Global Nursing - A Qualitative Case Study of Tanzanian Nursing Students' Experiences of Student Exchange in Sweden

Background: Due to globalization and a shift in population demographics, needs within healthcare are changing and nurses require new skills and knowledge. Nursing education needs to facilitate these new demands and student exchange programmes provide an opportunity to develop necessary skills. Aim: The aim of this study was to explore Tanzanian nursing students' experiences of student exchange in Sweden. Method: A qualitative design was used for this empirical study. Semi-structured interviews were conducted with six Tanzanian nursing students who had participated in student exchange in Sweden. The participants were recruited by purposeful sampling. Inductive reasoning and qualitative content analysis were applied. Results: The ndings revealed that the students experienced new approaches in Sweden, allowing them to develop skills and competences. Furthermore, they increased their global perspectives on nursing and interest in working with global health issues. However, they also experienced challenges in the new environment. Conclusion: The present study showed that the Tanzanian nursing students benetted from their student exchange, both personally, as well as for their future careers as nurses. More research is needed examining nursing students from low-income countries participating in student exchange in high-income countries.

Important components of global nursing are holistic care, cultural competence, and advocacy. The foundation of global nursing is to alleviate suffering and protect human rights with respect for cultural diversity (4). There are many organisations working with global nursing and the foundation of the International Council of Nurses (ICN) in 1899 was the rst international organisation of healthcare professionals. The organisation aims to create international collaboration between national nurses' associations and tackle global health challenges working closely with agencies such as the World Health Organisation. Their mission includes progress of the nursing profession and knowledge to create skilled nurses worldwide to meet today´s and future health needs (2).

Ethnocentrism
In today´s multicultural society it is important that nurses do not adopt an ethnocentric view, which refers to an individual´s belief that one's own ethnic group and culture is superior to others (5). This includes believing that one´s values, behaviour, customs, and standards are better than others. In ethnocentrism other cultures are often judged on the basis of stereotyping and bias (5). When nurses have an ethnocentric view this contributes to partiality to one´s own health care traditions(6). This in turn may result in a patient´s needs not being met and impacting their health and wellbeing negatively.
Ethnocentrism can also lead to discrimination and negative attitudes, which needs to be counteracted to provide equal care for all. Further, nurses can gain greater understanding of other cultures by becoming more aware of their own values(6).
A description, that is often portrayed regarding students who travel from High Income Countries (HIC) to Low Income Countries (LIC), is their experience of a culture shock (7). The researchers describe Norwegian nursing students who carried out exchange programmes in hospitals in Botswana, South Africa and Tanzania. The study showed that, on numerous occasions, the students experienced frustration over their situation. They encountered many differences in the healthcare systems compared to Norway, with many aspects that they believed were wrong. They were also judgemental towards healthcare staff and believed that these often acted unethically. The authors pointed out that the students had not re ected about their own culture and instead made judgements based on Norwegian standards, which can be viewed as ethnocentrism. Further, Swedish nursing students on exchange programmes in Tanzania and also experienced adversities in the situations they found themselves in. The Swedish nursing students tried to understand the different values of the context that they were in but nevertheless compared them to Swedish norms(8).
A literature review by Inyama,Williams and McCauley(9) show that while there is substantial research on African exchange students in general, research speci cally on African nursing students is lacking. One study states that Nigerian nursing students in the USA faced challenges such as di culties in integration and feelings of social isolation. However, these adversities also lead them to develop abilities to be persistent even when encountering obstacle (10). Another study showed that integration was di cult for nursing students from Cameroon in Italy; this was due to various reasons including languages barriers, differences in culture and a low interest from their Italian counterparts to interact (11). It was recommended that more preparation was needed in order to facilitate better integration and promote bene ts from the exchange experience. In order to remain open to the new environment in the host country it was suggested that becoming more aware of one´s own culture would encourage the process, in that way the students could be more accepting of differences rather than becoming defensive (11).
African nursing students on exchange programmes in Australia also experienced challenges, where they suffered prejudice and racism. Adversity was also reported in understanding the new culture and not knowing how to act in certain situations or what could be regarded as offensive. At the end of their exchange programme however the students stated that they´d gained cultural knowledge and awareness (12).

