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. By literally stepping out of the familiar educational framework into a different frame of professional practice, students might feel they are thrown in at the deep end. During clinical placements healthcare students can develop their professional competencies, according to predefined professional standards. Yet, when being introduced to an international placement, students might find circumstances very different from the ones they have encountered during their education so far. At the same time students are challenged to overcome personal insecurities and to adjust to the new clinical environment, so that they become ‘legitimate participants’ in practice (Wenger, 2010) and can actively engage in patient care (Dornan et al, 2014). An international learning experience may not only change their professional outlook, e.g. on how students experience professional autonomy as well as potential boundaries of their own profession, but also affect personal behaviours, such as the way students learn to deal with their own insecurities and manage (implicit) expectations. Therefore, 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. An international placement tends to differ markedly from local workplace settings. As a result, a learning environment outside familiar contexts might challenge students’ beliefs on illness and health. Often, hierarchy and task division are different within workplace settings, thus potentially enhancing the influence of existing barriers and facilitators to students’ learning (Sheehan et al, 2005). Factors that encourage workplace learning include: perceived responsibility, guidelines and procedures, supportive interactions with supervisor and/or staff, and proactive learning behaviour (Billet, 2004; Duvivier et al, 2014; Sheehan et al, 2005). On the other hand, workplace learning can be hindered by difficulties in communication, time constraints, lack of (practical) guidelines, and supervisor and learner behaviours, such as lack of participation or opportunities for practice (Attrill et al, 2016; Chen et al, 2014; Duvivier et al, 2014). A number of key differences may affect student learning when placed in an international context, 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, and without having established a local support network. There is an ongoing discussion of how to improve international students’ learning in clinical settings (Attrill et al, 2016), in relation to both incoming and outgoing students. As “learning is not an isolated activity in a teaching setting, but an ongoing process in interaction with the demands of the workplace” (Van den Eertwegh et al, 2013), one of the main concerns in workplace learning is the professional interaction between student and clinical teacher. For students in an international context social interaction with the healthcare team seems highly important in support of real patient learning (Van der Zwet et al, 2011), which relies on the interaction between a learner and a patient, facilitated by a practitioner (Yardley et al, 2013). Language barriers, differences in cultural backgrounds or simply different expectations can hinder professional interaction between student and supervisor in the international context (Newton, Pront & Giles, 2016). Workplace learning requires participating in novel activities (Wenger, 2010), yet is strongly related to context (Berkhout et al, 2016) whilst influenced by interaction with other healthcare professionals (Dornan et al, 2014). The student has to actively engage in healthcare-related tasks and responsibilities to be able to involve in patient care, engage with the team and become a real participant in professional practice (Dornan et al, 2014; Sheehan et al, 2005). Due to national health care policies, local rules and regulations, patient safety issues or simply the limited duration of clinical placements, healthcare students might find it hard to establish the right level of participation within an international setting. Evidence shows students are more likely to engage in practice once they have a supported role in the workplace (Chen et al, 2014; Duvivier et al, 2014). According to Sheehan and colleagues (2005) a student’s participation and therefore learning depends on the introduction to the new workplace setting, which is influenced by the team, supervisor and personal attributes, such as clarity of roles and expectations (Sheehan et al, 2005). In an international context, this need for a clear initiation into practice can be even larger since the student is stepping into an unfamiliar workplace setting, where different criteria and expectations apply with regard to professional practice (Wenger, 2010). Most of the existing educational research on international placements is related to the medical domain (Kumwenda et al, 2015; Lukolyo et al, 2016; Niemantsverdriet, 2007) and the field of nursing (Attrill et al, 2016). The question remains whether this evidence can be transferred to the domain of allied health professions. There is reason to believe international students have different needs and expectations when it comes to supervising in the workplace (Attrill et al, 2016; Newton, Pront & Giles, 2016). Therefore, the purpose of this exploratory research is to investigate workplace learning in international healthcare settings, with a focus on student’ participation during initiation in practice.

