1. Introduction and rationale Healthcare students from all disciplines increasingly engage in international placements, during which they are exposed to a wide variety of clinical workplace settings. To modern-day healthcare students, the challenges of undertaking international placements may form an important contribution to their overall education: growing into professionals that are ‘fit-for-practice’, open to ongoing developments in the field of their profession and ready to face future healthcare challenges. During clinical placements healthcare students develop their professional competencies, according to predefined professional standards. By literally stepping out of their familiar local context into an international context of workplace learning, students might feel they are not only challenged on their professional competences, yet also on a more personal level, when they encounter circumstances very different from the ones they have come to know during their education so far. Hence, an international learning experience may not only change their professional outlook, but also affect personal behaviours, such as the way students learn to deal with their own insecurities and manage (implicit) expectations. At the same time students are challenged to overcome personal insecurities and to adjust to the new clinical environment within relatively short time, so that they become ‘legitimate participants’ in practice (Wenger, 2010) that can actively engage with the local team and participate in patient related tasks in order to learn from their clinical environment (Dornan et al, 2015). For these reasons, educational programmes that offer international placements in healthcare settings seem to value these international internship experiences as they enable both personal and professional growth for students. Yet, there is little empirical evidence about the pitfalls and benefits of international healthcare placements in relation to development of professional identity (Van der Zwet et al, 2011) or students’ learning trajectories (Teunissen, 2015). When engaging in international placements, a number of key differences may affect student learning, such as being in an unfamiliar learning environment, having to follow different protocols and rules, whilst being potentially hindered in communication by linguistic and cultural barriers. There is evidence that students are more likely to engage in practice once they have established a supported role in the workplace (Chen et al, 2014; Duvivier et al, 2014). We hypothesize that this need for ‘supported participation’ (Dornan et al, 2015) is even larger when students engage in international placements, since the student is stepping into an unfamiliar workplace setting where different criteria and expectations apply with regard to professional practice (Wenger, 2010). Sheehan and colleagues (2005) have found that for real learning to occur, the initiation phase of interns in a new workplace environment needs to be completed successfully. Their study presents a model of how interns participate in clinical settings (Figure 1), clearly showing the different influences of the team, clinical supervisor and student on development of work-based learning (Sheehan et al, 2005; Sheehan et al, 2012). For students in an international context social interaction with the local healthcare team seems highly important in support of real patient learning (Dornan et al, 2015; Van der Zwet et al, 2011). Patient-related learning in practical settings relies on the interaction between a learner and a patient, and can be facilitated or limited by a practitioner (Yardley et al, 2013). Although in the international context language barriers, cultural backgrounds or different expectations might hinder professional interaction between student and supervisor (Newton, Pront & Giles, 2016) evidence shows it is very important to involve the student in patient-related tasks and team activities, as only active engagement will allow the student to become a full participant in professional practice (Dornan et al, 2015; Sheehan et al, 2005).

When studying the initiation phase of clinical practice, it is unclear how students are received and introduced to their new clinical environment in order to adjust. Students need to realign with their social learning context, or, in this case, the international clinical setting to create learning opportunities (Chen et al, 2014; Wenger, 2010), yet might find it hard to establish the right level of participation. They can feel restricted by local rules and healthcare regulations, communication problems or other barriers to participation and learning in the international context (Sheehan et al, 2005; Steven et al, 2014). Since learning conditions are determined by the clinical setting (Van der Zwet, 2011), these should clearly allow for ‘legitimate peripheral participation’ (Lave and Wenger, 1991; Van der Zwet, 2011), engaging students in novel activities to acquire new knowledge, skills and develop a professional attitude (Wenger, 2010). We hypothesize this will most certainly hold true for undergraduate healthcare students, engaging in international clinical placements. Therefore, the purpose of this exploratory research is to investigate initiation of international clinical placements from a student’s perspective.

Theoretical framework / educational background Underlying this proposal is the social learning theory on ‘communities of practice’ as described by Lave and Wenger (1991). A community of practice, such as a healthcare clinic, can be described as a learning system. To become a member of this community, students must be “able (and allowed) to engage productively with others in the community” (Wenger, 2010). In other words: active student participation is core to the meaning-making processes underlying contextual, social learning (Dornan et al, 2015; Teunissen, 2015; Wenger, 2010). Yet, upon entering a new clinical environment, students are faced with several factors that influence their ability to engage in practice, or, in other words: the “active and dynamic negotiation of meaning over time” (Wenger, 2010). Part of this ‘meaning making’ can be done through building relationships and engaging in interaction with other professionals in the workplace, supporting professional development (Sheehan et al, 2012). Although it is unknown whether the model for intern participation (Sheehan et al, 2005) holds true for undergraduate students from allied health disciplines, it certainly outlines a relevant theory to further investigate the initiation of healthcare students as part of their international clinical placement. We hypothesize this introduction to practice should take no longer than one month, after which workplace learning starts.