Cultural competence
Cultural competence refers to a nurse´s ability to relate to different cultures and provide adequate care for people with diverse cultural backgrounds (13). The basis of cultural competence includes cultural awareness, knowledge, skill, and desire. Cultural awareness means examining and becoming aware of one´s own culture as well as one´s prejudices and stereotypes about other people and groups. With cultural knowledge one can gain cultural skills in performing tasks in a culturally sensitive way. Through cultural encounters, interacting with people from culturally diverse backgrounds, existing beliefs and values can be corrected. Lastly the desire to develop cultural awareness and competence is an important component (13).
De Natale and Waltz(17) describe nursing students from the United States who carried out exchange programmes in Ireland developed both on a professional and personal level. They gained new perspectives that would help them in their work as nurses. They improved their skills in identifying individuals´ needs, to treat them with respect and above all they developed an increased awareness of the culture that they visited. In another study where nursing students from the United States went on student exchange in Hungary, Wi Mahmoud and Schuessler(16) explain how students developed their ability to appreciate a different culture, learn new skills and explore ways to communicate and increase their cultural understanding.
Bohman and Borglin(18) describe that Swedish nursing students participating in exchange programmes in various countries within and outside of Europe became more self-aware. Leaving their comfort zone and experiencing a new culture with different ways of thinking and living made them challenge and change prior attitudes. Maintaining an open attitude during exchange studies was indicated in a study on Norwegian nursing students in Tanzania (15). To understand the new culture, they had to remain open minded, they encountered situations that they rst thought unacceptable but when they then were given explanations, they often changed their minds. Through this process they gained cultural awareness and competence (15).
Nursing student exchange programme Kilimanjaro Christian Medical University College (KCMUCo) (19) in Tanzania has been collaborating with the Swedish Red cross University College (SRCUC) (20) in Sweden since 1997 (21). Various projects have been implemented where students from the respective countries participate in clinical practice and theoretical courses in Sweden and Tanzania. In 2017 a bilateral project with the Linnaeus-Palme programme was initiated for students from both countries to write their bachelor theses in the other country. The overall aim of the project is to strengthen the Global Nursing focus of the nursing programmes at the KCMUCo and at the SRCUC, in order to increase the capacity of the institutions to meet the future needs of society in a global health context. Through exchange programmes students will deepen their knowledge about global health challenges and global aspects of nursing science (21) The project relates well to the global SDGs for 2030 that, among other aspects, aims to end poverty, reduce inequalities, and promote education(1).

Problem statement and study aim
It is becoming more common to study abroad, but it is still predominantly students from HIC who visit LIC. In Tanzania, university education is currently increasing, as well as opportunities to study abroad.
Since Tanzania is classi ed as a LIC, it is an appropriate choice to investigate how students' experiences their student exchange in a HIC, such as Sweden. The experiences of student exchange can vary depending on the student´s country of origin and where they complete their student exchange. While there are several studies that focus on experiences among nursing students from HIC traveling to LIC, there are currently few studies that investigate the reverse. By examining experiences among nursing students from LIC it can lead to a more inclusive and extensive knowledge on the subject. It is important to present a broader representation of these experiences to create a deeper understanding of other cultures and promote skills and knowledge essential to today´s nursing needs. Therefore, the aim of this study was to explore Tanzanian nursing students' experiences of student exchange in Sweden.

Method
Design A descriptive qualitative design was used for this empirical study consisting of interviews. Polit and Beck (22) describe that this design is applicable when people´s experiences are to be investigated, which was the purpose of this study. Inductive reasoning was applied, where the speci c observations from the study lead to conclusions.

