Table 3 Factors which influence outcomes

 Ethics

Are local patients informed of the risk?

Corporate and social responsibility

Do patients come first?

Levels of standards

Health and Safety

“For example, it was not uncommon at first for an anaesthesiologist to encounter a complex paediatric patient having major surgery in the operating theatre where she was expected to proceed with anaesthesia without question and without preparation of adequate drugs or equipment.” (Kinnear, 2013)

“I just think the really important thing in the drawbacks is the health and safety issues-I think we have that as the biggest drawback-on both sides really; the volunteers and the patients in host countries” (Workshop Participant)

 Funding

Consistency of funding for project

Finance plan for project

Funding from a charity or grant

Volunteer funded by sending organisation

Volunteer fundraising

Support of a health link partnership

Self-funding

Specific funding for training

“The period of external funding is drawing to a close and the link needs more regular and predictable funding to ensure sustainability.” (Baillie, 2009)

“All international experiences are financed by the students either by assistance from grant awarding bodies, fund raising activities or personal finance.” (Thompson, 2000)

 Decision of host countries needs

Needs Assessment by both parties

High income party decides

Host country decides

“In South Africa, for example, the government tries to fill all clinical posts with local doctors. Only when a post has not been filled by a local doctor does the government seek external applications for which UK GP trainees can apply.” (Kiernan, 2014)

 Healthcare facility factors

Does the environment favour flexibility

Does management allow people to become multi-skilled

Level of organisational support

Use of specific activities/sessions for learning

Volunteer exposure to numerous systems

Opportunities for exposure to culture outside of hospital

Differences in protocols

Licensing and professional regulations

Level of corruption

Are volunteer skills best utilised?

Encouragement and motivation of volunteers

Financial and human resources

Criticism of project/volunteers

Mobility of local staff

Existence of local role models

Number of times volunteers and local professionals engage

“This support is, by necessity, mostly provided by the host supervisor, and home medical schools in effect delegate their duty of care to the host.” (Lumb, 2014)

“Students should be exposed to a variety of nursing experiences within the host country. This would give them a broad spectrum for comparisons between cultures, nursing practice and health care delivery in those cultures” (Button, 2005)

 Benefits for host organisation

Donations

Material/financial benefits

Payment for supervision

“In order to transform a process favouring the trainee into an equitable exchange, each trainee must recognise the need for reciprocity when a community contributes to his or her education. This might manifest through the provision of resources, such as books and surgical supplies, of teaching and new ideas, or of money, which could be reallocated to meet local need.” (Banatlava, 1998)

 Income of host country

Low

Middle

High

“They therefore concluded that there was no significant difference in level of knowledge and skill gained by going to a developed or developing country” (Button, 2005)

 Commitment of local staff to project

Staff time pressures

Empowerment of local staff

Involvement of hospital leaders

Project use local experts

Local perceptions of volunteers

Value of volunteer opinions

“It was reported that some overseas staff are wary of offering constructive criticism, not wishing to appear ungrateful. There is a move among many links to address this problem through structured appraisal and evaluation for each visit. One had begun to use anonymous feedback forms to learn from visits and improve the quality and effectiveness of health links.” (Baguley, 2006)

“As this host explains, two prominent negative aspects are insufficient input and time” (Pearson, 2014)

 Difference between host and origin country

Cultural distance between host and origin country

Level of cultural immersion

Severity of communication difficulties

Shared values and cultural fit

“The greater the cultural differences of the international placement, the greater the impact.” (Thompson, 2000)

“One of the main weaknesses has been difficulties with communication between the two partners in the link, exacerbated by problems with access to email in Uganda, intermittent exchange visits and an excessive reliance on communication through the two link coordinators. “(Longstaff, 2012)

 NHS and UK Factors

Accreditation

Existence of returner schemes

Bureaucracy

Political Climate in UK

Recognition of benefits by NHS/UK organisation

Trust, deaneries and PCT’s support and influence

Support of UK colleagues

“This placement is recognized by the (UK) Royal College of Anaesthetists to count towards training, and these trainees will all have completed their Royal College examinations before the trip.” (Button 2005)

“Many forward-thinking NHS trusts actively support relationships with overseas organisations but barriers remain.” (Dean, 2013)