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, 2014; 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). Sheehan and colleagues (2005) have published a model for intern participation in postgraduate medical settings in New Zealand hospitals, which distinguishes between the ‘initiation’ and ‘maintenance’ phase (Figure 1). According to the authors, the initiation phase of interns in a new workplace environment needs to be satisfactorily completed for the maintenance phase to begin and actual learning to occur. The model shows how involvement in patient care tasks and engagement with the clinical team will lead to intern participation, which must be encouraged continuously during the maintenance phase to further increase confidence and development of professional identity and reasoning skills (Sheehan et al, 2005). This model is supported by later evidence from Van der Zwet and colleagues (2011) on general practice clerkships, showing the need for a ‘developmental space’ as a prerequisite for workplace learning. The authors describe the concept of ‘developmental space’ as the available space experienced by medical students for personal growth during their professional participation, which is related to development of professional identity (Van der Zwet et al, 2011). Although it is unknown whether Sheehan’s model for intern participation (2005) holds true for (undergraduate) healthcare students from different disciplinary backgrounds, it certainly outlines a relevant theory to investigate the introduction of students into their new clinical environment, leading to the initiation of workplace learning. The opposite is also true: what will come of learning if the individual student engages in a short-term international clinical placement, quite common in nowadays healthcare education programmes, and is not able to move beyond this initiation phase due to different factors involved (Sheehan et al, 2005)? Clinical internships within the health care professions generally vary from several weeks up to months, with the purpose of students working on and developing their professional competencies over different placements over time. Even though part of workplace learning takes place based on observation, healthcare students strongly rely on their participation in practice (Dornan et al, 2014) to develop clinical skills. Learning in an international context involves ‘legitimate peripheral participation’, a concept introduced by Lave and Wenger (1991; Van der Zwet, 2011) explaining how students’ experiences of practice are bound by the process of realignment with their social learning context, or, in this case, clinical setting (Carrie Chen et al, 2014; Wenger, 2010). In general, students need to engage in novel activities to acquire new knowledge, skills and develop a professional attitude (Wenger, 2010). On the other hand, they might find themselves 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). Learning conditions are determined by the clinical setting (Van der Zwet, 2011), as can be seen from a pilot study with junior doctors who showed increased participation during short-term clinical rotations, as a result of experiencing role clarity, based on discussion of individual learning objectives with their seniors prior to ward rounds (Acharya et al, 2015). This is in line with the concept of ‘legitimate peripheral participation’ (Lave and Wenger, 1991). The purpose of this research is to investigate workplace learning in international healthcare settings, with a specific focus on different elements of initiation to the workplace that influence on actual student’ participation in practice. Similar uncertainties during placement may lead to very different learning outcomes, based on previous experiences, perceived support and current interactions (Westerman et al, 2013). 2. Aim of research This prospective research aims to improve the initiation phase of allied health care students’ learning in international workplace settings, during different stages of training. The purpose of this study is to explore participation of students during the initiation phase of internships in international workplace settings as part of their undergraduate allied health professions education. We will use the model, developed by Sheehan and colleagues (2005) for postgraduate medical settings as the starting point for this qualitative study, as it outlines the transition from initiation into maintenance phase in new workplace settings, yet without providing details on the expected pitfalls and duration of this initiation period (Sheehan et al, 2005). Little is known about why students might become ‘stuck’ in this initiation phase of work placements. Therefore, the main focus of our exploratory research will be on the interaction between student and local healthcare team, as seen from a student’ perspective, especially during the first weeks of international placements.

Main research question How does the interaction between allied healthcare students and local healthcare teams during initiation of international placements support or inhibit learning?

Sub question Why do allied healthcare students actively engage in practice or refrain from participation during international placements? 3. Target group / participants Within the Amsterdam University of Applied Sciences (Faculty of Health) students from allied health professions engage in local and international placements as part of their undergraduate training. The AUAS - Faculty of Health includes BSc. and MSc. educational programs in Physiotherapy, Occupational Therapy, Exercise Therapy and Nursing, training over 3300 allied health care students in total. Healthcare students from different disciplines will be interviewed individually during their preparation (one-two weeks before) and after their first month of international placements, following semi-structured interviews via Skype. The interview guide will be developed and piloted by the research team before data collection starts (Ramani & Mann, 2015). In the allied health context students are often supervised in one-on-one situations, whereas in medical education supervision in the workplace this is less common. Potential differences between different healthcare disciplines will be explored to analyse how and when students become part of the community of practice during the initiation of international placements. Initially, we will aim for maximal variation of sampling, based on student characteristics (gender, age, nationality), health care discipline, year of study, and number of international placements completed. We estimate 12-16 student participants at the Faculty of Health from the Amsterdam University of Applied Sciences (AUAS) will need to be purposively sampled, covering different healthcare disciplines. Further, we will apply theoretical sampling of additional participants to ensure theoretical saturation is reached. Participants will be selected from a total group of approximately 200 undergraduate students undertaking an international internship of minimally 10 weeks during the academic year 2017-2018. Internship periods of shorter duration will be excluded from this research. 4. Design and procedure This qualitative, exploratory research will be conducted at the Amsterdam University of Applied Sciences (Faculty of Health), involving undergraduate students in the allied health professions. The study will follow regular internship procedures, as these internships are embedded in the curricula of the different programs involved. One-on-one interviews will be scheduled according to the internship periods of the student participants. Healthcare students from allied health care disciplines will be interviewed twice: once during their preparation phase (one-two weeks before the start of internship), and once at the end of the first month of placement. These semi-structured interviews will take approximately 30-45 minutes and will be conducted via Skype. We will use MP3 Skype Recorder 4.20 to record Skype calls’ audio streams. This freeware programme offers automatic or manual audio recording capabilities for non-commercial purposes, and can store compact mp3 files directly onto a password-protected personal computer/laptop, with a back up via SURFdrive (the protected network-environment of the Amsterdam University of Applied Sciences). No video-recordings will be made during the Skype interviews. Data collection will take place between November 2017 and August 2018, without any further interventions as part of this study.