Setting
The exchange programme took place at the SRCUC, where the courses were held. The students wrote their bachelor theses during their 12-week stay in Sweden and 4-5 students participated in the exchange programme every year. The students were part of a small project group and they either wrote one thesis together or within the same larger project. The students conducted different research topics within the area of nursing care. Teachers from both SRCUC and KCMUCo supervised the thesis and these teachers were part of the teacher exchange. The students took an introductory course to scienti c writing and the Swedish healthcare system at the beginning of their stay.

Sampling
Purposeful sampling was used to recruit the students. This sampling method is used to nd participants who can contribute with the most information (22). The inclusion criteria were students from KCMUCo who had participated in student exchange programmes at SRCUC within the last two years.
A representative at the KCMUCo was contacted whom had information on which students had participated in the student exchange programme at the SRCUC. Potential candidates were then sent a participant information letter with details on the aim of the study and terms and conditions. Those who agreed to participate signed a consent form.

Participants
Six students, who had participated in exchange programmes in Sweden in 2018 and 2019, were included.
All participants were in their third year of their four-year Bachelor of Nursing programme during the time of their exchange. Three of the participants had taken part in the exchange programme in 2018 and three in 2019. The students who had participated in 2018, had since then graduated and two of them were performing their one-year post-graduate internships as nurses. The third student had taken a job project before starting the internship. The students from the 2019 exchange programme were in their fourth and nal year of nursing studies. Their demographic data is presented below in Table 1.

Data collection
Semi-structured interviews were performed using a thematic interview guide. The interview guide was based on topic areas and broad open-ended questions were created to match these (22). The topic areas were expectations pre-exchange, experiences during the exchange, knowledge and skills gained and impacts post-exchange. The focus of the interviews was the participant´s experiences and they were free to talk about what they felt was important. Therefore, probes were used to follow up the answers of the participants but still keeping to the topic areas to capture relevant information.
All six interviews were conducted at the end of April 2020, lasted for an average of 45 minutes and were performed in English. The interviews were all done individually at a time that was convenient for the participant. The online platform Zoom was used for the interviews due to the participants being in Tanzania and the researcher in Sweden. The interviews were digitally recorded and transcribed afterwards. In order to test the interview guide, a pilot interview was rst conducted with one of the Tanzanian exchange students and lasted for 53 minutes. Some adjustments were made to the interview guide, a few of the original questions were excluded as they were shown to be redundant or not relevant. After these alterations, the interview guide was then kept the same for the following interviews. The pilot interview was included in the study as the answers were conclusive to following interviews and relevant.
Participants received information on the study and their rights as participants prior to the interviews in the participant information letter, which was sent to them via e-mail, this information was also repeated orally at the beginning of the interviews. The participants were also free to ask any questions regarding the study or the terms as participants before the interview commenced. Informed consent forms were collected prior to the interviews. The interviews were digitally recorded and consent to do so was received at the beginning of each interview.
Con dentiality was achieved by assigning codes to the participants; these codes were used for naming the audio recordings of the interviews as well as in the presentation of the data. Furthermore, to ensure con dentiality the quotations from the interviews presented in the results did not specify which students had made a particular statement. This was done to avoid the risk of potentially identifying the participants, as the sample of participants was small.

Data analysis
The data, gathered from the interviews, was analysed using qualitative content analysis. Content analysis aims to nd patterns in the data and sort them into themes and was based on principles by Graneheim and Lundman (23). The interviews were transcribed verbatim and then read through various times to become familiar with them. The aim of the study guided the analysis and meaning units, sentences that represented concepts related to the aim of the study, were then chosen from the text. The meaning units were condensed while still conserving their meaning. The condensed meaning units were coded and grouped into sub-themes. The meaning units, condensed meaning units, codes and sub-themes are classi ed as manifest content, descriptions as seen in the data. In the last part of the analysis, themes were created, representing the underlying meaning, latent content. Examples of the data analysis are presented in Table 2.

