Experiences of Study Exchange Program in Australia from Asian Nursing Students’ Perspectives

Exchange programs are an important educational activity for student nurses. Each year, eight student nurses from a Taiwan University are chosen to go to Brisbane, Australia for one month as part of an exchange program. At the nursing exchange program, they not only attended labs, tutorials, simulations, lectures, and workshops, but also visited hospitals and aged care facilities. An explorative and descriptive approach was used to examine the experiences of eight student nurses. Four categories emerged from the analysis: 1) “Help from friendly environment,” 2) “having eye-opening experiences,” 3) “feeling home sick,” and 4) “feeling culture shock.” Although several studies have found similar findings, no recent studies discussing the experiences of Asian students in exchange programs in Western countries were found. The findings provide potential insight into the Asian students’ experiences of exchange programs in Western countries. Nurse educators can consider these perspectives in planning educational exchange program in the future and inform future potential participants what to expect during the program.


Introduction
Globally, nursing education has developed to increase international perspectives. Nursing education systems and training courses differ between countries. As a result there is a growing trend of international exchange programs to occur in nursing programs [1]. These programs aim to assist the students to gain a more international perspective of diverse nursing environments.
Australia is popular for an international exchange with Taiwanese nursing students due to its location in the Pacific and cooperation between nursing schools in both countries. Each country has cultural differences with people from diverse ethnic backgrounds. In addition Taiwan and Australia have differences in their nursing education programs, health care systems, geographies, climatic extremes, cultures, and nursing education system. The majority of hospitals in Taiwan are promoting international medical centres as an important goal in the future and the people of Taiwan wish to actively participate in international medical systems and their operations [2]. Facing this wave of globalization, nursing education in Taiwan aims to connect with other countries. Many nursing schools encourage their students to develop international competiveness and proficiency with the use of short term exchange programs and promotion of international research collaborations. If nursing educators can inspire students to promote their skills and English proficiency, students can have more international competitive abilities facing the diverse nursing environments. After these students graduate, they can be more adaptable to the global trend towards international medical environment.
The International Exchange program in this paper was between two Schools of Nursing, one in an Australia University and the other in a Taiwan University. The exchange program in Australia consisted of 4weeks of educational activities for nursing students within the School of Nursing and other related departments. This paper highlights the experiences of Taiwanese nursing students for this exchange within Australia in the winter of 2013. The objective of this paper is to focus on the experience of nursing students' learning in a foreign country and inform future programs of the benefits and issues that may arise.

Background
The trend toward internationalization of education, worldwide, has been developing since the 1980s [3,4]. Nursing education has also developed to the point of increasing the need for an international scope. From 2004, Taiwan began to expand its global vision for students by actively promoting overseas learning activities and opportunities through student exchanges with foreign universities [5].Overseas learning for students can have a positive influence in advancing their nursing professional field [6]. Studying overseas can expand professional skills, increase participation in multicultural integration, and expand international vision [7].
Taiwan's academic nursing education involves multiple academic systems, such as Universities, Technological Institutes, and Colleges. Nursing education within these academic settings includes study exchange programs which promote their students' competitive ability internationally. Some significant differences between Taiwan and Australia university nurse education are included in Table 1.

Australia Taiwan
Studying period 3 years 4years

Research Design
The aim of this study was to explore and describe the experiences of Taiwanese students studying in Australia during a nursing exchange program. Specifically, this study focused on the first experiences of Eastern nursing students to a Western country. This study aimed to promote greater cooperation between eastern and western nursing programs and to provide important preliminary information for future studies related to this topic.

Methodology
The study utilized descriptive phenomenology as the methodology. Phenomenology is the methodology of choice for a study such as this as the philosophical underpinnings of phenomenological approach are consistent with the values of nursing practice, the uniqueness of the person, the indeed of personal exploration, constructed reality and the potential for personal growth [8]. In this context, phenomenology as a philosophical framework and research methodology can provide personal self-reflection and knowledge about aspects of a person's life in the real world which cannot be accessed by observation alone [9].