 Relationship between host and sending organisation

Dependence on one-another

Quality of communication

Collaboration

Differing expectations

Equality of input

Ground rules and protocol

How the link is set up

Multi-departmental partnerships

Registered links i.e. THET

Sensitivity to local contexts

Sustainability of relationship

Length of relationship

Uni-professional or multi-disciplinary

“Links are not properly established until a visit has given collaborators time to become familiar with each other and to plan the first year, at least, of their work together.” (Parry, 1998)

“Links forged as trainees on these initial UROLINK visits have often been strengthened, and centres where these trainees have become consultants are now ‘twinning’ to continue the two-way exchange of experience.” (Gujral, 2002)

 Level of supervision and support

Mentor in UK

Support in UK

Supervision from western staff residing in host country

Linking of senior and junior volunteers

Supervision from local people

Support structure in host country

Access to HR

“less support from organisational structure, developed skills as a result’ (workshop participant)

‘the supervision styles of host supervisors as the major challenges faced ‘(Horton, 2009)

 Existence of other similar project in areas

Over-crowding of volunteers in hospitals

Support from others volunteers in another project

“specialises in delivering high-quality primary health care in very hard to reach communities, where government service provision is non-existent and where there are very few other NGO projects” (Nunns 2011)

 Focus of project

Agreement of focus

Focus on mutual benefit

Alignment of project with host country health plans

Capacity building focus

Service delivery focus

Developmental focus

Sustainability focus

Training focus

‘For IMV placements to work, both host and volunteer need to have realistic goals and a common understanding of the aims of the placement.” (Elnaway, 2013)

‘The most commonly-reported roles overall were clinical service delivery in a non-emergency setting’ (Seo, 2012)

 Practical Factors

Travel

Accommodation

Use of travel agent

Documentation

some students plan their electives in groups, all travelling to a particular destination. This process often involves students planning a travel experience rather than a learning experience. (Miranda, 2005)

 Structure of the programme

Aims developed by volunteers themselves

Informed by other similar projects

Informed by literature

Coercion

Continuation of project by other volunteers

Involvement of local governments

Countrywide initiatives

Do volunteers have a project?

How project is managed (i.e., well run)

Existence of guidelines and frameworks

Commitment/time allocation/number of UK admin staff

Programme tailored to volunteer needs

Spread of volunteers throughout the year

Quality control of services provided by volunteers

‘undertaking project work, particularly if beneficial to the host.’ (Lumb, 2014)

“It may have been helpful to obtain more input from similar programs at an earlier stage of planning, and it would be helpful in the future to establish formal links between programs or a forum for discussion” (Kinnear, 2013)

‘degree of developing country ownership’ (Smith, 2012)

 Length of placement

Long term

Short term

Adjustment

Short re-occurring trips

‘the average time out being 12 months, you really have time to get to grips with trusting people when you are volunteering that it takes that long before you can kind of be comfortable with it.’ (workshop participant)

 Project evaluations

Evaluations during placement

Post-placement longitudinal evaluation

‘The collection and application of feedback from hosts and volunteers, as well as the assessment of impact of such placements, are vital for ensuring that potential harms are mitigated and beneficial outcomes maximised (Elnaway, 2013)

 Project retention and recruitment of volunteers

Volunteer drop out

How are volunteers recruited

‘Retention of staff’ (workshop participant)

 Assessment and Education

Existence of set learning outcomes and objectives

Use of assessment

Use of model to facilitate contextual understanding

‘it’s all about gaining global health knowledge, so that’s their basic outcome, there’s no assessment, its quite fluid’ (workshop participant)

 Time of programme arrangement

In advance

In country

‘Communications between Hereford and Muheza are difficult so details of each programme are arranged on arrival’ (Wood, 1994)

 Training and preparation

Appropriate training and preparation before placement

Contact with previous volunteers

Debriefing

Encouraging people to share experience

Set training and preparation events

Health monitoring

Meeting in UK

Training and preparation in country

Volunteer involvement in planning

‘the intensity of the learning experience and pretrip preparation had a greater influence’ (Button, 2005)

‘subsequently question the actual benefit of their placement. Of note, this was despite the fact that all had received comprehensive pre-placement briefings and documents, and had had contact with previous volunteers’ (Elnawaway, 2013)

 Type of organisation

Health Partnership

Existing organisations

Commercial involvement

DIY/self-organised

Remote or physical volunteering

‘Links forged as trainees on these initial UROLINK visits have often been strengthened, and centres where these trainees have become consultants are now ‘twinning’ to continue the two-way exchange of experience.’ (Gujral, 2002)

