The findings revealed that the students experienced many new situations in Sweden and that they gained significantly from the exchange programme, both personally as well as for their future careers as nurses. However, they also experienced challenges in the new culture and environment. Furthermore, they increased their global perspectives on nursing and interest in working with global health issues. The discussion of results is described in three parts; Benefits of nursing student exchange, Challenges in nursing student exchange and global perspectives.
Benefits of nursing student exchange
Studies show that nursing students on exchange programmes reflect on practices and aspire to improve procedures in their own countries(24–26). The students in the present study were inspired by the new approaches that they encountered in Sweden. In the Swedish education system, they encountered new research methods, more self-study time and online resources as well as a more equal relationship between teachers and students. They expressed that they had gained new skills and increased understanding of different approaches that could benefit them in the future. The students were exposed to the nursing role and gender roles in Sweden through their theses where the majority of them interviewed nurses. They were influenced by the independent nursing role and holistic care provided in Sweden and hoped to implement these practices in Tanzania. Similar to findings were shown in a study by Maltby, de Vries-Erich and Lund(27) where the students reflected on the status of women and the gender roles that they encountered in Sweden. They found that women were more empowered in Sweden compared to Tanzania, something which they wanted to address in their country.
While many studies on nursing students examine the experience of clinical practice in another country, in this study the students only participated in theoretical courses but gained similar professional and personal skills as those doing clinical practice(26, 28, 29). The students benefitted from the student exchange by becoming strengthened in their roles as future nurses, which is consistent with previous research(28, 30). They became motivated and confident that they could work in any area that they wished and became aware of new possibilities for work and further studies that they had not considered before participating in the exchange programme(30). In our study, the students developed interaction skills and cultural competence as emphasised in many other studies as a benefit of nursing student exchange(14–16, 26, 27, 31). Being exposed to a new environment and culture gave the students a wider perspective about people from different backgrounds and how to communicate with them, something that will assist them as nurses when taking care of patients.
As well as developing on a professional level, the students in this study also gained personally from the exchange. Defending their theses in front of many people had increased their confidence and ability to speak publicly. This is a common feature among nursing students, where experiencing a new culture and leaving their comfort zone increases confidence(18). Additionally, nursing exchange studies can promote empowerment and awareness of own potentials(32), which was true for some of the Tanzanian nursing students in the present study. One student discovered skills in writing during the exchange and proceeded to write a book on nursing after the exchange.
Challenges in nursing student exchange
Although the students described their experience as primarily positive, they also faced challenges in the new environment and new culture. Encountering language barriers has been addressed by numerous studies on nursing student exchange(11, 27, 32, 33) and is a challenge that the Tanzania nursing students were confronted with. Even though they were able to communicate well with many people in their surroundings in English, such as their supervisors and student mentors, they encountered language barriers for example when going to the supermarket and using public transport.
Another challenge that the students in this study faced was some difficulties in getting to know new people apart from their supervisors and student mentors. This is a common challenge for nursing students on exchange programmes where integration has been difficult and low interest from locals to interact has been reported(10, 11, 32). In the present study however, the students described the difficulties in interaction as a cultural issue rather than low interest from others to get to know them. They expressed that in Swedish culture it is difficult to approach someone you don´t know and start a conversation, and they recognized that it was easier to get to know new people in certain settings where they met people with common interests. They socialized a lot with their student mentors, as well as being introduced to new people through them.
The support from the student mentors was not only important for the student’s social life, but also for various areas such as learning about practical matters like the transportation system, help translating Swedish and cultural etiquette. The students expressed that the help from the student mentors was fundamental for coping with their new environment. Implementing adequate support systems to increase integration and benefits of nursing student exchange programmes is recommended but reported as often lacking and something to be improved(10, 33).
Nursing student exchange offers students an important opportunity to recognize their own ethnocentrism(31) and various studies on nursing students from HIC traveling to LIC show that the students tend to adopt an ethnocentric view(7, 8). In the present study, however, the students did not show any signs of ethnocentrism, as they were open to the new culture and the differences they encountered. The cultural difference and challenge regarding interaction in Sweden was not expressed by the Tanzanian students in negative terms rather, they recognised and accepted this difference as suggested by Masera et al. (11). The fact that the claim by Edmonds(31) could not be corroborated here implies that whether students develop ethnocentrism or not may be highly context dependent. Studies should be aimed at investigating this further.
Many studies on nursing exchange programmes present students from HIC being exposed to poverty for the first time in LIC(7, 8, 33), however, in the present study the students were already exposed to health disparities in Tanzania. Instead of being a first exposure to poverty, the exchange programme acted to strengthen their desires to improve health in their country, especially maternal and child health and the health of people living with HIV. The importance of providing care and advocating for these vulnerable groups was acknowledged. They increased their understandings of global health issues and the SDGs(1) and interventions to deal with these. The students also wished to work internationally and were more confident to seek study or work opportunities abroad in the future as they now had skills to cope with a new environment.
This study suggests that nursing exchange programmes increase knowledge on global health and global nursing as indicated in other studies(34–36). Nursing curricula should also include global health to prepare nurses for the needs of the global community(37), such as the SRCUC who has adopted global nursing as their profile area.
Purposeful sampling was convenient for this study but can also lead to less variation in the participants and the data collected(22). Data analysis used for this study was content analysis. As content analysis consists of identifying the manifest and latent content and involves the researcher´s interpretation of the data, actions were taken to ensure trustworthiness(23). Credibility was attained by providing truthful data, this study conducted semi-structured interviews that encouraged the participants to talk freely while exploring topic areas(22). All the collected data was included in the analysis, examples of the analysis process was presented, as well as quotations from the transcripts. After the pilot interview was conducted some minor alterations to the interview guide were made and after that the same questions were asked during the remaining interviews. Confirmability includes measures to maintain objectivity and reduce bias(22).
The participants consisted of an equal amount of male and female and the researcher and participants’ didn´t have any prior relationship. Transferability relates to the possibility of the findings being applied in another setting or group(22). Though the sample size was small, valuable, and consistent findings were gathered. Results from previous studies show similar outcomes as this study where the same method with semi-structured interviews was applied. However, the exchange programme which the students had participated in had only been running for two years and the choice of participants was therefore limited. A study at a later stage including more students may give more variation to the data. It is also relevant to state that the first author’s own pre-understandings and bias may have influenced the questions chosen in the interviews and the interpretation of the answers, as she went on student exchange and found it beneficial, when studying at the SRCUC. However, the first author strived to be as neutral as possible and open to the specific experiences of the participating students.