International short‐term placements in health professions education—A meta‐narrative review

In order to be prepared for professional practice in a globalised world, health professions students need to be equipped with a new set of knowledge, skills and attitudes. Experiential learning gained during an international placement has been considered as a powerful strategy for facilitating the acquisition of global health competencies.


| INTRODUCTION
Globalisation has infiltrated most aspects of society including the delivery of health care.In order to tackle health issues locally, nationally and globally, it is imperative that health professions students develop a global perspective during their training. 1Therefore, health professions schools have been tasked with introducing a global dimension into their educational programmes to enable students to develop the required competencies.Various strategies exist for including content in relation to global citizenship and global health into the curriculum. 2 In terms of learning methods, didactic and experiential learning are the most frequently utilised approaches for global health learning. 3periential learning gained during an international placement, when students are immersed in an environment outside their comfort zone and cultural familiarity, is considered as a powerful strategy to promote the development of global health competencies. 4,5The opportunity to undertake an international placement during undergraduate training is now available to students in many health professions schools, which may be offered in different contexts as part of educational programmes. 6,7Several terms have been used to describe a learning experience in an international location, such as international elective, 8 international service learning, 9 short-term experience in global health, 10 study abroad programme, 11 or international exchange. 12veral published reviews have synthesised research investigating the impact of international placements on students in various health professions.4][15][16][17][18][19][20][21][22][23][24] However, various challenges have been raised, such as health and safety risks 25 and ethical concerns, 26 which may compromise the learning experience, particularly when the international placement takes place in a low resource setting.More recent reviews have also started to look at the impact on host communities showing benefits and harms for the host. 20,27,28st reviews have addressed a specific question in relation to one health professions group, 14,15,19 with the focus sometimes further narrowed down to a specific geographical region, 13,16,24,26 which provides only a limited view of the phenomenon from a narrowed lens.
Three reviews were noted to include studies with students from different health professions, 23,27,29 but findings were aggregated without taking account of the context and how they were produced.We conducted a meta-narrative review to address this gap in the literature and achieve an overarching synthesis of research on international placements in health professions education.We decided to focus on undergraduate students considering that the nature of training and responsibilities at undergraduate level differ substantially from those at postgraduate level.The two review questions were: (1) what constitutes a successful short-term international placement in undergraduate health professions; and (2) how have different scholarly communities considered research questions on international placements over time?

| METHODS
The meta-narrative review methodology was developed by Greenhalgh et al. 30 when conducting a systematic review on a topic related to health services.This approach is considered to be suitable for 'topics which have been differently conceptualised and studied by different groups of researchers'. 31The aim is to provide a rich understanding by looking at the topic area from different perspectives.It draws on the theoretical work by Kuhn 32 who proposed that the development of science occurs in paradigm shifts rather than in a linear fashion.A meta-narrative review should follow the six underpinning principles: pragmatism, pluralism, historicity, contestation, reflexivity and peer review. 33[36] In order to facilitate the understanding of the literature, studies are first grouped into research traditions, which are described as a 'series of linked studies, each building on what has gone on before and taking place within a coherent paradigm'. 31During the analysis stage, a time dimension is applied by providing a narrative account in a meta-narrative.The research tradition or meta-narrative serves as the initial unit of analysis.In the synthesis stage, the research problem is divided up into different dimensions or broad themes with a comparison of findings from each research tradition. 30is review was guided by the six phases described by Greenhalgh et al. 30 and followed the Realist and Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) reporting standards for meta-narrative reviews. 33

| Planning phase
This review was undertaken as part of a larger project, which looked at medical elective exchanges between socio-economically contrasting settings.

