Intended and Actual Outcomes of Study Abroad Programs: Nursing Students’ Experiences

Research Design and Participants

Data were collected in two complementary phases: (a) An online survey comparing participants’ perceived outcomes of Erasmus+ mobility with the program’s intended outcomes; (b) Focus groups exploring the key findings of the survey in more depth. In phase 1 of the study, all former and current nursing students at a university in Malta who took part in Erasmus+ mobility between 2009 and 2016 (n = 145) were invited to complete an online questionnaire consisting of three sections. Section A included close-ended questions about the participants’ demographic data and the exchange pursued. Section B comprised two open-ended questions about the respondents’ motivations for, and the main outcomes of, their participation in an Erasmus+ exchange. Section C used a 5-point Likert-type scale to assess the participants’ perceived level of attainment of the intended outcomes of the program (EC, 2015, p. 31). The participants were also asked to indicate whether they were interested in taking part in the second phase of the study. In phase 2, two 2-hour focus group discussions, both moderated by one of the researchers with the other assuming the role of note taker (Mack et al., 2005), were held among phase 1 participants who opted in to the second phase (n = 16; 5 men and 11 women). The principal themes emerging from the analysis of the open-ended questions of the questionnaire guided the focus group discussions.

Ethical Considerations

Participation was voluntary, based on verbal and written information. Completion of the online questionnaire implied consent. Written informed consent was obtained from focus group participants. The study was approved by the University of Malta Research Ethics Committee.

Data Analysis

Quantitative data from the questionnaire were analyzed using descriptive statistics. Answers to the open-ended questions in the questionnaire and the data arising from the focus groups were thematically analyzed using Braun’s and Clarke’s (2006) six-phase approach: familiarization with and transcription of the verbal data; generating initial codes; searching for themes; reviewing themes; defining and naming themes; and producing the report. Qualitative data are therefore presented and discussed across the series of overarching themes that emerged through the analytic process.

Theme 1: Enhanced Employability as a Nurse

All the participants believed that Erasmus+ mobility enhances subsequent employment prospects and job opportunities, with some participants claiming that “Having had a study abroad experience looks good on a CV and helps when applying for employment in nursing posts.” This perception mirrors the views of the various stakeholders (academics, students, and employers) participating in an Australian study by Crossman and Clarke (2009). A European study revealed a favorable association between Erasmus+ participation and employability, confirming that the challenges and costs involved in securing overseas experiences for students translate into “increased employability skills” (EC, 2014, p. 18). However, it is important to note that most of the participants of the current study were recently employed new graduates. A longitudinal study could explore whether this favorable view changes over time.

Theme 2: Exposure to Nursing Beyond the National Shores

The participants were seeking, and indeed felt they were provided with, exposure to “cultural diversity from all around the world.” Apart from establishing friendships with students from different countries, the participants emphasized that this extended beyond the social aspect. They valued the professional dimension of being exposed to realities beyond the confines of national shores in which they lived, studied, and worked. Most participants remarked that their interest to witness and learn about other health care systems was significantly addressed through Erasmus+ mobility. They appreciated nursing care delivery in contexts with different resources to what they were used to and opened their mind to students, educators, health professionals, and patients with different perspectives and mentalities. This aided the development of “new ways of thinking, both at the place of work and in one’s personal life,” according to one participant.

Data pertaining specifically to learning about clinical practice through the study abroad program were also elicited. One student remarked that, despite language barriers, during the mobility his skills improved considerably due to more opportunities for hands-on practice with minimal supervision than in the home country. Another student similarly noted that “working in a UK hospital increased my confidence as I had to face challenges which were out of my comfort zone.” A similar increase in confidence was reported by the Irish and Scottish study abroad participants in Casey’s and Murphy’s (2008) and Milne’s and Cowie’s (2013) studies, respectively.

These experiences highlight the learning achieved due to being away from familiar contexts and are comparable to those of the midwifery students participating in Marshall’s (2017) study. Such observations underscore varying realities in different nurse education contexts and experiences. Consequently, they reveal scope for discussion about the differences in the approaches and delivery of nurse education across different contexts, despite international frameworks and guidelines (Robinson & Griffith, 2007).

