Table 10 List of all outcomes and those that met consensus (those that met consensus were included in the core outcome set)

Increased awareness of/knowledge about cultural differences and similarities (e.g. understanding key issues within a culture, culturally acceptable behaviour and cultures of UK immigrants, learning about, accepting and changing assumptions about other cultures)

2

+

Increased awareness of/knowledge about the cultural aspects of health (e.g. greater understanding of health promotion, how culture affects daily life and professional work, cultural differences in health, the effects of politics on health, sustainable healthcare)

2

+

Ability to work with limited resources (e.g. being more resourceful, ability to target resources, ability to find solutions despite limited resources, making use of everything available, ability to work without reliance on technology, manage in a low resource setting)

2

+

Increased awareness of/knowledge about culture in practical assessments (e.g. the importance of collecting relevant cultural information about people’s presenting health problems and learning how to conduct cultural assessments and culturally based physical assessments)

2

+

Ability to apply clinical skills to another context (e.g. a more challenging environment or a low resource setting)

2

+

Ability to be adaptable and innovative in teaching (e.g. ability to transfer skills and knowledge to the most influential people or to another context, recognising different learning styles, being adaptable in assessment)

2

+

Increased awareness of/knowledge about how other healthcare systems function (e.g. developed insight into disparities within healthcare systems, understanding of other systems)

2

+

Ability to cope (e.g. improved coping strategies, ability to deal with lack of structure, knock backs and stress, being unfazed by things and taking things in stride, new approach to guilt for patients problems)

2

+

Increased cultural sensitivity (e.g. sensitivity to reasoning behind cultural differences, feelings of minority and language barriers)

2

+

Understanding that words and behaviours can have different meanings (e.g. understanding how words are perceived by others, understanding how to speak and behave so as not offend people)

2

+

Ability to apply knowledge across systems (e.g. ability to apply knowledge from host system to United Kingdom and vice versa, using knowledge gained in system to improve/change another)

2

+

Development of a new perspective (e.g. revising assumptions, seeing things differently, changed world views and outlook, look at everything in a new light, openness to new experiences, put things into perspective)

2

+

Improved flexibility and adaptability (e.g. acceptance of other ways of working, adaptation to responsibility, being able to adapt more easily to unfamiliar situations, able to cope more easily with change, gaining a wider perspective, understanding the flexibility of roles)

2

+

Ability to be innovate when overcoming challenges (i.e. finding unique ways of overcoming cultural and language challenges)

2

+

Increased respect for other cultures

2

+

Increased understanding of basic skills and ideas (i.e. back to basics, e.g. basic observations using eyes, less reliance on lab tests and technology, basic clinical skills and science)

2

+

Confidence in teaching ability (e.g. being more comfortable around others, confidence public speaking, confidence in transferring knowledge)

2

+

Improved confidence (e.g. in caring for clients from another culture, in quality improvement methods, to take bolder steps, to address challenging situations, self-confidence, confidence in professional ability,)

2

+

Confidence to work in other locations (e.g. confidence to move to another city/country, working with UK multicultural/underserved populations)

2

+

Increased awareness of/knowledge about global issues (e.g. re-evaluating world issues, shared purpose)

2

+

Increased awareness of/knowledge about conditions and procedures rarely encountered in the United Kingdom (e.g. greater understanding of procedures not used in the United Kingdom, unfamiliar equipment and delayed presentations, better management of conditions that are not common in the United Kingdom)

2

+

Increased awareness of/knowledge about tropical diseases

2

+

Increased awareness of/knowledge about the importance of mutual learning and respect (i.e. greater understanding of reciprocal learning)

2

+

Ability to be adaptable in leading (e.g. able to lead in complex novel situations, ability to compromise not dictate)

2

+

Ability to work within a system with unfamiliar power dynamics

2

+

Ability to adapt social norms to meet needs of another culture (e.g. change behaviours to fit into another culture, being aware of own social norms and adapting them)

2

+

Ability to exchange ideas with those from another culture

2

+

Increased self-awareness (e.g. understanding own skills and limitations, how to challenge own beliefs and importance of reflecting on own situation)

2

+

Patience and tolerance (e.g. accepting and working at other peoples pace, more tolerant)

2

+

Proactivity (e.g. thinking on feet, using initiative, efficiency, get on with things rather than look for someone to blame)