| Search strategy
We developed a search strategy by using Medical Subject Headings

| Identification and selection of studies
A two-step process was used in the selection of studies eligible for this review.The first step involved screening all references by title and abstract to assess broad relevance.Articles with titles indicating that they were clearly irrelevant were discarded immediately.In the second step, the full-text papers of all the remaining articles were obtained and assessed against the inclusion and exclusion criteria.SJ evaluated a randomly selected sample of 10% of all articles following the same two-step process.Any discrepancies were resolved by discussion until an agreement was reached.
The selection process occurred in an iterative fashion with further refinement of the inclusion criteria as the review progressed.Considering our interest in international placements taking place in a socioeconomically contrasting setting and the good availability of relevant literature, we only included primary research studies when sending and receiving institutions were located in countries of different income levels according to the classification by The World Bank. 37ports focussing on longer placements (> 3 months) were excluded because of differences in the level of exposure to the new health-care environment.A summary of the inclusion and exclusion criteria that were finally applied can be found in Appendix S2.

| Mapping phase
In a preliminary mapping exercise, we categorised studies broadly by health profession.We noted that studies from professions in medicine, nursing and allied health dominated the literature.Other health professions, such as pharmacy, dentistry and chiropractic made only minor contributions and were not further considered for this review.
Furthermore, we noted that researchers within each health profession had used different approaches to studying the educational process of international placements.Therefore, research traditions were also considered in terms of their paradigmatic approach, which was based on theoretical and methodological assumptions shaping which aspect of international placements scholars found important to investigate and how they did this.The construction of the research traditions was an interpretative exercise; theoretical assumptions were often not explicitly stated by authors and inferred from various sections of the report.The boundaries between research traditions were not sharply demarcated and BF grouped the studies according to the most dominant paradigmatic approach and health profession.
Each research tradition was further explored, with the aim to identify the key parameters and provide a narrative account of how the tradition unfolded over time following the principle of historicity.This process was supported by accessing relevant theoretical literature.

| Appraisal phase
We used an Excel spreadsheet (Microsoft Corporation, Redmond, WA, USA) for the data extraction.A coding framework was developed to capture relevant information from each study, which included administrative details, participant characteristics, type of international placement, study aim, study design, data collection method and text indicating theoretical assumptions.Text segments describing the key findings were extracted and coded according to broad themes and sub-themes, with the aim to prepare a distilled summary for each theme considered by a study.SJ checked the data extraction for completeness and accuracy in a 10% sample of included studies.
9][40][41] In the second step, an overall judgement on the methodological quality was made using a 5-point grading system (Appendix S3), which was developed by extending the classification used by Greenhalgh et al. 42 BF evaluated all included articles, with SJ assessing the methodological quality in a random sample of 10%.Any discrepancies were resolved by discussion until an agreement was reached.

| Synthesis phase
BF synthesised research traditions at an abstract level by comparing conceptual, theoretical, methodological and instrumental elements of research traditions with each other.Furthermore, empirical findings from separate research traditions were brought together in a threestep process for the synthesis at a concrete level.In the first step, each theme was taken in turn by tabulating empirical findings separately for each research tradition.In the second step, a synopsis of the empirical key findings was prepared for each research tradition contributing to a theme.In the third step, findings of research traditions were compared and contrasted following the principles of plurality and contestation.BF (medical educator; medical background) led the analysis and synthesis reviewing the constructions of research traditions and findings in regular meetings with FG (health science researcher; medical background) and DD (medical educator; medical science background) and discussing classifications of studies into research traditions with SJ (medical educator; humanities background) during the appraisal phase.

| Recommendation phase
Recommendations for research and practice were developed, which are described in the discussion section.