1. Aim of research Our study is aimed to explore how undergraduate physiotherapy students are received, introduced and adjust to different clinical internship settings worldwide. This qualitative exploratory study will be aligned with regular internship procedures as part of the BSc. educational programme of the European School of Physiotherapy at the Amsterdam University of Applied Sciences in the Netherlands. By following first year undergraduates closely and registering their experiences upon entering and adjustment to their first clinical placements, we hope to distinguish how initiation might lead to different student’ experiences and create a better understanding of how initiation impacts on workplace learning. We will investigate individual student’ experiences during the first month of international placements, and explore how these initial experiences can be indicative of a successful learning experience. Therefore, our study will focus on the following research question: how do undergraduate physiotherapy students experience the initiation of clinical placements in different healthcare settings worldwide? The results of this study are expected to inform future educational programmes in allied health care, by creating insight about the initiation of clinical workplace learning in different healthcare settings worldwide.
2. Target group / participants Within the Amsterdam University of Applied Sciences (Faculty of Health) international health care students engage in local and international placements as part of their undergraduate training. At the European School of Physiotherapy (ESP), around 220 students from different backgrounds and nationalities follow an accelerated honours programme (240 ECTS) to obtain their Dutch Bachelor degree in Physiotherapy after three years of intensive study. We are interested to find out how undergraduate physiotherapy students are received, introduced and adjust to different clinical internship settings worldwide, as this initiation of practice might influence on students’ learning experiences in the workplace. We will invite all students from the first year cohort of the ESP programme (n=54) that are admissible to enter their first clinical placement in June 2018, to capture their personal and professional experiences during the initiation into clinical practice. To do so, students are asked to make individual audio entries with their smart phone, in which they account for their experiences during their first month of placement. To structure the information gathered, we have designed an instruction sheet for audio diaries (see attachment). Students are free to choose the moment and amount of time spent on their audio entries, for which they can follow the prompts indicated on the sheet. They will be asked to create audio entries minimally twice a week during the first four weeks of clinical placement, with additional entries allowed. Based on previous studies (Crozier & Cassell, 2015; Helmich et al, 2017) we estimate 10-12 student participants will be needed to ensure data saturation. As we would like to control for potential dropouts due to the duration of this study, we will aim for 15 participants to start with, which still enables us to include all data to be part of our analysis. In case initial results will show that data saturation has not yet been reached, we will include more student participants from the same cohort, who were unable to meet formal admissibility criteria of the ESP programme in time for the June placements but instead will be scheduled for November 2018.
3. Design and procedure Data collection for this study will take place in June and July 2018. All students from the first year cohort of the ESP programme that are eligible for their first clinical placement during the summer of 2018 will receive a personal invitation via e-mail, together with an information letter about the proposed research (see 7). Student participants must sign informed consent, after which they will receive further instructions and information about research procedures. They are invited to keep a personal audio diary during the first month of clinical placement. This audio diary is meant to capture their experiences during the initiation of clinical practice. Students are asked to share their thoughts about the following prompts:
4. What have you been doing?
5. Who did you work with? During what activities?
6. What have you learned? Can you provide specific examples of this?
7. Were there any difficulties?
8. What did you like? The participants will be asked to use their smartphone to create and share individual audio recordings via data streaming through an application (‘Easy MP3 Streaming Server’) that must be downloaded, according to instructions, before start of the research. This data stream will be connected to the main researcher, who will upload the MP3-files directly into the password-protected network-environment of the AUAS on SURF drive. All audio recordings will be transcribed and coded, before being destroyed.
9. Methods We will use audio diaries to create more insight in student’ experiences during the initiation of clinical placements. This exploratory study follows a qualitative design, with data collection taking place in June/July 2018. Students will be asked to share their thoughts about experiences within the clinical setting, minimally twice a week, during their first month of practice, following the prompts described above. These audio entries may vary in length, as they should allow for rich narrative data (Monrouxe, 2009). A small pilot study will precede actual data collection. The main researcher will further inform and instruct the students about the purpose and procedures of this research before data collection starts.
10. Analysis We will apply thematic analysis to analyse the qualitative data. All individual audio entries will be transcribed verbatim. Two researchers (main researcher and research assistant) will individually read the transcripts and perform basic coding, following an iterative process of constant comparison. After initial categories have been established, they will then apply an experience-centered approach to thematic analysis (Worth, 2009) to further analyze the outcomes. Once key elements have been identified, initial results will be shared with the research team to resolve potential conflicts in coding and interpretation, and establish consensus on identified categories before moving on to the conceptual level. All data will be categorized using qualitative data analysis software (Atlas.ti).
11. Ethical considerations Sampling All first year students of the European School of Physiotherapy in Amsterdam, the Netherlands (n=54) will be invited to participate in our study, provided they are admissible for their internship in June 2018. This cohort represents students (21M/33F) from different backgrounds and nationalities (6 Dutch/39 EU/9 non-EU), with an average age of 23 years (ranging between 18-41 years). Additional details about placements (such as country and healthcare setting, see Appendix) will be taken from the online database of the School of Physiotherapy at the AUAS, for which students need to sign informed consent. We will include maximally 15 participants, of which 10 students within private practice setting and 5 students within institutions (such as hospital or rehabilitation centre). Participants will be selected on a ‘first come, first serve’ policy, as we expect the first respondents to be most interested therefore likely to commit to research procedures required. By studying undergraduate students who are entering their first clinical placement, we hope to gain more insight on the initiation of clinical placements worldwide, by means of capturing student’ experiences during the first month of physiotherapy practice.

