“It’s a mind-changing game!”: Health professional educators working abroad

Higher education is now a global industry. As students and staff travel across the globe to study and teach, both the student population and the academic staff profile is becoming increasingly international. While there is a reasonable literature documenting the experiences and challenges of international students, little is, however, known about educators who chose to work outside their country of origin. Following a pilot study carried out in the Middle East, a revised online survey canvassed the global community of health professional educators (n = 89) to garner not only demographic information but also first-hand accounts of their experiences as international educators. The educators were overwhelmingly positive about their rich experiences in new cultural contexts, acknowledging considerable personal development and broadening perspectives. Their challenges were largely personal, in terms of the impact on their families and adapting to new ways of doing things. We propose an innovative model taking into consideration the many individual and environmental factors involved in the pre-departure and the immersion phases.


Background
Higher education, like all other business, is now a global industry.The last two decades have therefore witnessed the "globalisation" of higher education, as thousands of students travel between continents for their tertiary education.To meet these demands, many established Australian, American, UK and Indian universities have established offshore campuses in Asia and other emerging economies, e.g. the Middle East.Thus, not only are students increasingly on the move, so too are educators (Bodycott & Walker, 2000;Dunn & Wallace, 2004;Harden, 2006;Smith, 2009;Fenton, 2010;Kim, Wolf-Wendel & Twombly 2011;McLean, 2013;McLean, McKimm & Major, 2014;Bovill, Jordan & Watters, 2015;McLean et al., 2015).
While much has been written about the expatriate workforce, this has largely been from the perspective of the globalisation of businesses and corporations.By comparison, the academic expatriate workforce has barely been researched (Bodycott & Walker, 2000;Fenton, 2010;Dunn & Wallace, 2004;Smith, 2009;Kim et al., 2011;McLean, 2013;McLean et al., 2014;Bovill et al., 2015).The move to another country to study or work will undoubtedly immerse the individual in a different culture or at least, a different way of "doing things", requiring adjustment and adaptation (Grove and Torbiörn, 1985;Haslberger, Brewster and Hippler, 2013).
"Culture" is, however, a highly contested term (Bovill et al., 2015), with multiple meanings.While some individuals might perceive it as a constraint (e.g.restrictions on women), others might view culture as the inherited traditions that connect members of a community (Cleaver, 2001)."Culture" is also used in the context of an organisation (i.e.organisational culture), depicting how "things are done", the relationships that exist and the administrative structures.The term, "culture shock", has been used to describe the situation of an individual realising that he/she cannot fully meet the demands of the environment or when the environment does not meet expectations.This leads to stress, generally perceived as negative emotions, which in turn leads to an unfreezing of the mental frame to allow changes to be made, followed by a refreezing of the mental frame (Lewin, 1997) (i.e. adaptation).This adaptation involves cognition and emotions (internal), behaviour being the observable (external) manifestation (Grove & Torbiörn, 1985).For some, however, this may lead to cognitive dissonance, i.e. when one needs to behave in a way which contradicts one's norm (Haslberger & Brewster, 2005).This paper describes the experiences of a group of health professional educators who had been or were working away from their "home" country.Our aim was to use existing frameworks to develop a renewed model that captures the individual and environmental factors that impact on their adjustment and adaptation as academics to new cultural contexts.For the purpose of this study, respondents will be referred to as international educators.

Setting
An online survey, piloted in the Middle East (McLean et al., 2014) was adapted for an international audience.Our data collection was framed around the following research questions: What drives health professions educators to work abroad? 1.
What are the perceived benefits and drawbacks for institutions hiring foreigners? 2.
What are the personal benefits and challenges of being an international medical educator?3.
What advice can these educators offer? 4.
What traits and attributes are required to work internationally? 5.

Survey instrument
Details regarding the development and refinement of an approved online survey instrument piloted in the Middle East have been described elsewhere (McLean et al., 2014).Modifications for an international audience included removing two items, rephrasing three (e.g.removing reference to the Middle East) and adding six new questions to gather information about respondents' professional and personal experiences whilst working abroad.Using both selected response items and open-ended questions, the survey instrument anonymously collected biographical information as well as details of participants' past and current positions and roles as international educators.The questionnaire comprised 42 items.Of relevance to this study are the 17 questions (largely open-ended) relating to their experiences and views on being international educators.

Participants
Through the authors' contacts and collaborative networks and the hosting of the online survey on MedEdWorld (www.mededworld.org)for two months during late 2012, the responses of 89 participants (58% male; 42% female) with a mean age of 51.4 ± 12.1 were analysed.Participants were born in 29 countries, had undertaken their undergraduate and post-graduate studies in 27 and 22 countries, respectively and collectively and had worked in more than 87 countries.For 45%, "home" was no longer the country in which they were born.The majority (64%) were medically qualified, with 89% having post-graduate qualifications (clinical specialisations and/or Masters/PhDs) (McLean et al., 2015)

Data analysis
The largely open-ended responses to the questions posed were thematically analysed (Vaismoradi, Turunen & Bondas, 2013).Three researchers (MM, SM and ADS) independently identified the main themes and sub-themes within the comments.These were compared and discussed until consensus was reached.

Why did respondents choose to work abroad?
The reasons offered for working abroad were both personal and professional, with the most frequent being to gain experience (n = 11), as part of a current job (n = 11), by invitation (n = 11), a job offer (n = 9) or motivated by interest (n = 9) or career or self-development (n = 8).The word "opportunity" was used by 15 (± 17%) of the respondents.Around 11% of the participants referred to wanting to work or gain experience in a developing country or low resource setting, suggesting an underlying altruistic motivation.Only three respondents indicated that their move was financially motivated.

