1. Introduction and rationale As part of contemporary education in healthcare, students may take the opportunity to travel and learn from other healthcare professionals in an increasingly globalizing world. In this study proposal we speak of international placements when students spend 4 weeks or more in a clinical practice in a country different from the one in which their home institution is located. This definition represents a wide range of clinical experiences, that may vary between placement, educational programme and student. International clinical placements have been the topic of educational research, although current evidence seems to have focused mainly on prerequisites, such as health, safety and ethics, and training conditions instead of students’ learning (Thomas et al, 2018; Wiskin et al, 2018; Watson et al, 2019). During international placements students often find themselves confronted with different criteria and expectations when it comes to professional practice (Newton, Pront & Giles, 2016), which may cause insecurities or uncertainty about their position and role as an intern. Peters and colleagues (2017) described that active student’ participation already poses a challenge within the healthcare system of training, let alone in an international environment where other healthcare rules and regulations apply. Students on international placement can experience additional barriers to participation, such as communication issues due to linguistic or cultural differences (Steven et al, 2014). Besides, students are often challenged to respond to and cope with different personal and professional circumstances, whilst having to function more independently without their familiar network to support them (Thomas et al, 2018; Wijbenga et al, 2020). The way students learn to deal with these unfamiliar circumstances is therefore very likely to influence both personal and professional development. Previous research has shown that healthcare students can experience struggles with the transition between classroom and clinical training, both on a personal as well as on a professional level (Atherley et al, 2019; Peters et al, 2017). A similar transition occurs during the initiation of international clinical placements, where students need to take time to orientate and adjust to their new learning environment before being able to meaningfully contribute to practice (Wijbenga et al, 2020). Attrill et al. (2016), in their study on supervision of international students during clinical placements, have emphasized the importance of supporting students. To arrive at workplace learning it is essential the students are facilitated to actively engage with the team, and participate in patient-related activities (Sheehan et al, 2012; Dornan et al, 2014). Students generally see social interaction in their learning environment as their main priority and consider it their goal to be accepted by their environment (Cronin, 2014). In case students perceive little or no support during the initiation phase of international clinical placements, these might result in negative learning experiences. For example, an intern may be confronted with unwilling and uncooperative patients or face professional conflicts due to hierarchical positions of staff members. Building social relationships in the workplace can help overcome such negative experiences and stimulate active participation (Dornan et al, 2014; Atherley et al, 2020).. Evidence on workplace learning emphasizes that student support is crucial for workplace learning, especially in such unfamiliar and challenging learning environments as an international placement (Acharya et al, 2015; Sheehan et al, 2012). Support networks during clinical placements often reflect the social interaction between student and local healthcare team, including peers, and are likely to change dynamics over time (Atherley et al, 2020). Students will mainly depend on contacts in their clinical space for support when realigning and adjusting to their new workplace and social learning environment (Chen et al, 2014; Wijbenga et al, 2020). Besides this clinical network, students’ existing network, such as their mentor, family members and friends, may continue to play an important support role during international placements from a distance. . The initiation phase is considered an important phase for students to optimize workplace learning (Sheehan et al, 2005; Wijbenga et al, 2020). If anything goes wrong during initiation, this may negatively impact the remainder of placement time. During international placements there might be moments that student’ learning is disturbed by factors in or outside the workplace, and a so-called ‘critical incident’ might cause student’ focus on learning to take less priority. One can assume students will have a different understanding of critical incidents in the workplace than the people in their clinical support network. For example, a patient’s refusal to be treated by a student can be considered critical by the student, whereas the clinical instructor might pay only little attention to the event. . It is unknown why and from whom students seek support during initiation of international clinical placements, and how their support network can be of use to healthcare students when confronted with challenging circumstances in- and outside the clinical workplace. Although Atherley and colleagues (2020) demonstrated undergraduate students create a deliberate and diverse support network during their transition into practice, we hypothesize that clinical supervisors or other members of the local healthcare team will feel they also have a responsibility in actively providing support to international students. . This study will focus on the perceived role of the support network during initiation of international clinical placements by means of exploring the nature of ‘critical incidents’ in the workplace. By investigating students and supervisors’ perspectives of recalled moments where student’ learning was compromised due to critical incidents in the workplace, we aim to answer the following question: . What role does the clinical support network play in solving critical incidents during the initiation phase of international clinical placements?.
2. Aim of research This research aims to describe the role of the support network during the initiation phase of international clinical practice, as perceived by students and their clinical supervisors, and focused on moments when students’ learning was compromised: critical incidents. We will investigate both the support available in practice (such as the clinical supervisor, healthcare professionals and peers), as well as at a distance (academic supervisors, family members and friends). Results will help prepare students for critical work-based situations during international placement, and help them organize their support network in an optimal way. .