Design and data collection
A purposive sample was used as the students selected for the exchange program were approached to participate in this study. Each student within the program explored and described personal experiences during their time in Australia with the researcher/ supervisor. The researcher/supervisor previously studied her Ph.D. at this exchange school and was familiar with the environments/school. During the time in Australia, the supervisor lived together with the eight students and accompanied them during the program in Australia to provide her (lived and cultural) experiences when the students were confused. Pseudonyms were used in place of participants' true names to assist in confidentiality of data. The data collection was conducted at two different times in the course of the exchange program: the first time was after three weeks in Australia, and the second data collection occurred the first week after returning to Taiwan from Australia.
Data was collected through face-to-face in-depth interviews that were audio recorded. Notes were also written by the researcher during the interviews. Each interview lasted approximately 40~60 minutes.
All interview data was transcribed by the researcher in Taiwanese and translation of interviews were checked for accuracy of the translations into English by a professional Taiwanese to English translator. Further discussion re translations can be found in the Data Analysis section of this paper.

Participants
A purposive sample was used as the participants were the students participating in the exchange program. The Australian university responsible for the exchange program accepted eight international students for each program. All participants needed to be current students at the Taiwanese school where the researcher was involved. The selection process included English interviews and participation in 32-hours of English class and Australian orientation (including Australia culture and history). Eight students were selected by three academic scholars including two Australian teachers at the Taiwan School of Nursing. For the group selected in the particular program that is the focus of this study, there were five undergraduate nursing students in their third year of study and three postgraduate students. Of the eight students, the three postgraduate students had three-years working experiences in hospital. The five undergraduate students had worked part-time in the hospital. All participants were female students, aged between 21 to35 years. They each had a GPA above 5. None of them had any previous experience in Western countries. All students have a minimum English proficiency of IELTS 6.

Data analysis
The study used an explorative and descriptive hermeneutical approach. A hermeneutical approach can allow the researcher to listen, interpret and direct all the transcripts at the same time [10,11]. During the transcript analysis process the researcher listened to the interview tapes several times during which diarist notes were taken for future reference during the process of analysis. The benefits of the researcher transcribing her own interviews was that it allowed her to become more involved in the research process by being able to reflect on the actual transcript content as well as the actual interview itself [11].
The researcher listened to the students' stories, interpreted by presenting opinions of the students' descriptions, and directly asked the students' perspectives from their communications [12]. It was important for the respondents to clarify essential experiences during the interviews, and reflect upon their experiences in the course of the interviews so the contexts and detail that were obtained were accurate for each participant [13,14].
Prior to the commencement of the analysis process all interview data were transcribed in Chinese -the language in which the interviews were conducted -and subsequently translated into English by this researcher who was able to converse in both languages. The transcription process involved the researcher listening to the interview tapes several times during which, notes were taken about the tone of voice used by participants when describing their experiences, pauses in conversation, and emphasis on certain points which were important to the participants for future reference during the process of analysis. After the translation process had been completed and prior to commencing the process of analysis all interview transcripts were given to a licensed professional Chinese-English translator (Taiwanese) to review the English translation of the interviews and to back translate the transcripts from English to Chinese to determine The process of analysis used Colaizzi's (1978) phenomenological method. Colaizzi's phenomenological method involves extracting significant statements from the interview transcripts, creating formulated meanings, aggregating formulated meanings leading to the identification of the fundamental structure of the phenomenon. Significant statements explicated from the participants' interview transcripts were then re-read several times to obtain a sense of their respective meaning. The fundamental question asked by the researcher was: "what is the meaning of the experience of exchange program inherent in each significant statement?" Formulated meanings were developed from each significant statement and then sorted into theme clusters. Significant statements and formulated meanings were reviewed by the researcher and an Australia academic scholar.
An additional step of analysis was included in this study: a review of literature in relation to the findings of the study making it a nine-step approach to analysis. This was added to determine relationships with the results of this study with other relevant literature currently available.

Ethical Considerations
In undertaking this project a number of ethical issues were addressed including: ethics approval, informed consent, anonymity, confidentiality, storage of data, level of risk, and right to withdraw without prejudice. Ethics approval was granted from the University Ethics Committee in which this study was conducted. Prior to commencement of the study informed consent was obtained in writing from the participants in this study after full explanation that the researcher was interested in the participants experiences, and was not trying to prove a particular hypotheses, promoting an honest sharing for the project and attempting to reduce any perceived power between the researcher and participants.