Results
The results in this study describe the experiences of Tanzanian nursing students on student exchange in Sweden. Four main themes were formed; Experiencing new approaches, Dealing with a new environment, Developed competences and New career aspirations. Nine sub-themes were created with the themes, the themes and sub-themes are presented in Table 3. The student exchange in Sweden exposed the Tanzanian nursing students to different approaches in various areas, these areas are described in the three sub-themes: Education system, Nursing role and Gender roles.

Education system
The students found differences in the education system in Sweden compared to Tanzania, rst of all the research method that they used for their theses was new to them. The majority of the students conducted qualitative interviews for their bachelor theses, something that they had not done earlier. They explained that in Tanzania the nursing undergraduates usually did quantitative research and they had little previous knowledge about qualitative research. They described that this new knowledge had led them to have a broader understanding of different research methods. This new knowledge also opened up possibilities of conducting further qualitative research and many of the students expressed increased interest in pursuing more research in the future.
So, I have gained access to knowledge about that. And I think it´s, it will help me even if now someone tell me can you help me to conduct a qualitative research? I'll be able to do that.
The students pointed out difference in the way the schedule and classes were organised in Sweden compared to Tanzania. They expressed these new approaches as positive; that classes started on time and that when cancellations were made that the students were noti ed. They also described that the time in class was limited and the students had a lot of time for self-studies. A contributing factor to this was that many exercises and materials could be accessed on-line and the students could therefore choose to study for example from home or from the library.
I mean that students have a lot of time for self-study, they don't spend a lot of time in class. They are exposed to libraries and online learning and other things.
A bene t of self-studies and not having to spend all day in class was explained by one student as enabling time to deepen knowledge and not just learn from what the teacher says. Furthermore, the student expressed that having seminars focusing on discussions put higher requirements on the students to have knowledge than just listening to the lecturer. The access to spaces for studying like the library and group rooms as well as good Internet and printing facilities were described as assisting learning.
Another aspect that the students emphasized was the good relationship and interaction between teachers or supervisors and students. They expressed that the relationship was more equal than what they experienced in Tanzania. The relationship between teacher and student was based on collaboration, and open discussions could be held where they could negotiate rather than the teacher always believing that they were right. This permitted the students to advocate for their ideas while accepting suggestions from their teachers. The teachers were not seen as superior and the students considered them as their friends.
But also, another thing the difference of interaction, between the teacher and the students. In Sweden it was very good that, at any time when you have a problem, you can try to contact the teacher at any time and she, he or she, will be able to give you the feedback in advance. But here we are trained in the sense of, the sense of, there is a very big gap between teacher and students.

Nursing role
Though the students didn´t participate in clinical practice, many of them interviewed nurses for their theses and in this way, they were presented to the work and role of nurses. They discovered that nurses in Sweden have an independent role and that each healthcare profession is respected for their competence. They also learnt that working with an interprofessional approach was essential for the bene t of the patient, as well as learning to work in a team. All the nursing students con rmed the importance of the independent nursing role which they expressed as sometimes lacking in Tanzania, where doctors often were seen as superior and wouldn´t respect the speci c knowledge of the nurse. They also talked about how nurses provided holistic care to patients in Sweden.
Yeah, I think some things I will…I will…I will use some things which I gain in Sweden, I will use in Tanzania also like the way how that the nurses are independent in their decision. And also, the way how they…they got…they provided the, the holistic care, you know in Sweden they provide the holistic care.
The students expressed that they would like to implement more holistic care in Tanzania but they also stated that a problem in Tanzania was that a nurse took care of many patients, sometime up to 30 and therefore it was hard for them to get the time to provide holistic care.