Theme 3: Personal Growth

Like the U.K. nursing students in Lee’s (2004) study, the participants in the current study sought and experienced growth on a personal level through their study abroad experience. Enablement of skill development toward independent living, ranging from enhanced management of domestic chores, personal finances, and budgeting, to the successful navigation of lone travelling within and between countries, and from getting to know oneself to increased assertiveness and decision-making ability because of space and time for personal reflection, was noted in the data. One participant wrote, “I became a better person…accepting new challenges and being more confident in decision making. Besides, coping with cooking, cleaning, shopping, and travelling to the other side of the continent makes you more independent and that boosts your self-confidence to a whole new level.” Similarly, the Maltese midwifery students in Marshall’s (2017) study identified “learning how to use a washing machine and cook for themselves” (p. 11) as part of the unplanned benefits arising from their Erasmus+ mobility experience. This reflects the reality of students living in Malta, where, due to the short traveling distances and other sociocultural issues, the proportion of Maltese students living with their parents is the highest in the EU (Eurostudent Project, 2019).

Participants shared experiences of “enlightenment” during an Erasmus+ exchange. One participant explained that “it sparked an overwhelming need to travel around the globe.” Another stated, “I confirmed how interested I was in working abroad; also, my love for travel flourished.” Enlightenments of a different nature included: “I started to appreciate everything my parents give me much more,” “I found a desire to further my studies,” and “I realized that once I successfully completed an Erasmus exchange I can do anything.” Thus, the outcomes of students’ study abroad experiences clearly extended beyond the area of study, as intended by the Erasmus+ program itself (EC, 2015).

Theme 4: Context-Sensitivity of Nursing Care Delivery

Given that all the participants were nurses or nursing students, it was not surprising that most of the data pertained to some aspect of the profession. However, the participants were keen on highlighting the occasionally surprising practices they witnessed in the host country. Data examples include: “the box for depositing unwanted babies outside the hospital was shocking!” and “it was strange to see tea being poured down nasogastric tubes!”

The underpinning contention around these observations was the participants’ realization that despite the presumably universal nature of the nursing profession, the delivery of care was, nevertheless, sensitive to the context in which it was delivered. These and similar examples highlight the importance of fostering open-mindedness among nurses in their practice, besides a curious and accurate eye for learning from what is new and different to what one is used to. This was previously underscored in primary studies among Swedish nursing students (Bohman & Borglin, 2014), Maltese student teachers (Caruana & Vella, 2012), and English and Maltese midwifery students (Marshall, 2017), as well as in a comprehensive review of international studies by Button et al. (2005).

Theme 5: Language and Citizenship

The Erasmus+ program specifies the development of language and citizenship as intended outcomes of student mobility. The data suggest a varied experience among participants regarding these two outcomes, ranging from “I did not manage to learn the Finnish language at all” to “I went from being barely able to speak the language to filling in as an interpreter between English and Italian.” One participant lamented that “there was a huge language barrier to my learning.” Indeed, language has consistently been reported as a perceived barrier in previous studies about factors influencing students’ intentions to study abroad (Goodman et al., 2008; Kent-Williamson et al., 2015; Owen et al., 2013). Securing a basic introduction to the host country’s language may enhance students’ eventual learning experiences. In turn, the measures and structures with which the language skills of individual outgoing students are assessed may need to be reviewed and adjusted accordingly.

The data suggest a favorable effect of the mobility on citizenship. Several students claimed that they became more aware of both their rights and their duties as EU citizens. Some were prompted to join voluntary organizations “to give something back out of [their] own free will.” Others increased their awareness about environmental issues through practices (such as cycling to work) observed in the host country, which they tried to adopt.

Because the expected nature, extent, and magnitude of outcomes related to citizenship and language are not specifically determined by the mobility program, the actual measurement and evaluation of such outcomes is, to date, limited. This emphasizes the importance of developing institution- or context-specific expectations and objectives. Defined expectations and objectives pertaining to these intended outcomes of citizenship and language are a prerequisite for developing measures and initiatives to enhance and support their attainment.