2

+

Ability to work with resources available in specific contexts (i.e. understanding the reasons behind lack of resources)

2

+

Ability to work towards solutions (e.g. solution focused approach)

2

+

Understanding that speed and language competency affect communication (e.g. awareness of how speed affects comprehension, understanding language differences and checking recipient comprehension, ability to use an interpreter)

2

+

Increased awareness of/knowledge about the importance of community participation in health (e.g. understanding the community and social influences on health, the role of the community in health, public health and the importance of community work)

2

+

Ability to use a broader range of clinical skills (e.g. enhancing existing skills and acquiring new clinical skills, greater all round competence)

2

+

Understanding that changing behaviour is complex (e.g. understanding how to make small changes and not to force your perspective onto others,)

2

+

Ability to improve service (e.g. renewed enthusiasm for service improvement)

2

+

Increased staff knowledge and skills (e.g. increased staff knowledge of low cost healthcare, more knowledgeable staff able to cover more areas, to discover better ways of doing things and more aware of waste reduction)

2

+

Increased awareness of/knowledge about how context affects communication (e.g. effectively conveying ideas in a contextually appropriate way)

2

+

Increased awareness of/knowledge about the need for and importance of training (i.e. understanding how important effective training is in)

2

+

Improvement in teaching skills (e.g. learning new techniques, greater training delivery skills, lecturing skills and small group teaching skills)

2

+

Ability to deal with the unexpected

2

+

Ability to manage projects

3

+

Deeper engagement with issues of equality and diversity

2

+

Ability to overcome communication challenges (e.g. ability to communicate effectively in high pressure situations, engage in challenging conversations and liaise between groups)

2

+

Ability to be innovative with clinical skills (e.g. use of innovative techniques, finding new ways to approach a condition, new ways of working)

2

+

Appreciation of having the right tools and equipment to be able to do the job (i.e. resources: technical equipment, disposal equipment, cleaning products and protective equipment)

2

+

Appreciation of excellent human resource in the NHS (e.g. multidisciplinary teams, HR structures, appreciation of own profession, understanding hierarchy and the importance of each person within it)

2

+

Improved emotional intelligence (e.g. changed engagement with self, knowledge and world)

2

+

Ability to identify and anticipate potential problems (e.g. identify problems when setting up a new project)

2

+

Increased awareness of/knowledge about appropriate clinical behaviour (e.g. knowing when to stop and when to move forward, when to ask for help and different populations needs)

2

+

Ability to make independent clinical decisions (e.g. ability to make an urgent decision in an emergency, dealing with uncertain outcomes, evaluating risks to patients and self)

2

+

Understanding own potential to empower people

2

+

Ability to work as part of a team (e.g. understanding team group norms, perception of roles within the group, managing personal objectives within a group)

2

+

Ability to build a global network

2

+

Ability to disseminate best practice globally

2

+

Appreciation of free universal health (e.g. the NHS system of free healthcare for all, privilege and opportunity, the expectations that are placed on NHS by service users)

2

+

Improved situational awareness (i.e. understanding your environment so you can understand what to do)

2

+

Increased job satisfaction (e.g. increased motivation and morale within profession, renewed passion for work, sense of reward)

2

+

Personal satisfaction (e.g. personal achievements and challenges, new experiences, experiencing a different lifestyle, a holiday, appreciation of own life, personal fulfilment)

2

+

Can-do attitude

3

+

Ability to co-operate (e.g. willingness to see another point of view)

2

+

Appreciation of clinical governance procedures within NHS (e.g. waste disposal, audit, teamwork, education system, tests and investigations)

2

+

Appreciation of the importance of care and compassion (e.g. ability to compare compassion in both systems, empathy and fairness)

2

+

Ability to provide better care (e.g. ability to integrate primary and secondary care, to provide multicultural care, to develop most effective approaches to care and taking responsibility for providing quality of care)

2

+

Increased awareness of/knowledge about the positive impact of clinical policies and governance (e.g. understanding the benefits of a comprehensive checklist)

3

+

Increased awareness of/knowledge about ethics (i.e. experiencing ethical dilemmas, understanding the importance of ethics)

2

+

Changed perception of otherness (e.g. understanding importance of being a friendly stranger in the United Kingdom, feeling like a foreigner)

2

+

Integrity

2

+

Independence (e.g. lone working)

2

+

Ability to plan and organise (e.g. ability to set direction, improved audit skills)

2

+

Ability to make decisions (e.g. understanding who the decision is for, taking action on decision, making judgements

2

+

Ability to manage risk (e.g. manage risk in advance, evaluation of environment, understanding the clinical importance of risk management and the wider implication of poorly managed risk)

2

+

Increased patient satisfaction (e.g. staff better able to respond to UK multicultural populations, staff able to compare how systems affect patient satisfaction, have greater relationships with multicultural population, more in tune with patients and more aware of individual needs of patients).