| RESULTS
The final list of studies included 243 papers (Appendix S4), with and allied health (n = 55).Most articles were published in English apart from two reports in French. 43,44st articles originated from institutions in North America (n = 173); other regions included Europe (n = 32), Australia and New Zealand (n = 30), Southeast Asia (n = 4), Africa (n = 3) and Middle East (n = 1).The home institution of students was usually located in the same country as the institution of the first author.6][47][48][49][50][51][52][53][54] Students from institutions in North America travelled commonly to countries in Latin America for their international experience.Destination countries of students from institutions in Europe and Australasia often included countries in sub-Saharan Africa and Asia, respectively.Students from institutions in LMICs undertook international placements in North America or Scandinavian countries.
In most studies (n = 155), a qualitative methodology was employed.Quantitative methodologies and mixed methods were reported in 48 and 36 articles, respectively.A case study design was used in four studies.Eighty-seven studies were rated of very good quality with an overall rating of 4 (31.7%) or 5 (4.1%).Another 121 studies had an overall rating of 3 (49.8%)showing several limitations but providing valuable contributions to conclusions.Common limitations were a small sample size and a lack of detail in the description of methods.Studies were not excluded on the grounds of the methodological quality, but studies with ratings of 3 and above were preferentially considered in the synthesis.

| Synthesis of research traditions at abstract level
The 12 research traditions are organised by paradigmatic approach.
Each subsection starts with a brief explanation of assumptions before showing how the paradigmatic approach applies to each of the three health professions and has evolved over time highlighting similarities and differences between research traditions.Appendix S5 details trends over time by paradigmatic approach for each health profession.

| Educational effectiveness (positivism)
6][57] Knowledge about this reality can be uncovered by breaking down the phenomenon into a set of defined variables and measuring the relationship between these variables.
The focus of investigation is to demonstrate the value of international placements, so that the use of resources can be justified.For example, the authors of a study investigating the impact of an international immersion rotation in Mexico on Spanish fluency noted the importance of empirical evidence to 'inform decisions regarding how and if to allocate resources' for such activity. 58Due to difficulties in undertaking true experiments with randomisation of participants, quasi-experimental designs are ideally used to compare measurements in travelling and non-travelling students.
The empirical study of international placements began in the late 1970s, when national examination scores of travelling medical students were compared with those of a control group, with the authors attributing significant differences in public health knowledge between groups to the participation in an international health elective. 59In medicine, subsequent studies have examined the impact on a broad range of educational outcomes with questionnaires developed by the authors.More recently, studies have also used survey designs 60,61 to establish the frequency of ethical issues and other concerns, which may compromise the educational experience.In nursing, research has been strongly influenced by trans-cultural nursing theory 62 and the desire to encourage the development of cultural competency. 63,64re the purpose of investigation is to measure the effect of international placements on cultural competency by using a validated instrument, which has been also a focus of research in allied health.
This paradigmatic approach has considerably influenced research in medicine, but it has shown a decline more recently, whereas a recent increase can be noted in nursing and allied health.

| Educational effectiveness (interpretivism)
Research of this paradigmatic approach builds on interpretivist philosophies, which reject the notion of a single reality, but instead reality is constructed by the individual. 57It is the task of the researcher to discover these realities by stepping into the world of the individual.Such a way of thinking opens new avenues for investigating the educational value of international placements.Instead of focussing on a small set of variables, researchers can take a more holistic approach to studying the educational value of international placements by making use of qualitative methods, such as interviews, focus groups and reflective journals.For example, the authors of a qualitative study 65 analysed reflective journals to explore the meaning of an immersion experience for students considering study abroad options as 'a powerful strategy to enhance the development of cultural competence'.
This paradigmatic approach has influenced research on international placements in the three health professions disciplines considerably, particularly in nursing and allied health.It was in the late 1990s that the first report of a study in nursing was published, 66 with publications rapidly increasing in the following years, although some downward trend can be noted after 2015.Here again research often draws on theories of transcultural nursing and cultural competency, but the aim is to explore the process of how students develop cultural competence instead of measuring changes in the learner.Rather than focussing on one particular outcome, researchers show an interest in the experience of students during the placement in general and the impact on personal and professional development.In medicine, this paradigmatic approach has played a less dominant role, with publications increasing only moderately over the years.These studies explore what new learning students gain, and also what happens when students learn in international placements. 67-69