Justification of research Workplace learning is of great importance within health professions education, as it contributes to competence development of healthcare students, whilst at the same time preparing future professionals to be flexible and adaptive to ongoing developments in their field. Due to the globalization of health professions education, healthcare programmes are facing an increasing number of international students, incoming as well as outgoing. The proposed study aims to create better insight in the initiation practices during international internships as experienced by undergraduate physiotherapy students, potentially leading to educational changes influencing workplace learning within their professional training.

Information and consent The proposed study is aimed to expose new, relevant information for future educational programmes in the field of physiotherapy and other allied health professions, in relation to the initiation phase of (international) placements. All first year students from the European School of Physiotherapy (ESP) will receive an information letter and informed consent form via personal e-mail, with an invitation to participate in this research. They will have two weeks to respond to this invitation, after which the main researcher (MW) will contact them again via e-mail or in person. MW works as clinical coordinator at ESP, thus has access to the school’s database. She is not involved in teaching this cohort of students, nor does she play a role in pass/fail decisions regarding individual clinical placements. Participation in this study is completely voluntary and should hold no disadvantages for students other than time investment, although the audio recordings might make the individual student reflect upon situations experienced, potentially increasing stress or pressure. On the other hand, these reflections might also support individual adjustment to practice, creating opportunities for learning. Students will be compensated for their time investment (estimated at 2 hours, in one month’s time) by receiving a personal iTunes gift card of 25 Euros via e-mail after their participation is completed. All students are requested to sign informed consent before data collection starts. Students are informed that their audio recordings will be exchanged via a free downloadable Application on their personal smartphone, enabling direct upload into a protected network environment and MP3 files will be destroyed after transcription, making sure that no personal risks are involved. All data gathered during this study will be handled with great care to respect individual privacy. Recorded data obtained is considered private and will not be communicated with third parties. All audio recordings will be transcribed verbatim and coded. Only the main researcher (MW) will have access to individual recordings and to the key of codes, thus to traceable data. The other members of the research team (RD, SR, PT and ED) only have access to coded data. Students are informed about the fact that they can reconsider their options at any time and decide to no longer participate in this study. Participation is voluntary and this decision will have no (personal or professional) consequences for the participant. Research data obtained before this moment will be destroyed immediately after and no longer be used for purpose of this study. Coded research data belonging to this study will be safely stored and kept at Maastricht University for maximally 10 years, in accordance with the Dutch Code of Conduct in Research (VSNU), before being destroyed. All research data will be made anonymous before publication. In case any data obtained in this study might be re-applied for follow-up studies conducted by the main researcher, related to similar research questions, participants will be informed timely. By signing the informed consent form students agree to these conditions.