2

+

Ability to communicate non-verbally

2

+

Ability to establish communication systems (e.g. formal and informal)

3

+

Increased clinical knowledge in relation to other professions (e.g. doctors understanding nurses and vice versa, multi-disciplinary awareness)

3

+

Ability to get the most out of people (e.g. encouraging people to work together, recognise their own strengths and to take possession of their own work/projects, ability to assess the capability of others)

2

+

Ability to manage people (e.g. able to allocate tasks and co-ordinate people, to deal with people with differing objectives, to negotiate with multiple stakeholders, to manage difficult people)

2

+

Ability to develop friendships (e.g. relationship formation skills, developing new friendships)

2

+

Ability to manage self (e.g. own expectations, self-reliance, self-management, self-assurance, reflexivity)

2

+

Changed judgement (e.g. non-judgemental attitude, changed self-judgement)

2

+

Diplomacy

2

+

Ability to find facts to solve problems

2

+

Developing redundant or bad skills/attitudes (e.g. developing non-transferable skills, bad habits, deskilling, returning with overconfidence in own ability, poorer communication skills, loss of confidence)

3

–

Financial loss (e.g. costs of getting involved, loss of earnings, pension or employment entitlement)

4

+

Reduction in NHS drop outs (e.g. increased staff retention, when they volunteer and come back to NHS)

3

+

Ability to observe and examine patients (e.g. increased intuitive knowledge of clinical signs and clinical judgement ability to make diagnosis without investigations)

2

+

Ability to work in a professionally competent way (e.g. having wider view of profession, intellectual development, reminder of professional responsibilities, stronger work ethic)

2

+

Increased understanding of how to be a good teacher (e.g. allowing students to learn from mistakes, ability to suggest and acknowledge improvements in teaching, understanding how communication affects learning, how to target training most effectively and the importance of experiential learning)

2

+

Act as a role model (e.g. lead by example)

2

+

Influences career pathway (i.e. affects specialism choice, exploration of potential career pathways, pursuing careers in primary care, family practice, public service, sub-specialism in global health, teaching)

2

+

Ability to manage time and prioritise (e.g. ability to respond quickly in an emergency, managing immediate need vs long term need, prioritisation of limited resources)

2

+

Increased ability to change behaviour in colleagues or patients (e.g. ability to implement behaviour change and to assess the impact of healthcare systems)

4

+

Ability to manage tragedies

3

+

Reduction in staff competence (e.g. brain drain reversal: NHS loss of competent staff to overseas placements, staff unable to cope with paperwork on return)

4

–

Exposure to ethical dilemmas (e.g. expected to work outside of competency, to do clinical work, little regulation, little supervision, too much responsibility)

3

+

No recognition or accreditation upon return

4

+

Increased international reputation (of United Kingdom)

3

+

Increased international reputation of NHS (e.g. greater fulfilment of social responsibility)

2

+

Ability to verbalise knowledge (e.g. ability to verbalise core concepts and deep knowledge, ability to explain complex ideas to others)

2

+

Increased awareness of/knowledge about the importance of trust between colleagues within healthcare systems

2

+

Increased awareness of and knowledge the functioning of systems (e.g. able to identify stakeholders and change agents, understanding influencing patterns of those in power, value systems and the difficulty of questioning organisations)

2

+

Refreshment and reinvigoration (e.g. chance to take time away to become refreshed and feel reinvigorated to work upon return)

2

+

Increased awareness of/knowledge about the importance of consciously making an effort to get on with colleagues (e.g. learning colleague’s names)

3

+

Ability to manage healthcare environments (e.g. ability to manage wards and staff)

2

+

Increased awareness of/knowledge about the costs of healthcare

2

+

Ability to accept and understand failure (e.g. to continue with something that did not have desired outcome at first, learning to accept failure, thinking differently about failure, persistence)