Facilitation of the Exchange Program
The main components of the nursing exchange program at Australia included a campus tour and library tour. The exchange students obtained student cards from the Australian school for library and computer access and familiarized themselves with the campus and surrounds. The students attended lectures, tutorials, clinical laboratories and the School of Nursing Clinical Simulation Centre sessions. The nursing exchange program included attendance at the Australian 2nd and 3rd year nursing program, and also attended postgraduate students' seminars. The students had chances to discuss cultural perspectives with the Dean of the Australian school and other academic staff and students from within the School of Nursing. The Australian university also arranged Australian students and staff to meet with these exchange students and participated in social events and cultural exchange activities.
The exchange students also visited some healthcare organizations including hospitals and health care facilities, community aged care facilities, the school's Health Clinic, and Wound Care Clinic, and their Institute of Research Centre. During their tour to the clinics and hospitals, the exchange students participated in patient interviews and observed the registered nurses' healthcare to the patients.
During the final week, these exchange students attended postgraduate seminars and obtained training certificates which allowed them waive two credits at their university in Taiwan after completion of the program from the Australian university. From these lectures, clinics, and shared experiences, they were provided numerous opportunities to appreciate the differences in nursing education and nursing practice between Taiwan and Australia.

Findings
Following the process of analysis using Colaizzi's analysis (1978) four categories were revealed: "help from friendly environment", "having eye-opening experiences", "feeling home sick", and "feeling culture shock." Theme One: Help from friendly environment Friendly staff played a pivotal role in exchange students' learning. All participants described how the friendly environment helped them to enjoy the learning experience in Australia.
For Sindy, the friendly environment was positive I never went to Western countries. Although I am afraid of language ability, I get used to the environment quickly. All the students and the teachers are very friendly and welcoming. I can say that without them, I cannot be concentrated on studying and learning new knowledge.

Emily further stated
The teacher is so patient even though I do worse in the stimulation class. She still discusses with me how to do right in the further. Friendly environment helps me learn a lot.

Amy echoed similar sentiments to that of Emily when she described her experience
All of our hope before the exchange was that perhaps we would return with lots of great memories, had an even more glowing view of Australia than before we left, have made many (potentially lifelong) friends, and be reasonably fluent in the language. All these have been realised and more! Friendly friends and teachers really help.

Mary felt that after the program, she was not afraid of making new friends
The first is new friendships. These have been formed with people from school, fellow exchange students and my coordinator. I now feel comfortable approaching strangers and find it easy to form new friendships. I am no longer as anxious or shy about meeting new people. If I do not meet with them, I cannot survive the foreign country. The building of my interpersonal skills will help me greatly in the future as I feel like I can now communicate easily with anyone.

Jill further described
Even though it's really scary going into classrooms because nothing can ever prepare you for what you're going into and I am afraid of speaking English but you make so many great friends and teachers at your school. Day and day, I am not scared anymore.
When experiencing a different culture and environment, it was necessary to have friends who helped each other. As part of the program, the students not only learned how to get along in a foreign environment, but also how to be independent.
Language was another issue to be considered in Western countries for Asian students; however the students found that nice and warm friendships helped them get along with the environment and their concerns about language. Amy described: My language is slowly (but surely) progressing. I think even if you have been learning English for years before arriving here; it is still a shock to start off with. While it may seem impossible at the start, when you get to the point that I am at now, going from nothing to being able to understand and respond, the struggle is definitely worth it!. Having learnt nursing at school for a few years, I expected that I would be anxious attending the class, however, it wasn't a problem, and that I had fun attending the class with friendly staff and classmates. As I said, learning different teaching styles was good. " Theme Two: Having eye-opening experiences All the nursing exchange Asian students described eye-opening experiences during the program. They discovered that the facilities and teaching environment were very different when compared to Taiwan. The students in Australia liked to speak out in the classroom and shared their information. Jill described: At the last day of the week, we went to a lecture: Professional Studies. The teacher taught us what it meant to care: Compassion, Competence, Confidence, Conscience, Commitment and Comportment. Then she asked the students what they thought and I was impressed by the teacher's brief story full of education. The main point in being a nurse was that we should use our compassion and realise that anyone could be your mum, your friend or someone you love, and in doing so we could treat them better not causing any harm. During this lecture, I saw that many students wanted to share their opinions and so the teacher allowed them to do so. Furthermore, I learnt that there was no standard answer. It could inspire students to think deeply. It was different from Taiwan, students always expected the teachers to give us a standard answer, and were usually afraid of sharing their thoughts due to lack of confidence or fear of being wrong.
All the students noticed that Australian students had a passion to gain knowledge and brought what they found (materials and papers) to discuss in the class, which was different from Taiwan. For a number of participants, in Taiwan they only attended the classroom, but nothing was prepared before the class.

