DOI: 10.34894/y8msn3
title: Study 4: Student’ experiences during clinical placement abroad: a qualitative rich pictures study
title: Miriam Wijbenga - PhD Project data for study 4

description: &lt;B&gt;1. Introduction and rationale&lt;/B&gt;&lt;BR&gt;&lt;BR&gt;
Workplace learning in healthcare is most effective when students perceive a supported role in the clinical environment (Dornan et al, 2014, 2019). Student support is especially relevant during placement abroad, to learn about local, often unfamiliar, healthcare practices and overcome challenges to participation in patient-related care or team activities (Acharya et al, 2015; Sheehan et al, 2012; Steven et al, 2014). Being able to actively participate in practice is crucial for students to arrive at workplace learning, with students going through different phases of orientation and adjustment before being able to contribute to patient care, and becoming ‘legitimate’ part of the local community of practice (Sheehan et al, 2005; Wijbenga et al, 2020; Wenger, 2010). Yet, there can be multiple reasons why this ‘learning-by-doing’ may be limited during placement abroad. In a recent study, we have explored a variety of professional and personal challenges that influence on student participation and wellbeing during placement abroad (Wijbenga et al, 2023). Language and cultural background are only part of many challenges that influence learning interactions between student, healthcare professionals, patients, and peers in the clinical workplace (King, 2019). Apart from the more obvious examples, students may also encounter specific issues related to living alone in an unfamiliar environment, feeling isolated whilst being physically away from friends and relatives, lack of financial resources, or other (Wijbenga et al, 2023). &lt;BR&gt;&lt;BR&gt;
One way for educators to support student’ experiences during clinical placement is by helping them establish support networks that reflect social interaction between student and local healthcare team, including peers (Atherley et al, 2020). Offering tailored guidance in the workplace, creating structured learning opportunities including a supportive learning environment helps students to overcome challenges to workplace learning (Yardley, 2012; Matus, 2020). Although undergraduate students generally demonstrate proactive behaviours such as feedback and information seeking when adjusting into a new workplace, they have difficulty negotiating individual learning tasks (Atherley et al, 2022). To clarify local workplace culture and norms, and better understand educational and professional approaches, students should actively engage in learning conversations with other professionals (Van der Zwet et al, 2011; Wijbenga et al, 2021). This may be difficult based on previous learning experiences, personal and contextual factors that challenge their perspective and position as an intern, leading them to take a more peripheral or central role (Wenger, 2010).&lt;BR&gt;&lt;BR&gt;
We believe that student participation in workplace learning is a complex process, determined not only by the student and their supervisor, but also involving other members of the community of clinical practice, including peers (Olmos-Vega et al, 2018). To better understand the complexity of challenges regarding the personal, social and professional context of students, and how this affects their learning, participation and therefore their wellbeing in the workplace, we will explore the following question: 
How do personal and professional challenges affect student’ learning, participation and wellbeing during clinical placement abroad?&lt;BR&gt;&lt;BR&gt;
&lt;B&gt;2. Aim of research&lt;/B&gt;&lt;BR&gt;&lt;BR&gt;
This study aims to explore the experiences of students aims to explore the personal and professional experiences of physiotherapy students during placements abroad, to learn how they deal with personal and professional challenges which influence on their learning, participation and wellbeing in the workplace. The study is part of a larger PhD project on healthcare students’ learning during international placements, and therefore follows up on previous findings. Understanding the complexity of workplace learning from a student’s perspective, especially in an unfamiliar context such as during placement abroad, is likely to provide educators and clinical supervisors with suggestions on how to start a learning conversation, and create optimal support during student placement abroad.&lt;BR&gt;&lt;BR&gt;
&lt;B&gt;3. Target group / participants&lt;/B&gt;&lt;BR&gt;&lt;BR&gt;
At the European School of Physiotherapy (ESP) at the Faculty of Health, Amsterdam University of Applied Sciences (FG-AUAS), students follow an intensive three-year bachelor programme (BSc., Hons). During their undergraduate training, students are required to complete four different clinical placements, of which minimally two must take place outside the Netherlands. Clinical placements can take place in a variety of healthcare settings, ranging from private practice settings to academic hospitals and rehabilitation centers. During a ten-week period the level of independence regarding working activities, supervision and complexity of care will vary, in accordance with the phase of education. Supervision is generally provided one-on-one by professional physiotherapists, in collaboration with other healthcare providers. The student’s mentor monitors their learning process from a distance during placement.&lt;BR&gt;&lt;BR&gt;
&lt;B&gt;4. Design and procedure &lt;/B&gt;&lt;BR&gt;&lt;BR&gt;
Following a qualitative study design, we will apply a combination of the rich pictures method and semi-structured interviews to understand how physiotherapy students navigate the complexity of the workplace during clinical placements abroad (Cristancho, 2015; Cristancho & Helmich, 2019; van der Goot et al, 2020). By using a combination of drawings and interviews we can take a more holistic approach towards student experiences (Velthuis et al, 2021; Wijbenga et al, 2020). We expect the rich pictures drawing tool will reveal more detail on the potential disruptions or challenges regarding the personal, social and organizational context of healthcare students transitioning into professional practices across borders (Cristancho, 2015). &lt;BR&gt;&lt;BR&gt;