1. Methods A qualitative research design will be used for this exploratory study. Data collection will take place by means of individual, semi-structured interviews via Skype, taking approximately 30-45 minutes. The research team will develop two interview guides for the preparation phase and follow-up, based on the model by Sheehan and colleagues (2005). These interview guides will be piloted before data collection starts (Ramani & Mann, 2015). Questions are related to influential factors to make a newcomer feel invited to participate and engage with the team, such as: involvement in tasks of patient care (team organization, supervision behaviors and personal behaviors) or engagement with the team (team attributes, supervision or personal attributes). Initially, we will purposively sample 12-16 student participants from the Amsterdam University of Applied Sciences (AUAS) via the online database, further adding theoretically sampled participants until data saturation is reached (see .6).
2. Analysis The research procedure will follow a constructivist grounded theory approach (Chapman et al, 2015; Kennedy & Lingard, 2006), applying an iterative process of simultaneous data collection and analysis. The first researcher (MW) will conduct all interviews, which will be transcribed verbatim before being coded by 2 independent coders (MW and RD), following a process of open coding. Data analysis will inform subsequent data collection, leading to adaptations, thus following an ongoing, cyclic process until saturation of data has been reached and no new insights emerge from data collection. Once both coders have found consensus on identified categories, the research team will then apply axial coding to define connections between categories, refining and regrouping them into overarching themes. The emerging theory will be developed further using constant comparative analysis through memo writing, until reaching a more abstract level (concept) of theory that is ‘grounded’ in data.
3. Ethical considerations Sampling Student participants will be selected from the online database (OnStage) of the Faculty of Health at the AUAS, which contains information on all clinical placements. Allied health care students planning to undertake an international internship of minimally ten weeks during the academic year 2017-2018 are included in this research. Selected students will receive an information letter from the first researched (MW), which includes a personal invitation to participate in this study. They will have two weeks to respond to this invitation, after which the first researcher will contact them again via e-mail. All participants who volunteer for this study must sign informed consent. Once theory starts to emerge from the data collected we will theoretically sample additional volunteers, until full data saturation has been reached.

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. This development has evoked concerns regarding the challenges of supervising international students in the clinical workplace, which highly depends on professional communication and mutual trust between student and supervisor to create ‘developmental space’. The proposed study aims to create better insight in the initiation practices during international internships from the context of allied health care professionals, leading to educational changes influencing workplace learning in allied health care. Within the Amsterdam University of Applied Sciences (Faculty of Health) students from allied health professions, such as physiotherapy, occupational therapy and nursing engage in local and international placements as part of their undergraduate training. We are interested to find out how individual experiences during the first weeks (initiation phase) of work placements might influence on their overall learning experience. Therefore, we will focus our research on the (expected) interaction between student and local healthcare team before and after the first month of international placements, from a student’s point of view.

Information and consent Participants are collaborating on a voluntary basis. In case they would reconsider their options at any time and decide to no longer participate in this study, this will have no (personal or professional) consequences. Research data obtained before this moment will be destroyed immediately after and no longer be used for purpose of this study. The proposed research is aimed to expose new, relevant information for future educational programs in the field of allied health professions, in relation to international internships. Participation should hold no disadvantages, although the interviews might bring individual students to realise how much they can/should do to prepare themselves well for the upcoming internship, potentially increasing stress or time pressure. On the other hand, it could also support them in their preparation, and help setting expectations for clinical practice. Students are asked to invest approximately 1,5 hours of their time, divided over two individual interviews (2x 30-45 minutes). Upon completion of both interviews, the students will receive a personal email containing an iTunes gift card of 15 Euros as a small gesture to say ‘thank you’ for participating in these sessions. Participation will not lead to any personal risks, since individual privacy will be guaranteed by means of coding transcribed data, rendering all individuals anonymous. Participants must sign informed consent for audio-recordings, which will be destroyed directly after transcription. Only the main researcher, Miriam Wijbenga, will have access to the key of codes and thus to traceable data. The research team, existing of Robbert Duvivier, Stephan Ramaekers, Pim Teunissen and Erik Driessen will only have access to coded data. All data obtained during this study will be made anonymous before publication of results, so that results cannot be traced back to individual participants. Data obtained in this study might be re-applied for follow-up studies conducted by the main researcher, in relation to similar research questions. In case new, relevant information is revealed during this study, participants will be informed timely. The main researcher (MW) works as clinical coordinator at the European School of Physiotherapy, and thus has access to the online database that contains information about clinical placements of students at the AUAS - Faculty of Health. Her tasks as main researcher/interviewer during this study are unrelated to performance assessment of students or pass/fail decisions of individual internships, since the research only covers the first month of practice. Interview data obtained are considered private and will not be communicated with third parties by her or any of the other researchers. 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. By signing the informed consent form (see separate document) all participants must agree to these conditions. We do not collect any personal data for this study.