2

+

Humility (including professional humility)

2

+

Ability to think through problems in a logical way (e.g. analytical/lateral thinking)

2

+

Ability to engage senior people

2

+

Loss of interest in profession (e.g. not wanting to work in your profession when home)

4

–

Extreme nationalism towards the United Kingdom

3

–

Health consequences (e.g. animal bites, tropical diseases, STD’s, injuries and transport accidents, infection, jet lag, skin disease)

2

+

Increased workforce productivity

3

+

NHS becomes a more attractive employer (e.g. an employer that offers staff the opportunity to volunteer)

2

+

Reinforced ethnic and cultural identity (e.g. understanding of own ethic and cultural identity)

No Con

Ability to listen

No Con

Increased awareness of/knowledge about the importance of assessing healthcare on an individual basis (i.e. the uniqueness of each patient)

No Con

Ability to apply evidence based practice (e.g. understanding its importance (sometimes through being unable to apply it overseas), understanding how to apply it innovatively with limited resources)

No Con

Ability to give and accept praise

No Con

Ability to encourage others to take responsibility for own health

No Con

Ability to speak the host language

No Con

Ability to challenge breaches of privacy and confidentiality (e.g. ability to stand up for patients/peoples rights if they are jeopardised, increased awareness of human rights, ability to respect regulatory standards of home and overseas regulatory bodies)

No Con

An upper hand when competing for careers

No Con

Spiritual development

No Con

Escapism (e.g. freedom from bureaucracy, space outside of regular routine to clarify objectives, escape from agendas and workload, a chance to take time out of training and practice)

No Con

Improved research skills (e.g. grant application skills, research design and implementation)

No Con

Ability to present work

No Con

Ability to write reports and academic pieces

No Con

Costs to British patients (e.g. staff desensitised, staff less tolerant and patient, staff bringing tropical illnesses to the United Kingdom)

No Con

Loss of trained staff (e.g. utilisation of key staff time, financial cost of losing staff, having to find cover for staff)

No Con

Negative perceptions of NHS (e.g. NHS reputation jeopardised if a health link is badly organised)

No Con

Distracted staff (e.g. staff going on international placements coming back disengaged with UK work and pre-occupied)

No Con

Difficulty getting the job or training position that you want upon return (e.g. returning to work in a locum position, not having a permanent job upon return)

No Con

Reduced experience and exposure to UK procedures, protocols and research (e.g. NHS procedures that do not exist in host country, missing out on formal training and conferences, chronic disease management over time, health conditions that are common in the United Kingdom and not in host country, NHS protocol and updates, loss of professional networks and relationships)

No Con

Affects professional progression (e.g. lengthens training, less time to prepare for exams, time for professional readjustment upon return, career suicide, loss of partnerships)

No Con

Negative colleague perceptions (e.g. colleagues think it’s a holiday, colleagues have to cover)

No Con

Use of time (e.g. using annual leave to spend time on international placements, physically spending time on placements that could be spent in another way)

No Con

Professional revalidation issues (e.g. gaps in consultants portfolio)

No Cons

Litigation (e.g. legal issues involving clinical/professional risk)

No Con

Security (e.g. exposure to aggression, violence and death, becoming a victim of crime, political unrest)

No Con

Carbon footprint

No Con

Culture shock

No Con

Environmental and infrastructural risk (e.g. being in dangerous infrastructures and environments)

No Con

Experiencing negative feelings (e.g. feeling as though imposing on UK colleagues to provide cover, feeling failure, feeling out of depth, frustration, guilt and regret about death)

No Con

Psychological consequences (e.g. depression, anxiety, stress, traumatisation and nervousness)

No Con

Compromises of health and safety

No Con

Exhaustion and burn out

No Con

Loneliness (e.g. lone working, isolation, social isolation, no or few friends in host country)

No Con

Missing things at home (e.g. missing home comforts, missing life in the United Kingdom, time away from family and friends)

No Con

Loss of interest in global health and international placements (e.g. not wanting to do it again, negative perceptions)

No Con

Socio-cultural risk (e.g. corruption, local resistance to western influence)

No Con

Becoming judgemental

No Con

Negative feelings towards the NHS (e.g. questioning NHS, questioning the disposable culture of NHS, having a different system to compare to NHS)

No Con

Medical school more attractive to students (e.g. if allows students to go abroad)

No Con