Data collection and analysis will follow a constructivist grounded theory (CGT) approach, in particular the principles of purposive sampling, iteration, constant comparison, open, focused and selective coding, memo-writing and co-construction. This allows us to explore the complex relation between personal, social and professional challenges that influence on student’ learning, participation and wellbeing in the clinical workplace. The CGT is an appropriate method to come to understand social phenomena that are complex in nature, making use of the co-creation of data between participants and researchers (Charmaz, 2014; Watling & Lingard, 2012). Using a combination of the visual tool and interviews will enable us to explore students’ experiences and struggles in more detail (Cristancho et al, 2015; Cristancho & Helmich, 2019). The interdisciplinary constitution of our research team is likely to contribute to the interpretation of the data, as it represents multiple backgrounds and perspectives. To strengthen our design and analysis of results, we have added WG to our team for her expertise in using the rich pictures drawing tool in her previous research (van der Goot et al, 2020).&lt;BR&gt;&lt;BR&gt;
&lt;B&gt;5. Methods&lt;/B&gt;&lt;BR&gt;&lt;BR&gt;
&lt;I&gt;Sampling&lt;/I&gt;&lt;BR&gt;&lt;BR&gt;
We will follow a purposive sampling strategy, involving undergraduate students from the European School of Physiotherapy (BSc.) at the Faculty of Health Amsterdam University of Applied Sciences, to cover a variety of factors that may influence on workplace learning, such as preferred language, gender, age, level of internship and workplace setting (Wijbenga et al, 2023). These data are all shared within the online database for student placements within the FG-AUAS, and thus accessible to the research team, as the principal investigator of this study (MW) holds free access, being the clinical coordinator of the ESP programme. Although MW coordinates student placements worldwide, she is not involved in any pass/fail decisions related to internship grading of the student participants. &lt;BR&gt;&lt;BR&gt;
Firstly, we will invite all ESP students eligible for summer placement between June-August 2023 (n=80) by means of an informative email on behalf of the research team, with an open invitation to participate in our study. MW will follow-up on this invitation within two weeks, to answer questions related to the research project and provide additional information, if necessary. Participation will be on a voluntary basis, with written informed consent being taken before the start of data collection. 
A second round of sampling will take place among ESP students eligible for September placement (n=13), with a potential third round including the November placements (n=60), to allow for an iterative process of data collection and analysis, focused on emerging theory. &lt;BR&gt;&lt;BR&gt;
&lt;I&gt;Data collection and storage&lt;/I&gt;&lt;BR&gt;&lt;BR&gt;
Data collection for this study will take place between June 2023 - February 2024. The interview sessions will be organised and conducted in an iterative manner, following the regular study programme of student participants. Individual sessions are expected to take between 60-90 minutes and will take place at the faculty building. During the first 30 minutes, students will be asked to visualize an exciting and a challenging experience encountered during clinical placement abroad, in a ‘rich picture’ drawing (refer to Appendix 1 for instructions). Rich pictures are self-selected representations of complex situations or environments, such as the clinical learning environment. This drawing may include objects, metaphors, symbols, interactions, and people involved. In the second part of the session, we will conduct interviews (refer to Appendix 2 for the interview protocol) to learn more details about the drawings created, and what they represent. Also, we will focus on what this means in relation to personal and professional wellbeing of students during clinical placement abroad. This interview part will be audio recorded. After the session, the audio recording will be transcribed verbatim and converted into pseudonym, before being shared with the individual participants for member check (Velthuis et al, 2021). The drawings will be pseudonymized and stored separately from the interview data, so that we can scan and store these at a later stage of the research process, and avoid the connection to individual participant sessions based on time and date. In addition, we will take care to remove any metadata before storage, to minimize traceability. All materials will be safely stored into the password-protected network environment of the Amsterdam University of Applied Sciences (AUAS) for the duration of the project (see also 7). Only MW will hold access to raw data, including participant characteristics, as she will conduct the interviews and perform transcription. &lt;BR&gt;&lt;BR&gt;
&lt;I&gt;Privacy protection &lt;/I&gt;&lt;BR&gt;&lt;BR&gt;
Participation in this study is completely voluntary. Participants may always, at any time, reconsider their options. If a participant decides to stop before the transcription of data has been completed, their interview data, including the drawings, will be destroyed and no longer be considered part of the project, without any (personal or professional) consequences. This has been indicated in the information letter for participants. In case the participant decides to withdraw after the transcript has been converted into pseudonym, the audio recording will be destroyed according to protocol, yet the transcript and drawings will still be used for the purpose of this study, since this data can no longer be traced back to individual participants. No further interventions scheduled as part of this study. 