Janet further gave her opinion that
It has been extremely difficult, challenging, eye-opening, entertaining and I will never regret anything I have done. What an amazing experience, and what a fantastic opportunity to live in an incredible culture! I found that it is really different from my learning experiences in Taiwan. If they have questions, they just raise their hands and ask in class. The students here are quite independent and they even bring their iPad and notebook to class. That does not happen in Taiwan. The students in Taiwan never actively talk in class. Sometimes, they seldom bring anything to class, and learn nothing. I guess the learning environment pushing me to do so. It motives me to learn more.

Amy spoke of her surprise when she stated
Back in Taiwan, there were always some students who would fall asleep during lectures. Most of the students in Taiwan seem to be tired or to have a lack of interest in lectures. Students usually only studied for examinations and most of them memorised the things that they would be tested on, without really thinking about it. They lack the skills of critical thinking because they were taught to obey the teacher's instructions rather than rely on themselves. Whereas here, I learnt that there was no standard answer. This could inspire students to think deeply. It was different from Taiwan. The students in Taiwan always expected the teachers to give a standard answer, and were usually afraid of sharing their thoughts due to lack of confidence or fear of being wrong.

Another eye-opening experience was that of personal growth. Sindy and Ann found that the program helped to open their minds. Ann stated
It is my career goal. Having a year after graduating from school has allowed me to find myself and think deeply about what I hope to achieve in the future. This exchange has given me the time to decide exactly who and what I want to be. I think it is personal growth. Having the opportunity to travel overseas has given me greater awareness of my own national identity. It has also allowed me to widen my perspective and become self-sufficient. I am now always thinking about things from a broader point of view. My world has been expanded significantly and with it I have expanded as a person. I am much more self-aware and already feel more confident and independent than when I left Australia.

Sindy, in reflecting on the thought of being open-mind stated
The program made me open my mind. At the beginning, I could not know I could go out to study; however, now after the program, I felt I am braver after the program. I would like to go to a foreign country to study after this experience.
When visiting hospitals and aged care centres, working attitudes of staff were also memorable for the students. Mary stated "The people working in the hospital loved their jobs and their working environment. I was surprised. In Taiwan, the nurses generally don't like their working environment and job. Job was for making money." Theme Three: Feeling home sick Missing family and familiar food were two issues all participants identified during their time in Australia. Ann (36 year-old) was the oldest participants in the program, and at the final week, she started to stay away from the group and stayed in the library until late. Ann's English was not as good as others. She stated that: I found the first couple of weeks really difficult with homesickness because my English was not as good as other students. I felt I did not want to stay much longer. I missed my family and the food in Taiwan. I did not know how to cook. I usually needed to eat outside. Sometimes, my roommates cooked, but I felt embarrassed. In addition, the costs of things were so expensive compared to the living allowance in Taiwan... I was homesick. I will never go to other county to study again. Taiwan is my loving home.