| Critical approach
This paradigmatic approach has emerged more recently at a time when concerns about ethical issues in global health became more prominent. 70,71It has some roots in critical theory, which comprises a range of theories bringing to attention unequal relationships between social groups. 72,73erefore, here international placements are not simply viewed as an educational intervention resulting in new learning, but they take place in a problematic context shaped by unequal power relations between stakeholder groups.5][76] The attention to an unequal world becomes apparent in the use of language, which may include terms such as injustice, marginalisation, and exploitation.For example, in a qualitative study exploring motivations of students for participation in international placements, it was noted that 'international experiences may unintentionally result in oppressive practices'. 77Authors often draw on critical theoretical work of other scholars or use critical frameworks, such as postcolonial theory, [77][78][79] to inform data analysis.Qualitative methods are the preferred approach for research, with data collection occurring by interviews, focus groups or reflective writing.
Publications started in nursing in 2009, with studies exploring how students developed a critical understanding of global health issues. 79,80Since then, research activity has increased slowly but steadily in all three health professions, which show a slight difference in the focus of their research.

| Complex systems/relationships
2][83] It adopts a more holistic approach to examining complex systems with the rejection of reductionist thinking focussing on cause-effect relationships and linear predictability.This shift in thinking has resulted in new ways of approaching research on international placements, which are no longer considered as a simple intervention, but as an activity involving multiple agents.
The aim of research is to find out more about the perspectives of the stakeholders and the relationships by using qualitative methodologies and mixed methods designs.Rather than problematising the context, the emphasis is here on the achievement of benefits for agents beyond the learner.For example, in a qualitative study exploring the experiences of visiting students and host community partners, the authors note 'mutual learning of all partners' as an important outcome. 846][87] There has been a steep increase in published research since 2011, particularly in medicine, where research is concerned with gaining a better understanding of the host staff perspective.In nursing, this paradigmatic approach has emerged later, with only two studies published before 2020. 43,88

| Synthesis of research traditions at concrete level
Empirical findings were grouped into four broad themes: (1) learner; (2) educational intervention; (3) institutional context; and (4) wider context.Each subsection explains key findings highlighting similarities and differences between research traditions.Table 1 provides a summary of key findings for dominant themes in each research tradition.

| Learner
A large number of studies provides evidence on the learner, with findings indicating a positive impact of international placements on personal and professional development.Research traditions differ in which parts of the educational journey they focus on and which outcomes they take a particular interest in.
][91][92][93][94][95][96][97][98][99][100][101][102] In the initial stages, negative preconceptions of the host culture predominate, with students moving further in this process by examining critically their assumptions and appreciating the validity of other perspectives, which may result in transformation of their own perspectives.[127][128][129][130][131][132][133] By contrast, only one positivist study has a strong focus on this outcome in medicine, reporting a significant increase in cultural competency in travelling students. 134Instead, studies show a positive impact on a range of outcomes, such as public health, 59,135,136 language skills 58 and clinical skills. 48,135Furthermore, more emphasis is placed on how international placements affect career choices, with several studies showing a positive impact on the interest in working with underserved populations [137][138][139] and pursuing a career in primary care, [139][140][141] although some studies report no impact on career choices. 142,143Interpretivist studies report ethical issues and other challenges, which students may encounter during international placements. 67,68,144 comparison with the aforementioned traditions, studies of critical approach make only a small contribution to the evidence on the learner, but they show that critical reflection plays an important role in the learning process, 79,[145][146][147] although this may not always occur at the desired depth. 78,148,149[47][48][49]

| Educational intervention
This theme is not included in Table 1, as only few studies have looked at features of the educational intervention and learning strategies, which may enhance the learning process.According to findings of studies in nursing, placements in both LMICs and high-income countries (HICs) have a positive impact on personal and professional development of students, although the content and extent of learning may differ between countries. 95,150,151Various strategies, which encourage the interaction between visiting and host students 50,152,153 and engagement in reflection, [154][155][156] stimulate learning in all three health professions disciplines.

