activities are organized and the experiences and perspectives of local students taking courses together with international students. The findings from this study give implications for academics, policy makers, teachers and others who are concerned with the development of international study exchange programs for nursing students.

Footnotes

Acknowledgements

We thank all the students who participated in the study.

Author contributions

All the authors contributed to the study's conception and design, data analysis and interpretation, as well as the writing of the article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

ORCID iDs

Elisabeth Karlsen Dogan

Thine Elisabeth Lunde

Christine Grave Meyer

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