Amy (aged 21 year-old) was the youngest participant in the program. She voiced some challenges of the exchange program as
After attending this program, it made me want to study in Australia and work as a registered nurse. But at the same time I found that I missed my family very much which bothered me greatly. I didn't like that I had lost the connection with my family. Even though I could still contact them through the internet or by phone calls, I didn't like the feeling of distance.…. In saying this, it was hard at first; however it's fun, interesting and exciting at the same time. One thing which I loved about Brisbane was that even though I didn't speak English well when I arrived, everyone made such a big effort in helping me out. They would speak very slowly, use hand gestures, and involve me in their culture.
The final theme, closely linked with the others discussed was that of feeling culture shock.
Theme Four: Feeling culture shock The students experienced culture shock and similar to the eye-opening experiences, many identified with increased personal growth. None of the students cooked in Taiwan. Cooking and preparing food in Australia were a significant culture shock for them.

Amy stated
For me, the other culture shock was cooking by myself. I have never cooked in Taiwan; however, I needed to learn how to cook. Also, shopping in supermarkets, taking bus to school and speaking English were also unusual for me when I was in Taiwan. However, I learnt how to cook before I came to Australia. I could cook for my group of members without any problems. I could take bus to school, and also I was not afraid of speaking English to foreign people.

Sindy found Australian students liked to bathe under the sun
My first impressions of the campus were very good. The students were lying down for a rest, reading books, and happily chatting with friends. I felt the sunshine on my face, which was so warm and comfortable. It seemed like everyone was so delightful and enjoying their time at school. I thought that it was different from our school, in that the students at my school, would not be seen sitting on the grass. People in Taiwan did not like to bathe themselves in the sun on a sunny day; instead, we covered our skin and kept out of the sun as much as we could.
The small class sizes were another issue which participants saw as a culture shock. Jill stated We attended a tutorial, which only had 10 students in the class. In Taiwan, the atmosphere in the classroom was very quiet, not like the class in Australia where students usually felt free to ask questions or wanted to share their opinions. I think that is one of the culture shocks.

Janet further described
School has been an interesting experience. I am in a class with 5 girls and 2 boys, which in Taiwan we never had this experiences. The class included lab, Lecture and Tutorial. We usually learnt with large number (40~50 students) of classmates at home. Everyone in Australia was eager to learn about nursing. I saw many students older than 30 to 50 year-old, and still studied as a nurse. In Taiwan, you can only see adolescents studying at school. Also, in hospital, we could see many senior (older) age nurses working there; however, we never saw older nurses (more than 45 year-old) working at clinical wards. It was impossible. Taiwan nursing workload was too heavy for older nurses.
The participants were keen to share their experiences about their program within Australia. It was interesting to see that although the countries involved were different from other studies there were similarities found within the literature, revealed in the following section, the Discussion.