| Wider context
This theme goes beyond the immediate learning environment in the host institution and looks at the relationship between sending and hosting institutions, and programme design.Findings have been predominantly provided by studies of complex systems/relationships in medicine and allied health.1][172] In medicine, studies often report a desire by host staff for more equitable exchanges with a bidirectional flow of students between HICs and LMICs and a need for improving communication between institutions 157,162,165,173,174 .

| DISCUSSION
In this review, we identified and synthesised 243 articles from 12 research traditions, which report on empirical work pertaining to international placements in health professions education.We found a substantial increase in publication activity occurring over the past decade, with most studies published after 2010.This trend reflects a growing interest in offering such learning opportunities in the context of an increasingly globalised world, and also a desire for strengthening the evidence base to enhance practice.4][15][16][17][18][19][20][21][22][23][24] Moreover, this review also provides new insights into how assumptions about what international placements should achieve vary between different scholarly communities and how these assumptions have shifted over time.
We noted that the development of cultural competency has not been investigated much in medicine in comparison to the other health professions, which seems surprising considering the importance of this competency in the medical curriculum to prepare graduates for the delivery of health care in multicultural populations. 175,176A possible explanation is an unfamiliarity or hesitancy to engage with underlying theory in a discipline that is more dominated by the biomedical approach, 177,178 which also influences the delivery of global health education. 179,180By contrast, the acquisition of cultural competency has played an important role in nursing for a long time, 62,63 which has resulted in the development of various theoretical frameworks facilitating the study of how and to what extent students develop these competencies.Therefore, there seems to be a much stronger expectation for nursing students that international placements provide this kind of learning than exists for medical students.with the development of mutually beneficial partnerships being considered as a strategy to address these inequities. 181,182As a result, international placements have been reconceptualised and, interestingly, this has proceeded in two different directions.Whereas some scholars regard international placements as an activity that is shaped by the perpetuation of colonial relationships, which should be either brought to the attention of the learner or even addressed by more substantial changes in practice, other scholars emphasise the collaborative nature as a key feature of the educational process without problematising this activity.
6][47][48][49][50][51][52][53][54] All these studies were published between 2012 and 2020, with the publication activity showing no changes in trends by contrast to the overall literature.These findings indicate that international placements are still primarily considered as a learning opportunity for HIC students, with unilateral flows of students continuing to persist.This imbalance has often been justified by perceptions that students may provide help in low-resource settings, 182 which may explain why more recent research has paid particular attention to the study of the impact on host communities.However, such an approach is questionable, when 'the world moves beyond the charity model of global health'. 183In effect, hosting students place a burden on receiving institutions in terms of staff time and other resources, which are not equally shared. 182,184Furthermore, global health education is equally important for LMIC students, who benefit from experiential learning opportunities in a resourcedifferent setting in a similar way as HIC students, 184,185 which is supported by the findings of our review.In order to achieve mutual benefits for both institutions, there is a call for more reciprocity in international student exchanges and the development of partnerships, which are based on principles of equity. 181,184,186It has been suggested that the COVID-19 pandemic may act as a 'catalyst' to accelerate change 181 after international placements were paused for several months. 187,188

| Recommendations for practice and research
This review highlights that multiple agents and their interactions shape the educational process of international placements contributing to a system that needs to be understood to improve practice and outcomes.The question should be no longer whether international placements are effective or not, but instead researchers should aim to gain a better understanding of the educational process, as it has been suggested by other authors. 189,190This is not to say that quantitative studies have no place in this research; but rather than comparing participation in international programmes with non-participation, we suggest looking at interventions within an international programme, which may be implemented to promote learning and enhance the experience.This review has shown that only a small number of such studies have been conducted.For example, Krishnan et al. 131 evaluated the impact of a cultural intervention in students who were exposed to this intervention and a control group during international service learning.Furthermore, there is a need for qualitative studies to explore the learning process of medical students drawing on theoretical frameworks of cultural competency development and transformative learning.
Research on the host perspectives in LMIC countries has been an important step moving the research agenda forward, but the question about how to design and implement international programmes, which work for all stakeholders and maximise the educational value, has not been answered yet.An institutional perspective has been adopted by some studies in allied health 85,170 but to a lesser extent in medicine and nursing.In order to develop strategies to improve the quality of international programmes and achieve mutual benefits for stakeholders, it is important to understand practices of sending and host institutions and evaluate current approaches.