 Transferability of skills learnt

Non-transferable skills

Skills latency period

Context dependency of skills

‘Areas in which responders were most easily able to transfer competencies to the UK to a moderate or significant degree were personal qualities (such as self-awareness and integrity)’ (Young, 2014)

 Volunteer dynamics within project

Different disciplines of volunteers in project

Number of volunteers in the project

Social support from other volunteers in country

Planned travel to destination as a group

‘Thus a broad range of departments become involved and a variety of activities are developed with the partner institution in the United Kingdom. As our experience grows, we are seeking to catalyse major links between medical schools and hospitals. This is preferable to a medley of individual links from a number of different institutions converging on a single overseas institution because it brings coherence to the goals of individuals and groups involved.’ (Parry,. 1998)

 Choices made/behaviour

Desire to become culturally sensitive

Wanting to work outside of competency

Willingness to work in dangerous situations

Use of stress reduction strategies

Understanding of local context

Communication with friends/home

Feeling like a foreigner

Being realistic about achievements

Engagement with project

Willingness to learn language

Perception of placement as negative or positive experience

‘a LMI country may present a temptation to students to undertake medical care or procedures which they would not be permitted to perform at home’ (Lumb, 2014)

‘learning the local language will enable nurses to succeed in developing relationships with patients or nursing students. In doing so, they will begin to move to the third level of cultural competence’ (Paterson, 2014)

 Motivations for international placement

Professional/career motivations

Personal

Cultural

Recognition from peers

Desire to help other

‘unclear whether those who participated wanted to learn from the experience or whether they saw themselves as aiding the perceived ‘unfortunate” (Button, 2005)

 Differences between volunteers

Level of advanced preparation

Age

Locum posts before or after

Have individuals volunteered before?

Stage in professional career

Level of experience

Use of professional leave

‘the range of professionals that are not qualified so they have to be supervised when they go out’ (workshop participant)

‘In practical terms, overseas working may be more accessible to younger GPs who have fewer family and financial commitments and may take up international work during training or during periods of job transition’ (Smith, 2014)

 Opportunities for reflection

Critical reflection

Set reflection tasks

Debrief

Self-reflection when choosing a placement

Time for post-placement reflection

‘the process of critical reflection was uncomfortable for some. Critical reflection facilitated in a safe place may support individuals to transform their way of thinking’ (Briscoe, 2013)

 Opportunities for clinical exposure

To experience complex situations and procedures

To be thrown out of professional comfort zone

To experience a different healthcare environment

To experience a measure to compare UK and NHS to

To experience unusual networks and hierachies

To work with higher severity of illness

To work with limited resources

To work with many illnesses: spread and volume

‘Participation in health links provides in depth experience of these increasingly global pathologies’ (Peate, 2008)

‘cannot emphasise enough how seeing a mind-bogglingly large number of seriously ill people has helped … in [their] subsequent career.’ (Seo, 2012)

 Opportunities for culturally different exposure

Risk exposure

To engage with people from culturally diverse backgrounds

To experience another culture

To experience being a foreigner

To experience challenging situations

‘being a foreigner- trigger for disturbance’ (Greatex-White, 2008)

‘the opportunity to work in complicated, poorly resourced and challenging environments’ (Kiernan, 2014)

 Opportunities for skill development

To test coping mechanisms

To use own approaches to care

For creativity and innovation

For hands on work

For student/volunteer-centred approach to learning

To use risk management skills

To convert knowledge to know how

To develop communication skills

To challenge communication skills

To practice clinical skills

To practice speaking in another language

To put theory into practice

‘There was lots of hands-on experience and opportunities to improve clinical skills (Kiernan, 2014)

‘opportunity to use skills- risk management’ (Workshop participant)

‘the opportunity to develop their clinical skills.’ (Barnabas, 1992)

 Opportunities for research skill development

To research unusual areas

To undertake collaborative research

To conduct research mutually

‘Many doctors undertaking research in the UK become frustrated with its perceived lack of relevance to health care: research in developing countries is often more applied and the benefits more tangible’ (Banatlava, 1997)

 Opportunities for leadership

To be included and opinions valued

For teaching

To lead and have responsibility

To use risk management skills

‘opportunities to develop leadership skills’ Smith (2014)

 Opportunities for atypical learning experiences

To learn about self

Mutual learning

‘Nursing electives at home or abroad may be one way of encouraging nurses in the UK to consider their role and function from a different perspective” (Peate, 2008)