Gender roles
The students were exposed to the gender roles in the Swedish society as well as in speci c topics that some of them covered in their theses. They all declared that the status of women was higher and that gender equality was better in Sweden.
And also, another difference it is about empowerment and in Sweden women are so empowered compared to Tanzania They expressed that women were free to study and work with what they wished. A contributing factor that was mentioned was the parental leave in Sweden where men also stay at home with the children and this promoted gender equality. One student pursued a thesis about sexual harassment among nursing students and learnt about the laws in place to protect women and expressed wanting to improve these rights for women in Tanzania.

Dealing with a new environment
The nursing exchange students had countless new experiences in Sweden and although they described their experiences as mainly positive, they also faced challenges in everyday life as well as matters related to their studies. It was the rst time abroad for all of them and they encountered many differences in the new culture. This theme is divided into the following sub-themes; Challenges in a new culture and Support from student mentors.

Challenges in a new culture
One of the most noticeable aspects in the new culture that the students talked about was di culty in interaction with Swedish people. They noted that Swedish people are not so sociable with people they don´t know and rarely start conversations beyond greetings. They stated that it was hard to start conversations with people for example on public transport, which they pointed out as a big cultural difference compared to Tanzania, where they were used to having conversations with strangers on buses. That Swedish people were often busy and in a hurry was also a reason given for them being not so sociable.
In Sweden, the people they don't talk to strangers. That's the difference, but then we asked our mentors say that´s the culture, everyone is just busy, trying to be conscious with timings. Most of people are shy and ok, just get it. I was like, this is a new culture and I should not interfere with it.
However, the students recounted that it was easier to interact and get to know people in Sweden in speci c settings and with people who they had things in common, for example other students or when attending church. Their student mentors were mentioned as a good way to meet people, as they were introduced to their friends and families.
Another challenge that the students encountered was language barriers in some situations, although they speci ed that many people in Sweden could speak English and they often found people that they could communicate with. They described that it was mainly in supermarkets and when using the transportation system that they encountered language barriers. They often found someone who could help them, or they would use their phones to translate information.
Ah as I have said earlier Swedish people, they are very kind and humble so whenever we nd a communication barrier, we tried to reach out to potential people whom we saw. For example, most of challenges that we got it was it was when you were attending maybe a, in the supermarket choosing some groceries, some home groceries. So, and most of the things there were written in Swedish of which were aware, we are not con dent with the language.
An additional cultural difference that was described as a challenge was time management in Sweden, that things were done strictly on time and that you should be time conscious. They related that the public transport was very punctual, as well as coming to class on time and respecting deadlines. After adapting to this new attitude to time, the students perceived being on time as a good thing. They had a greater respect for time after returning to Tanzania and many expressed that they now sometimes became frustrated with the relaxed attitude to time in Tanzania. The students said that being punctual during their exchange had in uenced them and made them more aware of time.
Okay, it has…it has actually in uenced me so much and I have made a lot of positive changes into my life as a nurse but also as a person because I now make a, the on-time appointment ha ha Other challenges that were mentioned was the use of new technology such as paying with card instead of cash and also using cards in the transportation system. It took them some time to get accustomed to the transportation system as it operated very differently from Tanzania. The cold weather was also brought up as a challenge for them but which they got use to after a while.
So those are the challenges, weather, life system. And another challenge that I can say it was the language, language barrier it was challenge but we used the method which also was potential for us to, to get solutions and we coped with everything. Yeah, the other, those challenges but we're able to manage them and we learnt a lot from them yeah.
All the students concluded that they learnt a lot from the challenges that they faced during the exchange and that it had enabled them to develop coping skills. Being exposed to a new environment and a new culture had increased their con dence in knowing that they were able to manage in the future when confronting such challenges.