3. Target group / participants Within the Faculty of Health (FH) at the Amsterdam University of Applied Sciences (AUAS) in The Netherlands, physiotherapy students have the option to engage in international placements as part of their undergraduate professional training (BSc). We will follow a convenience sampling strategy, aimed at capturing different perspectives on the perceived role of the support network during the initiation phase of international placements. Students and clinical supervisors involved in clinical placements in different healthcare settings worldwide will be invited to participate in our study. We now estimate that we will need to preselect 40 participants (30 students, 10 clinical supervisors); less if theoretical saturation of data can be reached earlier. Physiotherapy students who have completed an international placement between May – December 2021 will receive an informative email on behalf of the research team in their AUAS Inbox, with an open invitation to participate. The same goes for the clinical supervisors who were involved in these student placements. Potential participants will have two weeks to return the written consent form. If there is no response, the principal researcher will follow up by means of a personal e-mail, to see if there are any questions left unanswered. Participants can still decide whether they will join or not during this follow-up, after which they will be left alone when not participating. Student participants will be selected to represent a heterogeneous group of students through all years of undergraduate Physiotherapy education; clinical supervisors will be sampled based on their (previous) connection to these student participants during placement. . Data collection will start in June 2021 and will take place via individual interviews, organized online (via MS TEAMS). All participants will receive further instructions after having returned informed consent. .
4. Design and procedure By applying the critical incident technique (CIT; Flanagan, 1954) we will investigate both students’ and supervisors’ perceptions of the role of the support network during initiation of international clinical placements, facilitating active participation in practice (Terry et al. 2020). Using the CIT allows us to explore the reasons leading up to, and consequences of, a specific incident in a certain context (Cunningham et al. 2020). In this study we have defined ‘critical incident’ as a moment when workplace learning was compromised because of an unexpected situation, personal or environmental factors. Participants will be informed about this technique prior to the interview, to generate a shared notion of which moments could qualify as critical incidents. Examples are: a patient’s refusal to treatment, or language hindering patient communication or active participation in team activities. During the interview, participants will be asked to recall a critical incident or moment in which they felt students’ learning was compromised by factors in or outside the workplace. The interviewees will then reflect on the (perceived) support provided, as experienced by the student or supervisor. We realize that the critical incidents that students will describe are likely to be different to the ones supervisors will describe. On the other hand, this will provide us with a better understanding of what students and supervisors consider critical for learning.
5. Methods Sampling. This study will investigate which persons are involved and why, to solve critical incidents in the workplace that negatively impact on students’ learning. Selecting a convenience sample of students and clinical supervisors will allow us to capture different perspectives from stakeholders on the role and influence of the support network during initiation of international clinical placements. We will start by sampling international students who have completed a placement in the Netherlands. If needed, the sample size can be expanded by adding the students who have travelled to their home country for placement.. Note: during the academic year 2020-2021 the Amsterdam University of Applied Sciences has exempted their physiotherapy students from general travel restrictions linked to COVID-19, only if the urgency and need for international clinical placement as part of their educational programme can be clearly motivated and supported by the Dean of Faculty..

Data collection and storage. Data collection for this study will take place between June 2021 – January 2022. Conducted interviews with different participants (students and clinical supervisors) will be organised in an iterative manner, to ensure saturation of data can be reached via an ongoing process of data collection and analysis. All interviews will be audio recorded, after which their files will be stored onto the secured research repository environment of the Amsterdam University of Applied Sciences/University of Amsterdam. All interviews will be transcribed verbatim by MW, and (after member check) will be rendered anonimously before being shared with the team. The audio data will be destroyed after trancription. with only the principal investigator (MW) and the data steward of the AUAS holding access to participant data (see 7.), which will be stored separately. Qualitative data analysis will be following a thematic approach (see 6.).