| Strengths and limitations
This large review has used a meta-narrative methodology to provide further understandings of the landscape of research on international placements in health professions education.It has followed the RAM-ESES guidelines using a systematic approach with a comprehensive search to identify eligible studies.
It is possible that some studies were not captured in the electronic search because of different terminologies used for international placements.In order to ameliorate this issue, the literature search was Griffiths was involved in the design of the study, contributed to the analysis and interpretation, and was involved in all stages of the drafting process.All authors read and gave approval of the final manuscript for submission.
International placements are likely to have different meanings for different scholarly communities, which influences what needs to be researched and how this is performed.The consideration of research from different perspectives would not only facilitate an understanding of the larger picture but also highlight research gaps and give new directions for research and practice.

(
MeSH) and free-text words expressing the concepts of learner, activity and context, which were combined by Boolean operators.In September 2016, BF carried out a formal search by using the following electronic databases: Medline, Embase, CINAHL, PsycINFO, Education Research Complete and Web of Knowledge.Details of the search strategy for Medline are shown in Appendix S1.The search was updated on four occasions, with the final update conducted in June 2022.All references were entered into a single library using Endnote X9.3.3.Other search methods included backward and forward citation tracking and additional searches by combining terms for 'activity', which were used repeatedly in titles of included studies identified by other search methods, with MeSHs and free-text words relating to learner and context.

Figure 1
Figure 1 providing details on the different phases of the study selection process.The overall publication activity has considerably increased over the past 30 years, with 81% of the studies (n = 196) published in 2011 or later.Nursing has been the most active health profession in generating publications (n = 115) compared to medicine (n = 73) This large review helps to appreciate how the focus of investigation has moved away from the learner to wider aspects of the context over time, which indicates shifts in what is considered as important for successful delivery of this educational activity.Particularly in earlier research, the value of international placements was predominantly judged by what new learning the visiting student had gained from this exposure.There have been growing concerns about how former colonial relationships shape power structures in global health activities, supplemented by other search methods.Furthermore, this review involved interpretation in various steps of the review process, in particular for the grouping of studies into research traditions.Other researchers may have identified different research traditions and classified studies differently, which may have affected the nature and unfolding of meta-narratives.All four authors are primarily involved in the teaching of medical students and have less experience in education of students from other health professions, which means that interpretations were primarily made from this perspective.4.3 | ConclusionsThis meta-narrative review allows us to understand how the professional discipline and the historical context have shaped what constitutes a successful international placement, which determines the research problem requiring investigation.Findings from different health professions complement each other and also highlight areas in which research is underdeveloped.Over time, there has been a shift away from the learner towards the consideration of wider aspects of international placements, which influences perceptions of desired outcomes requiring new ways of thinking about research.We hope that this review encourages a critical examination of assumptions about the purpose of international placements and provides directions for practice and future research.AUTHOR CONTRIBUTIONSBirgit H. Fruhstorfer was the principal investigator, led all stages of the review process and wrote the first draft of the manuscript.Simon P. Jenkins contributed to the literature search, reviewed 10% of the included studies and critically reviewed the draft.David A. Davies was involved in the design of the study, participated in discussions of analysis and interpretation, and critically reviewed the draft.Frances Summary of key findings of dominant themes in research traditions (one field represents one research tradition).