Case Series Comparing Physical Therapy International Clinical Education Experiences in a Developed and Developing Country and Measuring Against Professional Standards and Guidelines

Abstract

Background. 

With a growing vision for globalization and internationalization in higher education, a number of Commission on the Accreditation of Physical Therapy Education (CAPTE)–accredited physical therapist education programs across the United States have begun to routinely place their students at international sites for one of their full-time clinical education experiences in both developed and developing countries. The purpose of this article is to compare and contrast the physical therapy international clinical education experience in both the developed and developing country and compare the experiences to professional standards and guidelines.

Case Description. 

This case series describes the experience of 9 physical therapy students in an 8- to 10-week, full-time, international, clinical education experience. Four were placed in the developed country of Italy, and 5 were placed in the developing country of Belize. All students participated in preclinical preparation and experienced cultural immersion for the 8–10 weeks that they participated in the full-time clinical education experience.

Outcomes. 

Evaluative materials consisted of a student weekly questionnaire, an electronic student journal, a Clinical Site Evaluation Form, and comments/ratings from the student's self-assessment on the American Physical Therapy Association's Clinical Performance Instrument. Analysis of the data demonstrated that the participants were experiencing a depth and breadth of clinical experiences commensurate with CAPTE criteria in both the developed and developing settings. Both settings afforded learning experiences in cross-cultural communication and cultural considerations with the developing country posing more cross-cultural practice challenges than the developed country.

Discussion and Conclusions. 

Comparison of the data with a proposed model and guidelines for optimizing international clinical education experiences demonstrated alignment in both the developed and developing country experiences. Both international clinical education experiences met CAPTE standards and other professional standards and proved to be a broadening experience for the participants.

BACKGROUND AND PURPOSE

With a growing vision for globalization and internationalization in higher education,¹ a number of Commission on the Accreditation of Physical Therapy Education (CAPTE)²–accredited physical therapist education programs across the United States have begun to routinely place their students at international sites for one of their full-time clinical education (CE) experiences.³ Commission on the Accreditation of Physical Therapy Education formally recognized the potential positive impact of international CE in a 2009 position statement,⁴ and CAPTE's evaluative criteria² do not preclude physical therapy students from obtaining a portion of their formal CE requirements outside of the country. A 2012 survey found that 45 of 110 responding US programs currently offered international CE and another 12 programs had plans in development. Most of the international CE sites were in high-income and upper middle–income countries.³

International CE has been defined as “an educational opportunity that a student participates in, outside of the country where the physical therapist education program is situated, for which he/she obtains clinical education credit.”^{3(p. 70)} According to CAPTE, a full-time CE experience requires student participation for 35 hours per week or more, with the length of each placement flexible for the physical therapist education program.⁴ In CE, the focus is on the development of physical therapy skills, centered around the patient/client.⁵

International CE literature describes both the student experience^6-11 and the host clinical site experience.^12,13 Audette⁶ described international CE as a broadening experience for students with enhancing student value of cultural differences, responsibility for and collaboration with others, and creativity within the available resources. Wickford⁷ reported that student participation and reflection led to the development of insights into context and culture. Additional sources document improvement in student cultural awareness, use of narrative reasoning, and an appreciation of their role within the context of a different culture.^8-11 Literature providing the host clinical site perspective calls for extensive student preparation regarding cultural and societal practices, communication strategies/challenges, and specific education regarding the perspective of the host site to equip the student to enter and immerse within the host community effectively.^11,12 Host communities also value student immersion in the local community.^12,13

Ethical concerns have led several researchers to seek best practices for guiding international experiences. The occupational therapy professional education literature supports clinical placements of longer durations, allowing students to assimilate and experience the rich cultural experience.¹³ From the physical therapy profession, Pechak and Black^14,15 sought to identify an optimal model for international CE experiences by conducting a qualitative investigation of US faculty members with experience in sending students on International CE. They established a model that included essential core conditions, phases, and consequences. Later, Pechak and Black¹⁶ took established guidelines for best practices in medical student international CE and sought to modify them for relevance to physical therapy through 3 Delphi rounds with physical therapy experts. The product was a set of guidelines for physical therapy international CE experiences.

The current literature provides accounts of student experiences and exposes ethical considerations in international CE. To date, no work has been published that neither compares and contrasts international CE in both a developed and developing country nor compares both experiences to existing professional standards or guidelines for practice. The purpose of this case series is to explore the international CE experience in both a developed and developing country and measure the findings against the frameworks of CAPTE criteria,² a proposed model for Optimal International CE Experiences,¹⁵ and proposed Guidelines for International Clinical Education.¹⁶

CASE DESCRIPTION

The doctor of physical therapy (DPT) program at Widener University has been offering 2 international CE placements for 6 years. This international experience is intentionally offered at the start of the third year in the program as a first full-time CE experience rather than the second or third (terminal) full-time CE experiences. The terminal DPT CE courses require students to demonstrate clinical competence for entry-level practice in the United States, which includes the management of a full clinical caseload. The ability to consistently demonstrate management of a full caseload varies at the international sites because the caseload is often shared among DPT students and cultural expectations of a full caseload may not be equivalent to that in the United States. Other elements of entry-level competency, such as billing, documentation, delegation to support staff, and referral to other health professionals differ in the international sites, making it difficult to document entry-level competency.

The 2 international clinical sites were first identified by 2 students interested in completing an experience at each specific international site. Both host sites had established CE programs with identified local clinical instructors (CIs) and published websites with student resources for travel, packing, and general information about the setting/caseload. Once a student was accepted for a placement, resources were shared by the clinical site that included information on the local health system, common terms and translation, related research articles, and general information to promote student success. The Director of Clinical Education (DCE) assisted with the execution of an affiliation agreement that met the needs of all parties. One site was in the economically developing country of Belize and the other in the developed country, Italy, as defined by the United Nations.¹⁷ By definition, a developed country is more industrialized and has a higher per capita income level, and developing countries are less industrialized with lower-income levels. Higher levels of unemployment and poverty, lower education levels, and less access to health care, transportation, and public health needs are characteristics associated with developing countries.¹⁸ The host site in Belize, Hillside Health care International, supports/provides rehabilitation services to the local community in support of their mission to provide medical care and health education to the people of southern Belize.¹⁹ The placement in the developed country of Italy occurred through an intermediary organization, Eduglobal Associates,²⁰ who assisted with placement logistics. In Italy, public universal and comprehensive health care is provided free of charge or at low cost. After the first 2 students completed the experience, the DCE, students, and clinical site personnel communicated to discuss the students' successes, challenges, and future recommendations for the CE relationships. All stakeholders deemed the initial experiences to be a success, and the institution and the host site organizations agreed to continue the relationships for future clinical site placements.

The Application and Selection Process

Students formally learn about the international CE opportunities when previous student participants provide a presentation within their global health course. Interested students met with the DCE to express interest and review specific aspects regarding international travel, cultural immersion, and expectations for the student to be proactive about communication and clinical performance. Students had to have a minimum program grade point average of 3.0 to be considered. The DCE vetted all potential participants with the core faculty to ensure strength of the applicant academically and professionally. Student professional behaviors during faculty interactions, psychomotor testing, peer group activities, and those observed in clinical/community settings were informally discussed, with faculty expressing any positive, unique, or concerning behaviors. Strong performance in areas of professionalism, communication, and accountability are needed to promote student success in these settings. Additionally, each site had a competitive application that requires students to submit an essay articulating why they desire this placement. Students accepted by the host site move to the preclinical preparation stage.

Preclinical Preparation

In the preclinical preparation stage, accepted students met with the DCE and the experienced students to learn more about the sites and discuss safety considerations, educational opportunities, caseload expectations, general logistics, and overall challenges and opportunities. Students are guided to the website of the Centers for Disease Control travelers' section for additional information. Per University policy, students attain additional health and evacuation insurance. Both host sites provide student orientation information specific to the local health care system, language, culture, and student experience. Students have opportunities to review these materials and ask questions of the host, the DCE, and the experienced student travelers. Both host sites assist students in the scheduling and organizing of travel and housing.

Communication plans included midterm conversations, as well as weekly email communication between the student and the DCE. Communication during travel and the clinical experience were predetermined according to the capabilities at each site. Learning objectives were standard for this first full-time CE course and were no different than those for students placed at domestic clinical sites.

Site Logistics

Upon arrival at the host site, students received additional information. In Belize, the orientation included familiarization with culture, language, public health considerations, general schedule, and clinical opportunities. In Italy, information was more specific to the daily schedule, cultural communication, and clinical expectations. In Belize, the students lived on campus in a dormitory shared by a variety of student health professionals. The facility provided transportation to a nearby town for student shopping, dining, and recreation; or students could choose to walk, bike, or take a bus to the town. In Italy, student housing was coordinated by the intermediary organization, typically in a small town local to the health care setting. Transportation to the clinical site was by rental car. In both settings, living and engagement in the local community provided opportunity for cultural immersion. The CIs are employed by the host facility (Belize) or directly by the local medical facilities, which contract with an intermediary partner organization (Italy) and meet CAPTE standards for qualifications.²

Enhancements

Enhancements to both experiences continued as each group of students successfully moved through the clinical experiences and host communities provided feedback. Students highlighted the importance of increasing precourse experience preparation, particularly in the areas of communication with the local community and basic clinical skills. Postexperience debriefings with the DCE and returning students were introduced. Additionally, the experienced students would participate in an orientation session with the new students accepted to travel in the next year. These conversations revolved around safety, physical therapist clinical learning, and then moving to logistics of travel, housing, recreation, and packing needs. To learn about the clinical site and community, better understand the physical therapy clinical opportunities and thus promote a more complete preparation and focused midterm conversation, the DCE volunteered as a short-term guest preceptor at the site in Belize. The DCE also participated in one-to-one meetings with representatives of the intermediary company for the experience in Italy at professional conferences and via telephone. These experiences helped the physical therapist education program side to better appreciate and support the clinical site and promote student readiness. Two specific enhancements were related to documentation skills and focused reflection on the impact of cultural factors in physical therapy practice (Table 1).

Table 1. - Enhancements Enacted by Academic Institution and International Clinical Site by Year

Year	Academic Institution	International Clinical Sites
1	• Expanded upon global health course content • CE contract in place with clarity of reciprocal benefit	• Competitive application that included experience and rationale for seeking international CE placement • Web site, shared resource documents, onsite translators, assistance with travel/housing/money • CE contract in place with clarity of reciprocal benefit
2	• Student presentation to all DPT cohorts • DCE debrief with students and clinical site • DCE and future students discuss student success strategies • Added specific student preparation around basic clinical skills and communication with the local community	• Required student to submit objectives specific to international CE • Debriefs with DCE—focus on student performance and readiness for a first full-time CE placement • Developed country site required additional documentation
3	• DCE volunteered 2 weeks at developing country site • Encouraged strategies to maximize learning: language, use of down time, awareness of US billing, outcome measures • CE assignment altered to focus on cultural considerations	• Google translator use encouraged
4	• Provided resources for developing country: skeleton, books, supplies • Outcome measure project initiated with the Director of Rehabilitation in developing country	• Plan for academic program representative visit to Italy • Ongoing faculty trips to Belize

CE = clinical education; DCE = director of clinical education; DPT = doctor of physical therapy.

OUTCOMES

Data from a variety of sources help describe the experience of the DPT students placed in these 2 international sites for the 8- to10-week full-time CE experience. The participants were recruited to participate in the data collection after they were accepted to the international CE experience. All participants signed informed consent. The investigation was approved by the Widener University's Institutional Review Board.

Evaluative materials consisted of the DPT program's Clinical Site Evaluation Form, student weekly questionnaire responses, an electronic student journal, and the subjective student comments completed on the American Physical Therapy Association (APTA)'s Clinical Performance Instrument (CPI).²¹ The program's Clinical Site Evaluation Form is completed by all students at the end of a full-time CE experience regardless of location. This form captures information on clinical setting, case mix, learning experiences, interaction with other professional and paraprofessional personnel, and components of clinical skills. A copy of the Clinical Site Evaluation Form is included in the Appendix A (Supplemental Digital Content 1, https://links.lww.com/JOPTE/A106). The student weekly questionnaire was designed by the investigators to capture elements in the CAPTE criteria, the Model for Optimal International Clinical Education,¹⁴ and the Guidelines for International CE,¹⁵ sources that served as conceptual frameworks for this investigation. A copy of the student weekly questionnaire is included in the Appendix B (Supplemental Digital Content 1, https://links.lww.com/JOPTE/A107). Additionally, participating students maintained an electronic unstructured journal 3 days per week for the 8–10 weeks of their experience, allowing them to capture their thoughts and reflections. Finally, the investigators explored the participant's self-assessment ranking and comments in the APTA's CPI²¹ to verify that student participants were developing the clinical competence expected of this CE experience.

The first investigator conducted a review of the Clinical Site Evaluation Forms and organized the data across the developed and developing country experiences. Both researchers analyzed each participant's journal and weekly response entries individually and then triangulated across the cases for common themes related to their country of experience. Then, the researchers worked to compare their findings. Finally, the first researcher analyzed the CPI data for each participant to explore the attaining of clinical competencies and corroborating comments. Together the researchers triangulated all data points to fully assess the extent to which CAPTE criteria² were met, the International CE Model¹⁵ followed, and the International CE Guidelines¹⁶ considered.

Over the 3 years of the investigation, a total of 5 students were placed in rural southern Belize, and 4 students were placed at 3 different locations in the Tuscany region of Italy. Figure 1 shows the organization of the case series. Analysis and summary of the Clinical Site Evaluation Form revealed similarities across case mix, components of physical therapy practice, and learning opportunities that were similar to those students who completed CE in the United States. There was less opportunity for discharge planning in Belize, due to inconsistency in client visits, yet more opportunity for referral to/collaboration with other medical professionals, as compared with the experience in Italy. Students reported experiences in a variety of settings in both countries: in Belize, ambulatory/outpatient, home health, mobile clinics, and community-based rehabilitation/education; in Italy, ambulatory/outpatient and inpatient rehabilitation settings. In Belize, client ages ranged from 4 months to 90 years. In Italy, students worked with adult clients ranging in age from 30 to 80 years. A diverse case mix was reported by all, with opportunity to work with clients with both simple and complex diagnoses across the musculoskeletal, neurologic, cardiopulmonary, integumentary, and endocrine/metabolic systems. The findings yield more similarities than differences between the settings and demonstrate alignment with CAPTE standards regarding the required breadth and depth of full-time CE.

Figure 1.: Organization and triangulation of the case series. CAPTE = Commission on the Accreditation of Physical Therapy Education; CE = clinical education.

Assessment of Competency

Review of the final CPI and subsequent passing of the CE course revealed the student attainment of the level of clinical performance outlined by the first full-time CE course syllabus. Documented student opportunities, skills, caseload, and competence were similar to those documented for students completing a CE experience within the United States, but with additional opportunity for cultural immersion, navigating communication challenges, and professional growth. Students in the international experiences were rated higher than their peers in the area of Cultural Competence on the CPI. Students in both international settings described appropriate use of an interpreter, integration of client narrative/environment, and appreciation for cultural differences according to student self-assessment and CPI comments. Content analysis of the student weekly questionnaires and electronic journals across both the countries highlighted the communication and cultural considerations that served to broaden their experiences. Table 2 shows complete listings. Example quotes and narrative capturing the cultural communication and additional cultural considerations specific to each international experience follow.

Table 2. - Summary of Data From Student Weekly Questionnaire and Journal

Data	Developing Country		Developed Country
Diagnoses seen		• Cerebral vascular accident • Fracture with immobilization • Rheumatoid and osteoarthritis • Overuse injuries, sprain/strain • Spinal cord injury • Brachial plexus injury • Developmental delay	• Cerebral vascular accident • Fracture s/p surgery • Joint replacement • Multiple sclerosis • Ventilatory-dependent condition • Chronic obstructive pulmonary disease
Considerations and challenges with communication		• Use of interpreter • Words without translation in the K'etchi language • Health literacy challenges • Tactile cues and gestures	• Use of interpreter • Inaccuracies in translation • Tactile cues and gestures • Loud voice volume • Challenge of male/female words • Greet by kissing 2 cheeks
Considerations and challenges with culture		• Strong family roles and identity • Bed mobility training from a hammock • Impact of open cooking fires in homes on safety, respiratory health, and cooking postures • Impact of superstition on health beliefs and behaviors • Time is “flexible” • Lack of resources • Clients not valuing or understanding physical therapy	• Cultural differences related to modesty (were less modest) • Societal high value of activity and wellness • Time is “flexible” • Socialized health care system • Minimal documentation required • Family education not as valued

Cultural Communication Considerations

In the developing country, primarily English and K'etchi were spoken. The K'etchi are a Mayan people group who reside on the Yucatan peninsula and speak a language called by their name.²² Participants noted low health literacy among native Belizeans. Participants often questioned if translations were accurate, and sometimes words did not exist in K'etchi for appropriate translation.

The health literacy is very low in the villages, so it is challenging to think of a way and think of analogies to each people about their injury or pathology. (B1)

I began to understand how important it is to break down tasks into steps they can understand, to demonstrate, and recognize when I am speaking in too many technical terms. (B4)

These challenges led participants to note professional growth in communication.

I am a better listener/interviewer, seeing each person uniquely and better able to communicate with them in a way that is meaningful. (B2)

In the developed country, language barriers were very common, and participants reported high use of interpreters. Participants noted uncertainty about accurate translation but expressed less concern for health literacy and more concern for Italian language semantics.

The Italian language uses different words depending on if you are speaking to a male vs. a female. I have noticed how many times I say the wrong word, especially because the patients aren't afraid of making fun of me anymore. (I4)

Additionally, they reported cultural differences in nonverbal patterns of communication, such as loud voice volume, a high level of physical contact/touching, and customary greetings. One participant recorded, “When saying good-bye to a few patients, it is customary to kiss on the cheeks. There were a few awkward moments.” (I2)

Additional Cultural Considerations: Developing Country

Cultural considerations in the developing country were vast and included differences in daily routines, environmental challenges, health beliefs and family/societal values, temporal considerations, and the emphasis on community-based rehabilitation and a collaborative interprofessional team approach. Daily routines and environmental challenges included consideration of navigating sloped dirt floors, transferring from hammocks, cooking over low fires, repetitive machete use (a machete is a sharp multiuse tool often used in repetitive motions),²³ and carrying of children in lepobs (a Lepob is a K'etchi term for a sling to carry child or load in a sheet which is anchored around the forehead and the weight on one's back).^24,25

I realized my questions couldn't be “what kind of mattress do you have” or “how many pillows do you use?” The questions became, “do you sleep on a sponge or in a hammock?”(B1)

Participants frequently noted challenges with lack of resources but framed them as opportunities for creative innovation. For example, when a participant wanted to teach self-mobilization to a client but did not have a tennis ball or foam roller availability, she incorporated the use of a readily available cohune nut. Another participant noted, “I am learning how to be creative when working with limited resources and limited space.” (B1)

Participants also reported having to consider differing health beliefs and values. The concepts of therapeutic exercise or rest were often not readily accepted as both men and women reported that they were physically active in their day-to-day activities. Likewise, they found clients generally accepting of aging and chronic health conditions and therefore less likely to see the value of physical therapy. Clients frequently attributed their health condition to a “hot/cold” theory of illness and to various superstitions or curses.

I have definitely become more culturally competent during my time here. I have become more aware of different cultures' beliefs about alternative medicine and healing processes/remedies, so I won't be as quick to assume patients have the same beliefs about medicine as I do. (B3)

Participants reported a difference in the concept of time; Belizeans were patient to wait an hour to be seen by a medical professional or ride a bus, and likewise, they were comfortable being late for a scheduled appointment. A final consideration that arose from the data was the importance of community-based rehabilitation and the interprofessional team approach. The participants noted repeatedly their appreciation of the collaborative team and the opportunity to consider the client's needs from the context of culture and community.

This experience has given me a better understanding of the interprofessional team approach, and how each patient's values and lifestyle impact their goals. (B5)

Additional Cultural Considerations: Developed Country

Cultural considerations in the developed country centered around customary practices, health and wellness values, temporal considerations, and the uniqueness of the socialized medical system. A different customary practice that stood out to participants included differences in protecting client modesty.

It is not uncommon for patients to on tables with each other and performing session in their underwear. Draping, gowns, and curtains are not considered. (I2)

During a gait eval, my CI asked the patient to remove his clothes, and complete the eval with the patient in his underwear – this caught me off guard. (I3)

Participants also commented on the high cultural community regard for wellness and fitness. They noted that it was common for people to walk or bike to destinations rather than drive. Students also noted that in their limited experience, the Italian clients embraced and adhered to exercise programs more readily than clients in the United States.

Like in Belize, the concept of time in Italy was more flexible than that in the United States.

This week, I would say that I find myself being continually challenged by “Italian time.” Everyone is a lot more laid back here and things, such as appointment times, rarely begin when they are supposed to (I3)

The participants noted less interprofessional collaboration than they expected. For example, occupational therapy is not a recognized profession in this country; participants were empowered to address some of these client areas of need, such as dressing and grooming. Professions with whom participants did collaborate were physiatrists, nursing, and physiotherapists.

Safety Considerations

Review of the data revealed minimal to no safety concerns in either of the international settings. The only safety issue expressed by participants in the developing country concerned feral dogs when the participants were out jogging. In the developed country, the participants reported no safety issues, noting the use of recommended safety practices, including traveling in groups and in daylight when possible, keeping possessions and valuables in sight or secured, exercising polite and respectful behavior with all, having an awareness of surroundings, and informing others of plans.

DISCUSSION

Analysis of Meeting Commission on the Accreditation of Physical Therapy Education Standards

The full-time international CE experiences described provided students with experiences comparable to those offered in the United States. Both settings met CAPTE CE expectations around caseload, physical therapy skills, and CI instruction.² All participants reported engagement with clients across the lifespan with impairments across body systems, with opportunity for client interview, examination, evaluation, clinical reasoning, outcomes assessment, intervention, documentation, client education, and professional behaviors. Additionally, a clinical environment of mutual respect, learning, and opportunity to learn from CIs that are excited to teach enhanced the experience. These characteristics of a range of clientele, experiences, and an overall positive perception of the experience are congruent with reported student perceptions described in CE research by Rindflesch et al.²⁶Table 3 includes the relevant CAPTE criteria² and the program/site's compliance with the criteria. The international CE experiences in both the developed and the developing nation fully met CAPTE standards.²

Table 3. - Overview of Adherence to Published Standards and Guidelines

CAPTE criteria4 specific to clinical education

• Standard 8G: written agreement in place • Standard 4O: CIs met criteria for licensure and experience • Standard 6J: valid assessment measures used (CPI) • Standard 6L-L5: variety of ages and settings alignment with student expected outcomes of the institution. • Standard 7C: variety of diagnoses and systems; limited interprofessional collaboration and delegation to support personnel • Standard 7D-7D42: met all criteria except 7D24 (no direct access) and 7D27 (no PTAs for delegation)

Conceptual model of international CE15

Essential core conditions and essential phases alignment: • Development: site assessment, legal agreements, mutual understanding established • Design: student/CI selection, timing in curriculum, learning objectives, risk management all considered • Implementation: student preparation, communication during the student placement established • Evaluation: student reflection and assessment, CI, and site evaluation • Enhancements: action based on evaluation/communication among stakeholders, with the ultimate goal of expanding the experience for all stakeholders active

Guidelines for international CE16

• Relationships and experiences structured for mutual benefit • Clear goals, expectations and responsibilities for host site, academic institution, and student educational-level articulated • Ongoing assessment/updating of student preparation occurring • Effective communication between host and academic partner through all phases and conflict resolution happening • Student participants motivated for this experience, strong academically, and representing their country/program well • Promotion of participant safety happening • Collaborative evaluation between site and academic institution in place • Assuring CIs meet standards of professional accreditation • Conducting assessment of student experience • Following international guidelines related to donations

CAPTE = Commission on the Accreditation of Physical Therapy Education; CE = clinical education; CI = clinical instructor; CPI = Clinical Performance Instrument.

Alignment with the Conceptual Model of International Clinical Education

Review of the data demonstrated that both the developed and developing country experiences were in alignment with the Conceptual Model of International Clinical Education¹⁵ (refer Table 3 for information). Both sites met the Essential Core Condition of meeting the standards and expectations of CE; possessed the essential components of phases through development, design, implementation, evaluation, and enhancement; and demonstrated the essential consequence of a broadening CE experience. The broadening aspects of the experience were in the areas of communication and cultural considerations.

Participants reported an enhanced appreciation of communication in these international settings. Reliance on an interpreter, tactile cues, nonverbal facial expression and gestures, and health literacy challenges facilitated participant reflection on not only what to communicate but also how to communicate most effectively, aspects previously reported in the international professional health care education literature by Thompson et al²⁷ and Smith-Miller et al.²⁸

Specific to Belize, participants noted an appreciation for the social determinants of health and holistic health needs of the community. They were challenged to navigate resource limitations and work within culturally different ways of living. These findings equate to the broadening experiences describe by Audette.⁶ Interprofessional health care was present, with participants reporting an understanding and valuing of the nurse, public health professional, physician assistant/physician, pharmacist, and educator. Literature supports the role of interprofessional collaboration to best address community needs and foster interdisciplinary collaboration for the benefit of the local community in international settings.^27–29

All participants from both settings reported ongoing learning opportunities with their CI, an expectation to provide education to the local professional staff, and all expressed value in the cultural immersion. The extended time frame of a full-time CE experience in an international setting, as compared with a week-long service-learning experience, provide the opportunity to live, dine, shop, and travel in the local community, in addition to the CE experience. Participants had the opportunity for cultural immersion, authentic learning of local customs and languages, and experienced broadening insights and lived experiences, also documented by others.^6,9 All participants indicated that their international CE experience was valuable and would likely impact their personal and professional lives. Others have documented life-changing attitudes, insights, and personal growth with international learning experiences.^30,31 with participants expressing an increased insight into their professional role and cultural understandings.^6,30,31

Alignment with Proposed Guidelines for International Clinical Education

The Guidelines developed by Pechak and Black¹⁶ call for transparent and documented expectations, communication, and assessment for both the clinical site and the physical therapist education programs, clarifying responsibilities of each and consideration of local needs and priorities of the clinical site. In review of the Guidelines and the procedures in place, many recommendations are addressed within the CE contractual agreement, CE course syllabus, information shared by the partner agency/host site, and an email exchange focused on student assessment. Education of students regarding professionalism, communication and conflict resolution, and cultural competency is incorporated in various academic coursework completed prior to the student's first full-time CE experience. Potential students complete an application reviewed by the partner/host institution to further insure a mutually beneficial placement. Clinical education site personnel describe CI satisfaction and enjoyment from the relationships with the students, the opportunity to learn from each other, and the supportive patient comments regarding US student involvement in their care. The only relevant guideline that has not yet been addressed is the call to track participants’ postclinical experience to evaluate the long-term impact of the experience. This is an area for future research.

Limitations of this research include a small number of 9 participants from one physical therapist education program and only 2 international clinical sites, both who had developed and operational CE programs. The impact of student placements on the CI, host site, and local community was not specifically explored. These findings may not carry over to new or developing international clinical sites. This research may not be generalizable to other international CE programs and yet the amount of information and detail presented here may serve as a guide or resource for the development of similar programs. Attention to mutually beneficial relationships, accreditation/graduation standards, transparent communication amongst all stakeholders, and intentional focus on the unique aspects of the international student experience, specifically pertaining to communication, cultural competence and safety will promote and enhance development of additional international clinical sites. Future research might focus on the impact that participation in an international CE has on students in their future professional practice, service, and global citizenship.

CONCLUSION

This report is one of the first to examine the unique and relatively new DPT international CE experience. This work highlights the similarities and differences of these experiences within a developed and developing country, as well as how these experiences measure up to professional expectations. The results point to more similarities than differences between the 2 sites and confirm that both experiences met professional expectations. The consideration of the CAPTE criteria, the proposed model for Optimal International CE Experiences, and the proposed Guidelines for International Clinical Education validated that both international CE experiences were appropriate, meaningful, and constructive. The international CE provided ample clinical and professional skill development with client age, diagnosis, and clinical settings representative of those in the US Student journals and weekly summaries indicated that the experience broadened their personal and professional understandings and worldview. The cultural immersion and learning in conjunction with the site-specific learning opportunities for interprofessional collaboration, global/public health, and communication added value to these experiences. Ongoing communication between the academic program and international CE personnel supports the mutual benefit and continuation of these relationships. Our findings support the placement of DPT student at international sites for full-time CE. When clinical sites align with the published guidelines and the Optimal Model for International Clinical Education, this can be a win–win experience. Based on the student experiences at the 2 different locations in this report, these placements meet professional physical therapy CE expectations and provide broadening communication and cultural experiences for both the students and host clinicians.