Support from student mentors
The Tanzanian nursing students were each appointed a student mentor in Sweden, these mentors were nursing students at the SRCUC. The student mentors and the Tanzanian students had email contact before the exchange and the student mentors answered questions that they had about Sweden. During the exchange, the mentors were available to help with whatever was needed, receiving this help and support was expressed by all the students as extremely bene cial to them.
Yeah really, very, it helped us a lot cause, you know mentors help us to, to get acquainted with the environment. Sweden was a, particularly Stockholm it was the new, new image to us. We have never been there before, so having mentors they helped us to at least be conversant with the transport in system, basics in cultural things some etiquette in, in transportation areas or in using escalators like that.
The student mentors were able to provide help in all areas ranging from practical issues to cultural concerns. The student mentors showed the Tanzanian students the way to the school and how to use the transportation system. One student related an incident when they had trouble using their laundry machine and called a mentor who came to their house to help. The students also called their mentors when they couldn´t understand Swedish labels in the supermarkets or to ask about cultural things. The student mentors were also important for the social life of the Tanzanian students; they visited places in Stockholm and arranged dinners together.

Developed competences
The students stated that they gained and learnt a lot from their exchange through the new environment that they were exposed to. They also developed on a personal level and the sub-themes related to this theme are: Interaction skills and Con dence and discovering potential.

Interaction skills
During their stay in Sweden the students got the chance to interact with people from different backgrounds. The students described that interacting with new people from a different culture was a challenge at rst but that resulted in enhanced skills in interaction. This provided the students with a broadened understanding of other perspectives and aided communication.
But also, I can easily communicate with the friends from abroad because I know how they behave mostly and how they perceive stuffs.
They made friends with people who had different mindsets and it in uenced how they perceived others.
They stated that it had made them more aware and tolerant and that it was now easier to interact with different people after returning to Tanzania. They concluded that this new ability and knowledge would help them in their work as nurses to communicate with patients from different backgrounds.
Con dence and discovering potential The students expressed that the exchange had increased their con dence, which bene tted them personally, but also for their future careers as nurses. Some of the students also discovered potentials which they weren´t aware of before the exchange. Discovering potentials also in uenced their futures and the student cited below proceeded to write a book about nursing after discovering skills in writing during the exchange programme.
I can simply say that myself and my exploration that I had in Sweden has greatly opened a lot of opportunities but also has restored me with such a con dence I never had before. Because I, since came from there, I recognised some potentials, whom I didn't know that I had before. For example, I didn't know if I was having such a good writing skills.
Many of the students explained that defending their theses in front of other people had increased their overall con dence as well as being more comfortable speaking in public. One student described that he now felt comfortable speaking in mass or other gatherings.

New career aspirations
The exchange programme in uenced the student's aspirations for their future careers as nurses as many of them saw possibilities that they had not been aware of before the exchange. They also expressed a passion for working with global health issues. This theme comprises of the two sub-themes; International opportunities and Working with global health issues.

International opportunities
Many of the students expressed that the exchange programme had changed their mindset about what they could work with and achieve as nurses, before participating in the exchange programme they were not aware of the potential of working internationally as a nurse. When they chose to study nursing, they had not considered the possibility of studying or working abroad but only thought about working in their own country.
I, before I went, I never realised that you can go work with anybody and I never realised that nursing was a global career. I thought that by studying to become a nurse maybe I can work in my country or in the place where I´ll be selected or to join with the government.
All the students expressed interest in working internationally and that the exchange had given them the skills to do so. The student exchange had facilitated them to develop abilities to adjust and cope with a new environment and they were therefore con dent to work abroad in the future. They stated that working internationally and being exposed to other people´s cultures would enable them to give better care to their patients.
…if I work internationally, I still, I´ll get a lot of experience and so I'll be able to use my skills that I got as an exchange student to work for other people. But also, I will be able to explore other people's cultures and use them and use the experience to care for the patients.
One student explained that after using online resources in Sweden he learnt how to nd online opportunities for work and studying. All the students said that they were inspired by the exchange to do further studies and research in the future.
Working with global health issues The students developed increased awareness and knowledge about global health and speci cally the UŃ s SDGs (1), which were part of the curriculum. They expressed increased passion and interest in working with global health issues, especially improving the health status of Tanzania.
So, I mean that´s one among the Sustainable Development, Development Goals to decrease, to improve the health status of the patients. So, I really, really like to improve but the health status of our people. But especially in the case of the mothers and child.
Many of the students expressed interests in certain areas like improving maternal and children´s health and the health of people living with Human Immunode ciency Virus (HIV). They had learnt about and become more aware of global health and implementing interventions globally to improve health. Patient education and preventative measures were mentioned as important for supporting health. All the students declared that the role of nurses is very important in promoting global health and that they felt responsible to play their part.

