Midwifery practice needs to constantly adapt and respond to mutable social, cultural and political factors. Considering immigration patterns in England and Wales, the population has become ever more ethnically and culturally diverse over the past 60 years (Office for National Statistics, 2013). Consequently, midwives are called on to provide care for a range of com munities in a culturally sensitive manner (Nursing and Midwifery Council (NMC), 2015). Green et al (2008) argue that health professionals share common beliefs and underpinning values that go beyond indi vidual countries' boundaries; while the roles and clinical practices may vary in different states, there is ‘a constant in the idea of promoting health and contributing to the care of the public’ (Green et al, 2008: 982).
In a panorama of constantly changing populations in terms of social, cultural, religious and economical status, midwifery students should be encouraged to appreciate differing health care provision from a global perspective. Contemporary midwifery education, therefore, demands engagement in the wider context of international health care, particularly given the increasing number of migrant women and families in the UK (Migration Watch UK, 2012).
Evidence on nursing curricula suggest that by inter-nationalising education, students have the opportunity to engage meaningfully and responsibly with other cultures. This means that cultural differences are experienced, reflected on, respected and understood; an ability variously identified as cultural competence, awareness or sensitivity (Scholes and Moore, 2000; Law and Muir, 2006; Greatrex-White, 2008; Green et al, 2008; Milne and Cowie, 2013). Other positive outcomes of embedding internationalisation within health care curricula are an increase in cognitive development (Zorn et al, 1995); personal and professional growth (Haloburdo and Thompson, 1998; Scholes and Moore, 2000); development of communication skills and tolerance of others (Lee, 2004); appreciation of different forms of health care delivery (Green et al, 2008); and promotion of a mobile workforce (Milne and Cowie, 2013). Curriculum internationalisation does not offer value only to students; it may also have positive implications for academics, who are encouraged to participate in international debates, exchanges and collaborations within both education and research.
Despite the obvious need for student midwives to be exposed to meaningful learning experiences that consider engagement in the wider context of international health care and the associated benefits, there is lack of information on how this is achieved in midwifery curricula nationally and internationally. The implementation of strategies ensuring successful integration of cultural awareness and sensitivity within midwifery education are also unclear.
As internationalisation of midwifery curricula deserves far greater attention than is currently the case, this article will review the work that has been undertaken at the authors' higher education institution, the University of Nottingham, to ensure the midwifery curriculum is internationalised and global mobility is promoted to all midwifery students. The processes that were required to make these changes to the curriculum will be discussed, as well as the challenges for students, academics and administrative staff.
Defining globalisation and internationalisation
Although linked, globalisation and internationalisation are distinct concepts. Globalisation is defined as the standardisation of processes and systems within a global community (Hinchcliff, 2000). Internationalisation, in contrast, refers to the individual country or unit and values its interaction with other individual countries (Allen and Ogilvie, 2004). Therefore, the term ‘global’ considers a worldwide scope and focus while internationalisation relates to the diversity of cultures existing within individual countries, communities and institutions (Knight, 2003). For the purpose of the University of Nottingham's midwifery curriculum, we have taken a hybrid definition of our own, which considers globalisation as midwifery students being aware of the differences between countries and being able to develop skills related to cultural sensitivity (Scholes and Moore, 2000; Law and Muir, 2006; Greatrex-White, 2008; Green et al, 2008; Milne and Cowie, 2013;); this is facilitated by their opportunities to be ‘mobile’ and make connections with health professionals worldwide while studying to become a midwife. Internationalisation is represented by how the midwifery curriculum has been developed for students to learn how midwifery can be planned, adapted and implemented in a range of UK maternity settings, being mindful of different cultures and local needs.
The internationalisation of the midwifery curriculum
The University of Nottingham is known as a global university, with campuses not only in the UK but also China and Malaysia. The university's strategy is for internationalisation to be embedded across all its activities. Additionally, it has a strategy to promote global mobility across all programmes, with the aim that by 2020 30% of all students will complete an element of international mobility during their programme (University of Nottingham, 2015a; 2015b). Opportunities for global mobility should be open to all students. At the time of publication of the university's Internationalisation Strategy document, mobility across the university was 22% (University of Nottingham, 2015b). However, the midwifery programme was starting at a far lower rate, with only about 5% of midwifery students undertaking international placements in the academic year 2013/14.
In terms of national and international mobility, midwifery students had historically undertaken a 2-week elective placement, but this was largely used to stay local and return to placements where they felt they needed to most achieve their objectives. Additionally, just prior to reapproval, there was only one Erasmus+ agreement so there were limited opportunities for students across the cohorts to apply for the scheme.
The Division of Midwifery had the opportunity to review how internationalisation and global mobility would be articulated within the midwifery programme as a new curriculum was planned and developed for reapproval in 2015. This was first actioned by the appointment of lead and deputy lead for global mobility as recognised roles in the division. The new programme is based on a spiral curriculum (Bruner, 1960) where globalisation and internationalisation are considered across all modules throughout the programme (Table 1).
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The key to the success of the Division of Midwifery's strategy is that students are introduced to international opportunities at the recruitment stage, and this is reinforced across the programme leading up to the period when mobility might occur. This appears to stimulate curiosity among students so they look forward to the global mobility opportunities, as well as seeing the benefits it will have for their future midwifery careers. Mobility is encouraged in a number of ways, including Erasmus+, elective placements and other ad hoc short-term opportunities.