Discussion
Exchange study programs are one of the most effective ways to actively engage students in the entire cultural environment. By encountering people from various cultural backgrounds beyond the level of a tourist, students learn to avoid ethnocentrism, build their self-goals, enhance personal growth, and promote professional roles as a nurse [14]. Similar to Boateng and Thompson in 2013 [15] most of the students in this program felt they had gained knowledge and maturity after the exchange program and many discussed personal growth as a direct result of the program.
Edmonds in 2012 [14] identified multiple factors that influenced the learning behaviors among exchange students, including being home sick, culture shock, different hospitality, feeling unprepared, different norms of learning styles, different patterns of caring and nursing, comprehension of nursing education, and coping through reflection. This particular exchange program found similar issues.
Homesickness is defined as the distress or impairment related to an actual or anticipated separation from home and carries the unique hallmark of preoccupying thoughts of home and attachment objects such as parents and friends [16]. The transition to college or university in different countries can be an exciting new experience for many young adults. Thurber and Walton in 2007 [17] identified that homesick students have potential to obstruct their learning achievements if not able to adjust. Conversely, they identified that positive adjustment for students who are separated from their home countries could enhance their experiences. Fostering a hope and developing close relationships can promote resiliency and help young adults for future success [16]. For exchange university students, homesickness can be particularly problematic [16].
Whilst the students in this particular program identified feelings of being homesick they acknowledged the friendliness of the people they found themselves with in the foreign country as a contributor to reducing negative outcomes of this. This aligned with Cusimano's in 2005 study which showed that friendly staff is very important in the experience of studying abroad. Cusimano in 2005 indicated that if students could make new friends quickly and look at the exchange program as an adventure-new people, new surroundings, new learning experiences-then they would gain wonderful experiences for their lifetime. Levett-Jones, Lathlean, Higgins and McMillan in 2009 [18] focused on student-staff relationships during clinical training and also identified that warm and friendly host staff and students played the main important role for exchange students.
These students in this exchange program felt supported and valued during and after the program. Additionally, while evaluating the program, they suggested that they understood their own and others' value and culture more than before they attended the exchange program. Many students mentioned how much easier it was to be able to adapt and cope with unexpected things in a foreign country by having friendly teachers and students. They were surprised by how quickly they learnt new language skills to communicate socially as a nursing student in foreign country which concurs with Milne and Cowie in 2013 [19] who discussed similar findings.
Kent-Wilkinson et al. in 2010 [20] indicated that with education of exchange nursing students in trans-cultural programs, students might suffer cultural pain and shock but the experience might be exciting and stimulating as well. Additionally the stress of language, culture, and education, inhibited some exchange students' ability to participate and learn in the program [21].
Some of the students in this paper's study expressed experiencing cultural shock mainly when they felt they were unable to overcome the language barriers and were missing their Taiwanese food during their stay. This certainly coincides with the above mentioned studies of similar exchange programs in other countries.
One of the most important outcomes of the exchange program appeared to be an increase in the students' self-confidence. All participants spoke of their personal growth, feeling less shy or gave examples where they felt more confident in speaking in a foreign country. Myhre in 2011 [18] also acknowledged that student exchange programs (such as clinical placement) can enhance students' selfconfidence more than studying in their home country.

Limitations
There were some limitations within the program and study. One was the limited numbers of students who participated in the program. The numbers were restricted due to budget constraints and the timing of the program which could only set out during the school summer vacation in Taiwan (so the school teacher accompanying them was free from teaching duties). An additional limitation was due to classroom timetables in the Australian school the participants mostly attended 2nd and 3th year of classes. A further limitation for consideration was the relationship between the researcher and the participants. Whilst all things were done to reduce the feeling of power between the researcher in her role as supervisor and the participants, as students who were needing supervision, it would be difficulty to say there was no power influence within the description of experiences.

Conclusion and Recommendations
The nurse exchange program provided an effective learning opportunity to improve and achieve a number of objectives among students such as self-efficacy, development of global nursing perspectives, and self-confidence, just as indicated by Edmonds in 2012 [14]. The students within this Taiwan-Australia exchange identified four major themes of 1) "Help from friendly environment," 2) "having eye-opening experiences," 3) "feeling home sick," and 4) "feeling culture shock." Within their experience of the exchange program, they all felt it was ultimately a positive experience that other students should also undertake if given the opportunity As summarized by one of the participants in our study "the most important advice I can give is that everything in another country is different: nothing is lost until you try it; however, once you try it, everything is different, and it's important to be open to new ways of doing things." This was further acknowledged by Amy who stated "It really is a great month away, and it's guaranteed to leave you with lifelong experiences" Despite there being little exploration of the experiences of Asian students studying in exchange program in Western countries this study has provided potential insight into the Asian students' experiences in an exchange program to a Western country. Students can realise that many of the experiences they are likely to face are similar to those of other students who have participated in exchanges in other countries. Nurse educators can consider these unique perspectives in future study abroad activities in Taiwan and other similar Asian countries.
Recommendations for future exchange programs between foreign schools would include: 1. Interaction of ingoing students into such an exchange program meeting with previous students who have undertaken such a program. This would allow open and frank discussion about expectations. 2. Consideration of students who have not been away from family before. Issues of potential homesickness and strategies on how to deal with it should be addressed at length in the selection process of students to participate. 3. Consideration of ILES scores of 6 being raised to a minimum of 6.5 for all participants. 4. Possibility of access to lecture notes prior to attending lectures to allow translation or group session with supervisor before the actual sessions to assist in class contribution. 5. Knowledge of food outlets that can provide foods, which students are more familiar with, however not to replace all foods as part of the exchange program is immersion into foreign countries culture including food.