Internationalization and learning in health and social care

Globalization might justifiably be considered as today's driving force for world trade and economies, but it has also become identified with the increasingly supra-national context in which healthcare and higher education (HE) institutions are now operating. This new context represents a range of challenges that cannot be seen separately from the ones related to the developments towards a knowledge economy, the role of new technologies and developments towards global citizenship and lifelong learning. However, whilst embracing the advance of globalization, its impact on individual nations has to be balanced by a process of internationalization, in which countries adapt to this phenomenon while preserving their own individuality and respecting that of others. Nowhere is this more pertinent than in the fields of education, health and social care where the effect of globalization is increasingly dictating academic and professional requirements for graduates, and disciplines must adapt to provide adequate preparation, not only in academic and professional knowledge and skills, but also in cross-cultural skills and attitudes, without sacrificing quality and safety. We are likely to see increased expectations from funding and professional bodies that educators can show that they prepare their students well for global citizenship.

It is clear that globalization affects a great many aspects of our lives and we know that it raises many questions. If we take this to mean that the world is being moulded into a shared social space, questions regarding what we do in the design of our curricula (and research endeavours) that equips our students to responsibly occupy that space need to be raised. In health and social care education, we need to give attention to what it is that we seek from education and what we regard as an educated person, acknowledging that education is never value-free. Although internationalization concerns might appear social, cultural, humanistic and educational, they are also directly connected to globalization and the worry that a marketization ethos will lead to a lack of emphasis on teaching and learning and that academic quality will suffer.

Debates on the internationalization of HE have been prefaced by a number of underlying issues ranging from pressure on institutions to internationalize and the kinds of forces that are driving this, to a need for greater clarity or a common definition of the concept. Perhaps I need to delineate what I mean by internationalization, and here I draw on Van der Wende (1996, p. 23), ‘any systematic, sustained effort aimed at making higher education responsive to the requirements and challenges related to the globalization of societies, economy and labour markets.’ In this context, I associate globalization with competition, while internationalization is presumed to be associated with cooperation and collaboration. Internationalization applies to both a process of making something international (between nations: a process of exchange and mutual influence), or it can be conceptualized as an ideology or policy of some sort, see for example Higher Education Policy Institute Review (Hatakenaka, 2004). Internationalization is assumed to match the demands of the global and intercultural world. For example, it brings new challenges including how to boost student and faculty (including researchers) mobility, develop disciplines and curricula which are adapted to the needs of a global economy and global citizenship and how to face competition from institutions in other countries. Yet, it can also mean policy development to overcome the crisis in the global health workforce which is marked by critical imbalances. Ensuring a sustainable and appropriate healthcare system and workforce is a great challenge to both developed and developing countries. Additionally, limited access to HE sustains social inequality around the globe; thus, the internationalization of HE is sometimes seen as a major contributor to a more democratic, fair and equal world.

Critics claim that wealthy nations are attracting researchers, teachers, healthcare workers and fee-paying students from less developed countries to their own, creating a brain-drain situation. This has been a real cause for concern in relation to nursing, where some African countries are reported to be in crisis because so many nurses are leaving. Critics also claim that internationalization is driven by the developed world's economic and political interests – a strategy to maximize profit and ensure economic growth.

Like it or not, we live in a globalized world and HE policies have become increasingly internationalized, with policy makers, researchers and educators energetically stressing internationalization as a principal goal of HE. Health and social care professions are not immune to such discourses. Some protagonists have called for universities to embrace an educational philosophy with ‘no ideological national and cultural boundaries’ (Calleja 1995, p.41). From such a perspective, the internationalization of HE moves from being a marginal aspect to one of its central elements. In the UK, the Prime Minister's Initiatives 1 and 2 are strategies designed to secure the UK's position as a leader in international education, and sustain the managed growth of UK international education delivered both in the UK and overseas. Such policies are also developing in many other countries around the globe. It would appear that universities are being pressed to convince academics and students of the importance of internationalization, and against this backdrop, the papers in this cluster are timely and important.

The cluster of papers presented, the first of which is published in this issue of Learning in Health and Social Care (and the remaining two in the next issue), offer examples of how some HE institutions have risen to the challenges of facilitating the process of internationalizing their disciplines. They have been brought together with the aim of encouraging a higher level of awareness of the ways in which internationalization is affecting learning in health and social care. They are, to some extent, an attempt to resolve challenges and seize the opportunities being presented in and through internationalization. They help to illustrate not only the importance of internationalization but also highlight the challenges for the future. All the articles share a common thread that is concerned with preparing students for an increasingly internationalized world and exposure to difference and disturbance. Despite the rhetoric of internationalization from governments around the world, these papers illustrate how the rhetoric is being put into practice and influencing how we can educate our students for their future roles as global citizens.

Frequently, the discourse on internationalization in HE focuses predominantly on student and faculty mobility without concern for other important aspects. One aim of this cluster is to present a number of significant aspects of internationalization in learning in health and social care with attention given to both on campus and abroad pedagogic considerations. Light is shed upon the historical and cross-disciplinary research in relation to study abroad. It is assumed that university and healthcare professionals (be they faculty or student), have much to gain by sharing, collaborating and cooperating internationally. In spite of the ambitious aim, these papers should be seen primarily as the start of a more elaborate and open dialogue in the area.