Erasmus+ is an EU training programme that enables exchange through mobility of higher education students by providing grants to cover additional expenses for them to study at another European university. The programme guarantees that the period that is spent at the host institution is recognised by the student's home university. It enables learning abroad and also gives students the opportunity to live in another country and develop lifelong skills. The Division of Midwifery decided to move to the Erasmus+ training scheme where partner organisations exchange students for 2 calendar months. It was felt that this was a realistic time period for which students could be away without disruption to their programme. The Division of Midwifery has had a partnership agreement with one partner for a number of years but this offered limited opportunities, owing to the small number of students involved in the exchange. It has therefore increased the number of partner institutions from one to four, in Malta, Italy, Ireland and Denmark. With a total of 10 places a year, 13% of each year's intake have the opportunity through a competitive process to undertake an Erasmus+ placement. Students are selected using a number of criteria including academic performance, a personal statement on how international placements will benefit their midwifery practice, and a reference from their personal academic tutor. Student midwives are able to practise in the host institutions as they would do in UK placements, supported by a trained mentor, so they continue to meet competencies in antenatal, intrapartum and postnatal care and record personally conducted births and other activities. However, on return from the Erasmus+ placement, they need to have their competencies verified by a sign-off mentor according to NMC (2008) requirements. Students who do not have the opportunity to go on an Erasmus+ placement are able to learn about midwifery in other countries, both in theory and in practice, as they are given opportunities to engage with the incoming students.
The elective placement involves a 2-week observational period in a national or international clinical setting chosen by the student, occurring in the third year of the programme. Elective placements are aimed at encouraging students to: widen their perspective of health care practice; challenge assumptions; gain an understanding of midwifery practice outside usual placement areas; look at midwifery from a different angle and with ‘new eyes’; and work in unfamiliar settings to encourage personal growth and professional development. A clear process for arranging elective placements has been implemented to encourage students to plan their elective in advance and ensure all steps, including a risk assessment, are completed on time. Each year, the School of Health Sciences organises an elective fair that enables students to be introduced to the opportunities available, as well as funding streams.
Students have further chances to consider the importance of internationalisation to their careers. Funded attendance at local, national and inter national con ferences is possible. Midwifery has also recently been included in the Universitas 21 group, a global network of research universities. In addition, student midwives from other universities come to the University of Nottingham for short study tours. This gives all students the opportunity to meet students from across Europe to discuss, debate and exchange different midwifery practices.
Mobility promotion strategies
In order for students to apply for global mobility opportunities, they need to be made aware of the possibilities. Kent-Wilkinson et al (2015) link an increase in awareness and information available to a greater openness among students to consider studying abroad. The School of Health Sciences not only seeks to inform students of the opportunities available, but also uses mass communication to promote student mobility. To achieve effective communication, the School currently uses a variety of student testimonials as part of its student mobility promotional strategy, including videos, sharing tips and recommendations using a reviews system and through use of social media. Teng et al (2015) describe social media as online word-of-mouth. To maximise this, the School is running a photo competition using its social media pages to promote mobility by showcasing inspirational photographs from students. Mass communication is beneficial in that it provides the same information to all students at the same time; however, it is often one-way communication, making it difficult to assess how the message is being interpreted (Hundekar et al, 2009). Face-to-face communication between staff and students is also used to promote mobility. This provides an opportunity for questions to be asked and for staff to explain in more depth where necessary.
Evaluation of the internationalisation and mobility agenda
The School evaluates its Erasmus+ programme by under taking group feedback sessions with both visiting and returning students. The main aims of the feedback sessions are to uncover areas for improvement, identify what is working well and allow students to reflect on their experiences. Palermo (2013) acknowledges that communicating openly about weaknesses can be extremely difficult. It is important that staff keep an open mind when listening to students' feedback and do not become defensive. Feedback is always logged in order to identify trends and provide an audit trail of how areas for improvement have been addressed. In line with other health care students' perspectives reported in the literature (Cowan, 2007; Green et al, 2008; Tuckett and Crompton, 2014), Nottingham's incoming and outgoing students have commented positively on their international placements, especially in regard to experiencing a variety of maternity care services within a diverse cultural and social environment, aiding future career choices, and facilitating personal and professional development.
Conclusion
As a result of the implemented strategies outlined in this article, the University of Nottingham's Division of Midwifery has seen an increase in students undertaking an international placement from 5% in academic year 2013/14 to 10% in 2014/15 and 18% in 2015/16. Moving forward, our focus will now be around sustaining the Erasmus+ exchanges as well as increasing the number of students who undertake an international elective placement. The goal is to meet the university's global mobility target of 30% of all students having the opportunity to go abroad during their programme by the year 2020 (University of Nottingham, 2015b). Future work will aim at developing ‘virtual mobility’ so that students from different countries can engage in online activities on a midwifery topic of mutual interest. This widens the opportunities for students to engage with midwifery students in different countries, and enables participation by those students who are unable to undertake an international placement for any reason. We also propose to formally evaluate the experience and value of undertaking a midwifery Erasmus+ placement through a collaborative research project with European partner organisations.
In terms of broader implications for clinical practice, the internationalisation of midwifery curricula is expected to encourage students from different back-grounds to develop cultural competence, awareness and sensitivity alongside the required skills of a qualified midwife, contributing to the ultimate goal of offering compassionate, personalised, family-centred maternity care services.