Discussion
The ndings revealed that the students experienced many new situations in Sweden and that they gained signi cantly 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; Bene ts of nursing student exchange, Challenges in nursing student exchange and global perspectives.
Bene ts of nursing student exchange Studies show that nursing students on exchange programmes re ect on practices and aspire to improve procedures in their own countries (24)(25)(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 bene t 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 in uenced by the independent nursing role and holistic care provided in Sweden and hoped to implement these practices in Tanzania. Similar to ndings were shown in a study by Maltby, de Vries-Erich and Lund (27) where the students re ected 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 bene tted 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 con dent 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 bene t 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 con dence and ability to speak publicly. This is a common feature among nursing students, where experiencing a new culture and leaving their comfort zone increases con dence(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 di culties 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 di cult and low interest from locals to interact has been reported (10,11,32). In the present study however, the students described the di culties 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 di cult 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 bene ts of nursing student exchange programmes is recommended but reported as often lacking and something to be improved (10,33).

Global perspectives
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 rst 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 rst 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 con dent 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)(35)(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 pro le area.

Methodological considerations
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. Con rmability 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 ndings being applied in another setting or group (22). Though the sample size was small, valuable, and consistent ndings 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 rst author's own pre-understandings and bias may have in uenced the questions chosen in the interviews and the interpretation of the answers, as she went on student exchange and found it bene cial, when studying at the SRCUC. However, the rst author strived to be as neutral as possible and open to the speci c experiences of the participating students.

Conclusion
The present study showed that the Tanzanian nursing students bene tted from their student exchange, both personally, as well as for their future careers as nurses. The ndings support earlier research that nursing exchange programmes and partnerships promote knowledge in global health and global nursing.
The exchange programme in Sweden enabled the Tanzanian nursing students to develop essential skills in global nursing such as cultural competence, holistic care and advocacy. Nurses play an important role in the health of people worldwide and developing adequate skills to meet patients' needs in today´s multicultural society is critical.
The ndings of this study can be used to understand the bene ts and challenges of student exchange programmes in order to develop them. The ndings indicate the importance of support during the student exchange programme, such as student mentors, to promote integration and enabling a positive experience. It can be recommended that other nursing student exchange programmes implement similar practices for support. The study presents that nursing student exchange programmes include a variety of experiences and these experiences can vary depending on the origin of the students and the country where the exchange programme takes place. More research is needed to improve and promote the bene ts of these programmes. Research examining the speci c experiences of nursing students traveling from LIC to HIC is especially needed as currently little research exists in this area. signed informed consent forms before the study was initiated and their participation was voluntary, and that withdrawal was possible at any time without consequences and that data and information on the participants was to remain con dential.

Consent for Publication
Not applicable

Availability of Data materials
The data generated and analysed during the current study are not publicly available due to con dentiality of the participants but can be available from the corresponding author on reasonable request.

Competing interests
There are no competing interests to report.

Funding
The project was funded by The SRCUC and KCMUCo who supported with time for report writing. The student exchange program was supported by The Linnaeus-Palme Foundation, and Erasmus+. The funders had no role in the study performed by the authors.
Authors' contributions TAJ: planning of study, data collection, data analysis and manuscript writing. ESA: planning of study, manuscript writing and editing.PK: planning of study, manuscript editing.JR: manuscript editing.JC: planning of study, manuscript editing.GB: project leader, planning of study, data interpretation and manuscript writing.All authors approved of the submitted version of the manuscript.