Privacy protection. Participation in this study is completely voluntary. Participants may always, at any time, reconsider their options and decide to stop without any (personal or professional) consequences. This has been indicated in the information letter for participants. We will perform a member check with all participants after their interview, based on the initial transcripts. When a participant chooses to withdraw at that moment, their data will be destroyed and no longer be considered part of the project. Upon receiving participant’ agreement, their transcript will be made anonymous. In case the participant decides to withdraw after anonymization of the transcript has been completed, the audio recording will be destroyed according to protocol, yet the anonymized transcript will still be used, since this data cannot be traced back to individual participants. Note: personal characteristics of participants will only be taken during the interview as part of the audio recording, and will be reorganized by the principal researcher (MW) into separate file on group level, so that no personal data will be part of the final transcripts.. No further interventions are scheduled as part of this study.. 6. Analysis All audio data obtained will be transcribed and rendered anonymous, before applying thematic analysis to the qualitative interview data (Nowell et al. 2017). Atlas.ti will be used to support qualitative data analysis, following an iterative process. To ensure saturation of data, a cyclic process of data collection and subsequent analysis will be applied until no new themes or findings come to light. Thematic analysis will follow basic coding into categories, in a process of constant comparison (Ramani & Mann, 2015). After establishing initial categories within the team, two independent researchers will further analyze the outcomes, looking for similarities and differences about how and when students make use of their support network during the initiation phase of international clinical placements. Key findings will then be discussed within the research team to resolve potential conflicts in coding and interpretation, before moving on to the more conceptual level. Personal data obtained will only be used to report about characteristics on group level, to provide context of the study and improve generalizability of findings. Results may help prepare future students for critical work-based situations during international placement, and help them organize their support network in an optimal way..
7. Ethical considerations Sampling. A representative sample of 40 participants (30 student and 10 clinical supervisors) from the Faculty of Health of the Amsterdam University of Applied Sciences (FH-AUAS), will be selected to participate in our study. Participants will be selected to represent a heterogeneous group through all years of undergraduate education, including those with a study delay. All participants will receive an informative email on behalf of the research team in their AUAS or work email, with an open invite to participate in our study. They will have two weeks to respond to this invitation, after which the principal researcher will contact them again by e-mail. Participants first must give written consent before their interview will be scheduled and any personal data will be collected. . Justification of research. As part of contemporary education in healthcare, students are given the opportunity to travel and learn from other healthcare professionals in an increasingly globalizing world. Students on international placement are likely to experience challenges to enabling participation in practice, such as communication, and different personal and professional circumstances. At the same time, they have to function more independently without their familiar network to support them. Building social relationships in the workplace can help students overcome negative experiences and stimulate active participation, in support of workplace learning. . On international placements, the support network of healthcare students most likely exists of clinical supervisors, other healthcare professionals and peers. We assume that academic teachers/mentors, family members, and friends also play an important role in support of workplace initiation, albeit from a distance. To investigate which persons are involved by students when, and clarify how and why the support network is being used as it is, this study focuses on the following research question: . How does the support network influence the initiation phase of international clinical placements?. Outcomes of this study may generate recommendations about how to create an optimal support network and will serve healthcare institutions and educational programmes working together in organizing student-tailored international clinical experiences. . Participant information and consent. The proposed research is aimed to expose new, relevant information for educational programs in the field of allied health professions, in relation to the organization and contribution of international placements as part of undergraduate training. Selected participants from the database of the Faculty of Health at the Amsterdam University of Applied Sciences (FH-AUAS) will receive an information letter and informed consent form via a personal invitation by e-mail. Participants will have two weeks to respond to this invitation, after which the principal researcher (MW) will contact them again by e-mail. Miriam Wijbenga works at the Faculty of Health as clinical coordinator for the European School of Physiotherapy, and therefore can freely access the school’s database containing students’ placement information at the FH-AUAS. Her tasks as principal investigator and interviewer during this study are separated from any pass/fail decisions regarding individual placements, as these are not subject to this retrospective investigation..

Participation in this study is completely voluntary and should hold no disadvantages for all parties involved, other than personal time investment of approximately 30 minutes. Written informed consent will be taken before data collection starts, allowing for audio recording of (online) interview data by means of an external Dictaphone. No video material will be collected. All participants will be compensated for their effort by means of a personal online gift card (10 Euro), to be received after the interview. Participants are free to decide to withdraw from this study at all times, which will have no (personal or professional) consequences. Research data obtained before this moment will be rendered anonymously and only be used for the purpose of this study. .

All data gathered during this study will be handled with great care to respect individual privacy and will not be communicated with third parties. All interview recordings 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), as will the other research documents, in collaboration with the privacy officer of the Faculty of Health at the AUAS. All audio data will be transcribed verbatim, and made anonymous before being destroyed. Only anonymous research data will be 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 initial audio recordings and the file holding participants’ characteristics, and thus to traceable data. All research data will be considered private and therefore will not be communicated with third parties by any of the researchers involved (MW, RD, SR, PT and ED). Upon completion of the study, coded research data will be safely stored and kept at the repository of Maastricht University for maximally 10 years after collection, before being destroyed. Data management will be in accordance with the Dutch Code of Conduct in Research (VSNU). All data will be made anonymous before publication, so that it cannot be traced back to individual participants. 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..