The audio data will be destroyed once participants have had the opportunity to check the pseudonymized transcript. Data obtained in this study cannot be traced back to individual participants, except by the data officer at the AUAS and MW, who will hold access to the key of codes. For publication we will only use data that is untraceable to individual students.&lt;BR&gt;&lt;BR&gt;
&lt;I&gt;6. Analysis&lt;/I&gt;&lt;BR&gt;&lt;BR&gt;
Data collection and analysis will follow a constructivist grounded theory (CGT) approach (see also 4). All data will be rendered pseudonymous before further analysis. Transcripts will be shared with individual participants for member check. Both the drawings and interview data will be interpreted by the research team in an iterative process, based on sensitizing concepts informed by literature and research findings from previous studies conducted in this area of research, following the principles described above (Charmaz, 2014; Cristancho & Helmich, 2019). The researchers will use Atlas.ti (latest version) to support qualitative data analysis. Since MW is familiar with the educational setting and knows all student participants, due to the nature of her work at ESP, and because she is a trained physiotherapist herself, she will be able to level with the clinical experiences accounted for. To guarantee reflexivity during the research process, MW will keep an audit trail, including memos taken during data collection and analysis (Olmos-Vega et al, 2022). Saturation will be reached once no new or contrasting findings come to light.&lt;BR&gt;&lt;BR&gt;
&lt;I&gt;7. Ethical considerations&lt;/I&gt;&lt;BR&gt;&lt;BR&gt;
&lt;I&gt;Sampling&lt;/I&gt;&lt;BR&gt;&lt;BR&gt;
An estimated number of 12-15 student participants from the European School of Physiotherapy at the Faculty of Health, Amsterdam University of Applied Sciences will be purposively selected to participate in our study. All undergraduate students at ESP who will be undertaking a clinical internship outside The Netherlands between June – December 2023 are eligible as prospective participants in this study. &lt;BR&gt;&lt;BR&gt;
&lt;I&gt;Justification of research&lt;/I&gt;&lt;BR&gt;&lt;BR&gt;
This study is part of a larger PhD project on healthcare students’ learning during international placements, and will follow up on previous research findings. Understanding the complexity of challenges regarding the personal, social and professional context of students, and how this affects their learning, participation and wellbeing in the clinical workplace, especially in an unfamiliar context such as during placement abroad, is likely to provide educators and clinical supervisors with suggestions on how to establish a learning conversation, and create optimal support during workplace learning. Results may support healthcare institutions and educational programmes in working together when organizing international placement experiences. &lt;BR&gt;&lt;BR&gt;
&lt;I&gt;Participant information and consent&lt;/I&gt;&lt;BR&gt;&lt;BR&gt;
Selected students will receive an information letter and informed consent form via personalized email (see also .5-sampling). They will be informed that participation is completely voluntary and they can withdraw at any time. All data gathered during this study will be handled with great care to respect individual privacy and will not be communicated with third parties. Participants will be compensated by means of a personal online gift card (15 Euro) after the interview session. Written informed consent will be taken before data collection starts, allowing for audio recording of the interviews by means of an external Dictaphone and scanned copies of the drawings. No video material will be collected.&lt;BR&gt;&lt;BR&gt;
If, due to the nature of experiences discussed during the interview, participants might need to seek additional support, they will be referred to the student counsellor or confidential person at the Amsterdam University of Applied Sciences, who will be informed of our project.&lt;BR&gt;&lt;BR&gt;&lt;I&gt;Data management and storage&lt;/I&gt;&lt;BR&gt;&lt;BR&gt;
Data management will be in accordance with the Dutch Code of Conduct in Research (VSNU). Publication will only include research data that cannot be traced back to individual participants. Note that data obtained in this study might be used for secondary analysis in follow-up studies conducted by the principal researcher, in relation to similar research questions. By signing the informed consent form participants agree to these conditions.&lt;BR&gt;&lt;BR&gt;

All research data will be safely stored within the the secured research repository environment of the Amsterdam University of Applied Sciences/University of Amsterdam (hosted by SURF under Dutch license), in collaboration with the privacy officer of the Faculty of Health at the AUAS. Audio data will be transcribed verbatim, and transcripts converted into pseudonyms before being made accessible to other team members, for the purpose of coding and analysis. Only the principal researcher (MW) and the data steward of the FG-AUAS will have access to the key of codes, stored separately, and thus to traceable data. Upon completion of the study, the pseudonymous research data will be safely stored and kept at the repository of Maastricht University for maximally 10 years after collection, before being destroyed. &lt;BR&gt;&lt;BR&gt;