The first article in this issue by Kinsella (2008) opens the internationalization debate with a research study designed to highlight how multifarious factors can conspire to either facilitate or hinder a period of international practice education. The enablers and challenges identified should provide a useful resource for stakeholders of future study abroad programmes and placements. This study reminded me of my own experiences, not only of study abroad in Nicaragua, Nepal and Germany, but also experiences of planning study abroad programmes and carrying out research (see Greatrex-White 2007 in an earlier issue of this journal). It conjures up notions of learners as both immature and yet autonomous and self-determining; a notion echoed through all three papers in this cluster. Perhaps the success of the reported study abroad programme has something to do with the fact that more than ever before, healthcare students and educators understand that they and other professions are being shaped by many cultures and influences and that combining the familiar with the foreign can be a source of powerful insight and knowledge. Those who are exposed to the cultures of others and learn about them through communication across culture divides are more likely to see diversity as a strength and celebrate it as something to be treasured. Curricula send powerful signals as to what is valued and what is not. Culturally, limited curricula do no service to students who we would hope aspire to being global citizens.

The second article of this cluster by Patterson (2008) published in the next issue of Learning in Health and Social Care, describes an interprofessional education (IPE) initiative designed and run by students from a variety of healthcare disciplines, which comprised a series of seminars on the subject of Health in the Global Context. Such was the response from students that several of the seminars were extended to the wider university community, attracting students from such diverse faculties as Engineering and Languages. Key lessons to emerge were an appreciation among students of the ‘big picture’ in which the health of communities could be improved by broader social constructs, in addition to the more obvious classical medical interventions, and an understanding of how different professions contribute towards delivering common long-term goals. My own appreciation of IPE changed after reading this paper and I now wonder what kinds of IPE I could develop that might bring healthcare students together in my own institution. It helped me to understand how I can best serve students by more thoughtfully considering the focus of IPE courses.

Curriculum innovations such as IPE that go beyond the level of subject specialist knowledge and take responsibility for enabling new experiences that serve to expand cognitive and effective horizons of students is surely to be applauded. But as the author points out, perhaps we need more ‘role models’ to enhance students’ understanding of health in the global context. The IPE programme described goes some way to ensuring that international issues are available for students who cannot go abroad. In my experience, much more can be done to tap the wealth of study abroad experiences and to share this with students/faculty who, for whatever reasons, are unable to undertake a period of study abroad themselves.

My own paper (the third in the cluster, also to be published in the next issue) creates a link between the two previous papers by picking up the study abroad element from the first paper and the interdisciplinary theme of the second paper. Taking the form of a critical discussion of the study abroad literature, it is perhaps the first paper to attempt a historical and cross-disciplinary approach and argues for greater cross-disciplinary sharing of outcomes, methodologies and methods. It offers the reader an insight into the early study abroad research and brings it up to date with current research approaches, concluding that if researchers from different disciplines shared their methods (and perhaps more importantly made their data sets available to other researchers), we could collectively learn a great deal more about the study abroad phenomenon.

It is difficult to imagine omitting internationalization as a powerful driving force likely to affect many dimensions of any healthcare students’ lives. Perhaps we need to start thinking of students as whole people, rather than merely budding occupational therapists, nurses, doctors, physiotherapists, etc. and equip students with knowledge, skills and attitudes which will remain relevant over their whole life course. There needs to be a fine balance between the professional micro-perspective and the social/international macro-perspective of health and social care. Another balance is that between academic freedom and the need to protect the public from incompetent practitioners. These are age-old challenges that we have to face in the rush to internationalize. However, if the purpose of teaching and learning in health and social care is to make the world a better place and to prepare students, not only for professional practice, but also for life that is integrated into a culturally diverse space, then efforts such as those described in this cluster of papers will help to create a sharing oasis in the midst of the complexity.

I hope the papers stimulate critical discussion at a number of levels, including the underlying ideological motives of internationalization in learning in health and social care, its effects on curricula, students, staff and healthcare users and keeping the issue of internationalization in a state of becoming. I find much to consider regarding the growing internationalization of HE and how this is impacting upon the preparation of practitioners in health and social care. Increasingly, health and social care students are crossing national boundaries as they prepare for careers in the global economy. I am passionate about learning and raising standards in education in any country and this means we must be willing to share and to learn. It means sharing experience and knowledge and being open to innovation and creativity from whatever direction it comes. It is also about building sustainable partnerships; in the words of Tony Blair, ‘We want to see more shared research projects, shared courses and joint degrees; we want to see more exchanges of students and academic staff; we want UK education to become genuinely international’ (DfES 2006). But we also need to make sure this is truly global, with education in mind – not merely competition and building national and institutional empires. I would like to leave the reader with a few lines from Kipling's poem, ‘We and They’ which to me encompasses all that is important in the internationalization of learning in health and social care: