Introduction: Why Ethical Educational Placements?

Abstract

This introductory chapter opens with a discussion of the processes of internationalisation and globalisation that frame the growth in interest in educational placements. It situates student mobility within this wider context before examining the meaning of the term ‘elective’ and examining the ethical issues that such placements raise.

Globalisation, Internationalisation and Undergraduate Mobilities

Internationalisation has emerged as an increasingly important metric in UK university league tables and marketing. Indeed most, if not all, UK universities now actively promote an ‘Internationalisation Strategy’ (Coey 2013; De Wit et al. 2008). Much of this development has taken place within the past decade often as a key element of ‘marketisation’ (Molesworth et al. 2011). This does not imply that universities have not been involved in international relationships for many years; the more prestigious universities have been involved in international activities for over a century. Altbach and Knight (2007) point to a clear relationship between institutional prestige (and by implication resource) and historical engagement with internationalisation processes. Historically, internationalisation has been concerned primarily with research relationships and academic (staff) mobility (see De Wit 2008). In recent years, the internationalisation of education has become more firmly associated with the selling of educational programmes to international fee-paying consumers. The importance of English to these consumers, coupled with the relatively poor linguistic skills of young people in the UK, has influenced mobility flows and shaped the outward mobilities of UK undergraduates. In more recent years, and in some respects linked to the international ‘offer’, with the intention of making UK courses more relevant and attractive to foreign consumers, attention has shifted to incorporate an international dimension into teaching. And, linked to this but perhaps rather differently motivated, the broadening of curricula and educational experiences has been viewed as essential to the future employability, resilience, connectedness and culture competence of graduates. Additionally, as evidenced by Health Education England’s interest in funding the Ethical Educational Placement (EEP) project, internationalisation has been recognised as a mechanism for accessing new knowledge which students who participate in study and work abroad programmes can bring back to enrich home institutions.

It is difficult to talk about internationalisation without acknowledging and placing it within the context of globalisation (De Wit et al. 2008), and internationalisation and globalisation are often conflated. However, several writers indicate the importance of separating the two concepts. Altbach and Knight (2007) describe globalisation as the wider economic, political and social forces which steer universities towards internationalisation. In this rendering, globalisation can be understood as a set of macro-structures or processes, framing and shaping the internationalisation of the higher education sector: or as the forces which propel higher education towards greater international involvement. In other words, globalisation is an inevitable feature of modern society which has social, economic and political influences and education is becoming increasingly subjected to the wider global economy. On one level then, internationalisation can be seen as universities’ responses to globalisation. Equally, internationalisation processes in the university sector reinforce and shape globalisation (De Wit 2008).

Brooks and Waters (2011) add to this complexity arguing that globalisation is itself intrinsically linked to neo-liberalism in the context of increasing marketisation processes. On this basis, they argue that globalisation should be problematised particularly with reference to education. Altbach and Knight (2007) identify three features of the relationship between globalisation and higher education. In the first instance, this concerns the role that universities play in the commodification of programmes. Here, demographic trends are significant with student (consumer) flows showing a marked directional imbalance (from the global South-East to the global North-West). Secondly, the authors point to the rapid emergence of private, for profit universities, particularly in Asia and Latin America. And finally, they refer to new ways of delivering international higher education programmes through e-learning, franchise operations, satellite campuses and split-site arrangements.

Clearly, the global context within which higher education institutions operate is changing and internationalisation comprises an increasingly wide range of initiatives (De Wit 2008). In this environment, recent studies suggest that institutions are not adopting internationalisation strategies in a comprehensive and uniform manner. Further, an emerging body of research questions the compatibility of these marketisation (or neo-liberal) approaches with wider ethical concerns (De Wit 2008). Globalisation tends to concentrate wealth, knowledge and power in resource-rich institutions and international academic mobility favours these systems. As such, and left to its own devices, it compounds global inequalities (Altbach and Knight 2007).

Student Mobility

Student mobilities play an important role in internationalisation and globalisation processes. Until recently, student mobility has not been a major focus in academic research on international migration and population movements, and researchers interested in human mobility, particularly those investigating international migration, have neglected the importance of international student migration (Findlay et al. 2005). This is beginning to change as authors such as Brooks and Waters (2011) and Findlay et al. (2005) have drawn attention to the growth of this phenomenon and the factors involved. Findlay et al suggest that international student mobility is, in part, precipitated by ‘rite of passage’ aspirations [amongst] young post-modern individuals (2005: XX) rather than factors associated with traditional economic migration. Certainly, the role of travel has become increasingly important in young people’s lives fuelled by the promotion of the ‘gap year’ and other forms of mobility associated with and stimulated by higher education and commercial actors. In society as a whole, the role of travel has increased and student mobility needs to be seen within the context of that wider framework (Brooks and Waters 2011). Indeed, travel for (middle class) young people is now an almost taken for granted part of the life-cycle. Technological developments including mobile phones, Skype, Internet access and social networking have made it much easier and cheaper for young people to spend time away and keep in touch with family and friends reducing the ‘discomfort’ involved. Spending time overseas is becoming an increasingly attractive (and necessary) ‘option’ with personal, professional, institutional and societal benefits. The British Council (2013) suggest that international experience is particularly beneficial when competing for future employment and often mobility is seen as a way for graduates to make themselves distinctive and gain a competitive edge in the labour market (Brooks and Waters 2009). Indeed, over the last twenty years the ‘gap year’ has become a recognised phenomenon (Simpson 2004) and volunteer tourism, something of a rite of passage for growing numbers of young people. Although future employability is a key motivation to travel, mobility also plays a key role in identity development among young people as part of self-exploration and self-development and short-term electives may be important vehicles for this (Brooks and Waters 2009).

In summary, a complexity of processes combine to drive and potentially facilitate international student mobility. At the macro scale these include economic and cultural globalisation and internationalisation of systems. These are complemented by institutional level initiatives and individual motivations including the desire for adventure and future employability.

In March 2012, a Joint Steering Group on Outward Student Mobility¹ submitted a report to David Willetts – the UK’s University Minister – making a series of recommendations to encourage outward student mobility. These included:

• 1. There should be a national strategy for outward student mobility;

• 2. There is a need for stable funding for mobility for example from philanthropy, scholarships and bursaries;

• 3. There needs to be flexibility in the curriculum so students can spend time abroad during their studies and for their experience to be more widely recognised;

• 4. It is necessary to collect available data on mobility and there needs to be some consensus about which data are required in evaluation;

• 5. Best practice and greater institutional collaboration is needed to deliver greater efficiency and effectiveness and also to increase diversity regarding student mobility; and

• 6. There should be a stronger promotion of international electives at school level, at the stage before students enrol at University.²

The report also asserts that a national strategy on outward student mobility has the potential to support the widening participation agenda in UK universities³ by allowing widening participation activities to be integrated into the mobility strategy. The idea here is that that such opportunities should be promoted to less privileged social groups who historically have not participated. At the present time, students who exercise mobility tend to come disproportionately from privileged backgrounds, are relatively wealthy, have some foreign language skills and come from families who have a history of mobility and high educational aspirations. Brooks and Waters (2009) point to the gains to students from international mobility in terms of the acquisition of mobility, social and cultural capital. The concepts of mobility and social ‘capital’ are of immediate relevance to the current study. Mobility capital is best understood as the benefits accrued from international experiences which translate into enhance employability whereas social capital refers to benefits that travel brings in terms of social networks (Bourdieu and Passeron 1990). Larsen and Jacobsen (2009) argue that even ostensibly touristic activities can have a profound impact on mobility, social capital and future careers. The challenge facing the new generation of educational placement providers is to ensure that access to such career enhancing opportunities are, as far as possible, open to all.

The type of mobility referred to in Altbach and Knight’s work (2007) concerns ‘whole programme mobility’ with students moving to another country for an entire degree programme. A second form of mobility is sometimes known as ‘in programme mobility’, where students undertake short exchanges, usually for taught elements of their programmes. In the UK context this is often within the frame of funded European Union mobility schemes dominated by ERASMUS.⁴ The final form of mobility involves students who are registered in one country and undertake their taught programme there spending a short period of time on an elective (optional) placement.

The ‘Elective’

The ‘elective’, an optional form of study spent away from a student’s Higher Education Institution, usually for a period of 6 to 12 weeks (Banerjee 2010)⁵ has historically been – and remains predominantly – a feature of medical education. It is estimated that two-thirds of UK medical students take up electives overseas (Hastings et al. 2014). These typically involve students from high resource settings (such as the UK, US, Canada and Australia) choosing placements in low resource settings. The factors influencing the development of medical electives include a recognition of the diverse communities served by doctors and the need for them to understand these; the desire for students to expand their horizons by learning how other systems operate and the impacts of globalisation (Murdoch-Eaton and Green 2011). Although small in comparison, there are growing numbers of veterinary, nursing (Norton and Marks-Maran 2014), occupational therapy (Horton 2009; Clampin 2008), dentistry, midwifery and social-work students taking up international electives. Yet, in spite of the increase in the take-up of electives across academic disciplines, little attention has been paid to the ethical issues encountered by students and even less consideration has been given to their impact on host countries (Ackerman 2010).

The term ‘ethics’ refers to the moral principles that govern individual or organisational behaviour. There are thought to be three schools of ethical thought in Western philosophy: first, derived from Aristotle, the virtues of charity, justice and generosity are believed to be dispositions to act in ways that benefit the individual (agent) and the society in which an individual is placed. Second, influenced by Kant, ethics comprise duty, morality, rationality and the imperative to respect other (rational) beings. And, third, the Utilitarian position on ethics is that the guiding principles of conduct should be of the greatest benefit to the greatest number in a society. These schools of thought share a common focus on the moral responsibility of an individual or organisation to act in a manner which does not cause harm to other members in society. The phrase ‘First do no Harm’ (Primum non nocere) is a guiding principle for physicians in their practice and forms part of the Hippocratic Oath, the moral code for ethical conduct and practice in medicine. Derived from this is the principle of ‘non-maleficence’ (Sharp 1997) which denotes non-harming, or inflicting the least harm possible, to reach a beneficial outcome. For the purposes of this book, we borrow this maxim to frame our focus on undergraduate educational placements, and our examination of the learning and impacts which occur when students from high resource settings spend time in low resource settings as part of their university education. The concept of ‘Ethical Educational Placements’ raises two broad areas of ethical concern. The first area concerns practice in the sending country; in this case the UK. As noted above; the concept of an ‘elective’ in the UK has been closely associated with the mobility of medical students, and electives in that context have formed an increasingly important ‘rite of passage’ amongst this relatively privileged student cohort. This growing ‘expectation of mobility’ (Ackers and Gill 2007) or ‘mobility imperative’ (Cox 2008) is also seen in many other disciplines and places increasing pressure on students to build and evidence mobility capital. Although essentially extra-curricular, this experience forms an increasingly critical component of CV-building shaping access to career opportunity. To the extent that international elective placements are just that: namely ‘electives’ (implying optional choices out with the core curriculum)⁶ they raise serious concerns around equality of opportunity. Widening participation to university education in all areas, including medicine, coupled by the extension of this ‘expectation’ to a wider range of professions where students are less privileged and increasingly debt burdened presents ethical challenges. The Royal College of Midwives National Survey of student midwives (2011) suggests that 70% of student midwives reported having dependents; 70% earned less than £24,000 prior to entry into the programme; 73% anticipated accruing debt on completion and 70% received a means-tested bursary. Less than 31% held three or more A levels⁷ and 29% completed an Access entry course. This presents a markedly different profile to the student cohort entering medicine.⁸ On this basis we have used the concept of ‘Ethical Education Placements’ (EEPs) to distinguish them from ‘electives’, recognising that ‘choice’ always takes place within an environment of constraints. This also usefully distinguishes EEPs from forms of gap year ‘voluntourism’ facilitated through the growth of highly profitable companies as a component of tourism rather than education. The concept of ‘voluntourism’ is discussed in more detail in Chapter 5.

The second major ethical concern is with impacts in host (low resource) settings. Central to our discussion is a consideration of how sending institutions and students can avoid causing harm to host institutions and the communities they serve. In other words, we are concerned with the ethics and ethical practices of electives when there are power differentials between high and low resource settings. The aims of the book therefore are twofold; firstly, through our analysis of rich qualitative data generated with students, sending institutions and host institutions in Uganda and India, we provide new knowledge of the learning and impacts of international educational placements. Secondly, we present the Ethical Educational Placement Project (EEP) as a model embodying a set of guiding principles for ethical policy and practice in international educational placements across multiple disciplines. We now introduce the reader to the idea of the elective, its conceptualisation and the different forms they take before examining the EEP concept.

International Health Electives

Since the 1970s and 1980s in particular, international health electives have been a feature of undergraduate university medical education. Electives provide students with the opportunity to gain experience ‘in different cultural and clinical climates and have the opportunity to explore parts of the world that interest them’ (Dowell and Merrylees 2009: 122). There are different curricula elements to prepare students for electives, and various models exist which can have different impacts on student learning and host communities (Murdoch-Eaton and Green 2011). Electives can be a few weeks or a few months in duration and usually have a clinical focus, whether that is related to direct clinical practice or more towards data collection, audit or research which can feed into dissertation or publication writing. Some students engage in hands-on clinical practice during electives. There is growing pressure to regulate this in an increasingly risk aware (and potentially risk averse) environment with concerns about insurance, supervision, indemnity and liability. Placements for those students not allowed to engage in clinical practice are usually observational in nature. Aside from the clinical settings, more ‘packaged’ electives such as those offered by for-profit organisations may include either compulsory or optional cultural ‘add-ons’ or experiences which enable students to engage in learning foreign languages, crafts or tourist activities. Travel forms a key part of most electives and students often arrange personal holidays before, during or after their ‘core’ placement.

The potential gains of electives for students are well-documented (see Brookfield 1995; Elit et al. 2011; Murdoch-Eaton and Green 2011) and encompass in general terms, both professional and personal development and the acquisition of new knowledge in and of different contexts (Ackerman 2010). In more specific terms, these positive impacts for students are believed to include: the development of clinical skills in a new context; knowledge of and experience in different health systems; professional development; the development of generic skills, including organisational skills, communication, negotiation, self-evaluation, cultural competence, compassion towards patients, awareness of resource use, confidence, goal setting, widening students’ perspectives, independence and personal growth; reflective questioning of both the challenges and assumptions of practices; greater understanding of different value systems; and ‘social accountability’ (Brookfield 1995; Elit et al. 2011) leading to a range of ‘socially responsible’ educational outcomes (Murdoch-Eaton and Green 2011).

However, throughout the book we question whether it is possible for students to unproblematically acquire such skills and attributes since merely participating in an elective does not necessarily guarantee compassion and competence, cultural or otherwise. Furthermore, a lack of understanding of the broader structural processes at play may preclude meaningful reflection (Hanson et al. 2011). There are concerns across a number of disciplines, including nursing, dentistry, veterinary and social work, that electives are a form of ‘benevolent imperialism’ (Razak 2002 cited in Huish 2012) contributing to Western students’ assumptions of superiority (Elit et al. 2011). This in turn undermines the achievement of socially responsible outcomes. We discuss this in more detail below. In the following chapters, we also problematise the concepts ‘cultural awareness’ and ‘cultural competence’ and frame this discussion within the context of historical structural inequality between high resource and low resource settings (Hanson et al. 2011) and the differences in the positionalities⁹ of students from high resource settings and students/health workers in low resource settings.

The Ethical Educational Placement (EEP) Concept

There is a growing literature on the challenges of integrating ethically sound global health training into research and educational partnerships (see for example Dowell and Merrylees, 2009; Petrosoniak et al. 2010; Hanson et al. 2011; Huish 2012; Dasco et al. 2013). International medical electives are demand driven: some students have altruistic motivations and want to have the experience of serving in resource poor settings, while others are more career motivated and want to enhance their CVs (Huish 2012). On a global scale, medical schools and gap-year companies have responded to this increase in demand but ethical considerations have not kept pace, resulting in two broad challenges. First, in relation to the hubris¹⁰ of Western (medical) students; and second, the creation and perpetuation of structural dependency for host countries and inequalities between sending and hosting countries (Huish 2012). Although the benefits of electives for students are widely recognised, the returns to students often outweighs the benefits to host organisations (Elit et al. 2011). It is becoming increasingly apparent that there are educational and moral reasons to develop more considered and ethical approaches to the design and operation of electives to avoid the pitfalls of medical or poverty tourism (Dowell and Merryless 2009) and minimise the potential harm caused to host communities (Petrosoniak et al. 2010).

Most research on the ethics of electives has focused on international placements in medical education with a primary focus on student experience and safety (Huish 2012). The British Medical Association (BMA 2009) guidelines on ethics in medical electives focus primarily on issues of competency arguing that students should always act within their competence even when dealing with emergencies. The guidelines also emphasise the importance of maintaining ethical standards required in home placements with an emphasis on honesty and integrity, dignity and respect, non-discrimination, prioritisation of patient needs, confidentiality and communication. The guidelines do recognise the importance of cultural openness and the potential burden on the host country but there is little specification of what this means and how it should be handled. The BMA is clear that medical students are not doctors, and that the main benefits for them are an increase in global health knowledge and understanding health service provision in another context: the acquisition of new clinical skills is not seen to be the goal. However, the development of clinical skills is often expressed as a motivation for students or as an intended outcome of electives (see for example Murdoch-Eaton and Green 2011).

It remains apparent then that there is uncertainty and a lack of clarity on behalf of students, sending and host organisations about how to ensure best practice on electives. Despite guidelines, while navigating different medical cultures, students often work out of and beyond their competencies (Elit et al. 2011). There is also concern that the presence of elective students can be a burden on systems already struggling to manage patients with limited staffing and scarce resources (Hanson et al. 2011; Huish 2012). In this way, electives may exploit low resource settings. Significantly, the important issues of whether electives can better meet the healthcare needs of host countries and their contribution to global health remains under-researched, and feature less in discussions of ethics.

Planning and preparation of the elective is important in order to avoid ‘voluntourism’ approaches as this will negatively impact on both the learning opportunities available and the host country. It is generally accepted that for electives to be ethical, there needs to be genuine partnerships between sending and host organisations, and the establishment of mutually agreed goals to ensure that host settings are not exploited (Murdoch-Eaton and Green 2011). Dasco et al. (2013) propose a ‘host country first approach’ which focuses on social justice, academic equity, exchange, transparency, cultural competence and the establishment of mutual defined goals. Huish (2012) calls for a restructuring of international health electives curricula to incorporate issues around social science and moral ethics pedagogy and clarify how ‘global health inequity is ultimately a social constructed, anthropocentric phenomenon’ (2012: 14). Hanson et al. (2011) further suggest that Western students and host institutions need to have or develop ‘epistemic humility.’¹¹ We revisit these issues when we present the Ethical Educational Placement Project in Chapter 2. It is important that the curriculum, augmented by pre-departure training for those who do travel, prepares students to understand the context in which they will be placed (Murdoch-Eaton and Green 2011; Huish 2012). In other words, for educational placements to be ethical, students and sending organisations need to have a deep understanding of the environment and the application of concepts and values such as justice, power, fairness, cultural knowledge and self-awareness (Hanson et al. 2011). Further work with students on their return is critical to optimisation of learning. Mentorship is also an integral part of ethical placements and students need proper mentorship, informed and structured by ethical considerations (Ackerman 2010; Huish 2012). Finally, for educational placements to be ethically conducted and educationally efficacious for students, there is a need for explicit attention to their design, delivery and evaluation (Clampin 2008; Murdoch-Eaton and Green 2011).

The Remainder of the Book

Chapter 2: The Ethical Educational Placement Project describes the development, conceptualisation and operationalisation of the Ethical Educational Placement Project and identifies participating student cohorts and Higher Education Institutions (HEIs). We also summarise the evidence base for the presentation of a suggested ‘model’ for the development of EEPs.

Chapter 3: Student Learning on Ethical Educational Placements focuses on what students learn from educational placements in low resource settings. The term ‘learning’ is used quite fluidly to embrace wider experiential learning – what students often describe as ‘life changing’ or ‘transformational impacts’ and more specific curriculum or employment relevant skills.

Chapter 4: Ethical Placements? Under What Conditions Can Educational Placements Support Sustainable Development? focuses on the ethical aspects of the EEP concept to ask how and in what circumstances can hosting students from high resource settings be of benefit to low resource settings.

Chapter 5: Managing Reciprocity: No Harm Approaches to International Educational Placements draws together the research findings and reflects on what they contribute to the development of a more coherent body of knowledge about student mobility and especially student experiences in low resource settings. It ends with a summary of the key ingredients of Ethical Educational Placements.