What were the benefits of being an international educator? (Table 1a)
The benefits of being "international" largely revolved around experiencing a new country and/or culture, including different educational systems and practices, health care systems and networking opportunities.Another major theme was that of their personal development in terms of becoming more open and flexible.They wrote about their "horizons being broadened" by being in another culture and also about seeing things differently.In essence, they learnt more about themselves.They also identified the benefits of collaboration, for example, of working with others to develop a new curriculum.Others identified a deeper appreciation of the constraints faced by those living in under-resourced countries or regions.

What were the challenges of being an international educator? (Table 1b)
The major challenge responders identified about working abroad involved their families, largely the consequences of being separated and/or disruption if their partner and children accompanied them: "Sometimes difficult to combine with having a family with children.You want them not to be brought into a difficult position as you are away and yet you go for the challenge of going abroad….My marriage broke up during a stay with my whole family abroad.That was quite a stressful period for all of us, but mostly for my children and my partner, as I had my job anyway".
Another major challenge was that of adapting to working in a different culture, exacerbated if the language was different.Included in this theme were the challenges in the learning and teaching arena: "There were cultural challenges regarding respect for teachers, an expectation to treat or address students as you would address fellow colleagues.The culture of political correctness in what you do or say was also a big challenge because in my culture a teacher has more power/authority over students and therefore could get away with a few things"."Understanding my formal role in the system in which I was hired and my freedom to make decisions.In nonformal education: planning and time-keeping is hard and it requires some flexibility to adapt learning objectives to feasibility vs. find the right strategy to keep people on target".
Several respondents identified impact on their career trajectories (Table 1b), some positive but others (e.g. the academic employed at home but who worked abroad) noted that international activities were not recognised for promotion.

How did they deal with the challenges? (Table 2)
"Adaptation" emerged as a key word in dealing with the challenges, either in terms of gaining an understanding of the local norms (often through seeking advice from colleagues) or in terms of finding ways to deal with language differences (e.g.learn a few words; use of a translator in the clinical setting).There was acknowledgement that respect, dialogue and negotiation were necessary and some conflict might be anticipated.Some educators offered a different perspective, seeing a need for a two-way broadening of perspectives and some give and take, so that both parties (local and visitor) benefitted from the cross-cultural experience.
Respondents acknowledged that this adaption took time and that some "issues" could not always be resolved or were only partially resolved: "Cultural expectations regarding diligence and work ethic.Never fully resolved this, but tried to encourage the more diligent students and reward their efforts!… Dissonance by working with an older male lab technician from the north of the country (very chauvinistic stereotypically!).In general, by the end of four years, I felt a far greater understanding of the culture and environment, although some frustrations remained and were never fully resolved".

What are the benefits and drawbacks for the employing institution? (Table 3)
In the view of many respondents', the benefits for institutions of hiring international educators far outweighed the drawbacks.The primary benefit was the different worldviews and new perspectives they brought, followed by their expertise.Networking and the opportunity to benchmark standards was also identified.
A major drawback of hiring international educators was perceived or actual paternalism or colonialism (on the part of the educator).Examples provided included the implementation of inappropriate curricula and unsustainable educational and health practices.
Not unexpectedly, respondents identified that with hiring international faculty came cultural and language issues, with expatriates needing time to adjust to the new environment.Several respondents identified staff turnover (because of contract work) being a drawback, with the possible cost implications of ongoing recruitment.

What were their memorable experiences?
In response to this question, both positive experiences and challenges were recalled.Mostly, these related to language and culture.Also mentioned were experiencing different perspectives, being able to make a difference and seeing the fruits of their labour: "Having to teach an audience that could not understand English or French, relying on a translator 100% to get the message across over a 2-day short course!" "Language with interpreter: Finnish speaking English, interpreted by a Malawian into Putonghua" "My period in Japan: Challenging in terms of culture, language and feedback habits" "Knowledge of English of students, trainees and teaching staff was exemplary.Eagerness to learn was humbling" "It was interesting to be able to understand Portuguese even though I don't speak that language, I learnt from my students" "Religious considerations connected with Islam regarding medical topics that are forbidden in this religion" "I was unprepared for cultural differences between UK and Jamaica.Students and local doctors seemed callous towards their patients.Patients not involved in treatment planning" "The most memorable is probably Nigeria because it opened a wide dimension of community-orientated learning that has endured and provided leadership for the ensuing 35 years" "Inspiring to see medical students evolving from individual clinical care to global health view including social determinants of health; inspired by health professionals who wish to work in poor counties to help reduce global health service inequalities" "Small group teaching in rural Latvia...110 turned up including doctor, nurses….." "The surgical trainees in London thought I brought them the different view of learning surgical skills"

What orientation, induction or training had they received?
Less than one-fifth of the respondents had undergone some "training" in relation to their new posts.Although formal training such as university induction, notes, a link to a webpage or as an observer teacher was identified, more comments reflected informal "training", e.g.what they had gleaned from colleagues, presumably also expatriates.

Discussion
"Learnt so much, become a better person, have contact with so many wonderful people and their experiences.It's a mind-changing game!" The above comment captures the positive sentiments of a respondent who had worked abroad as an international educator.From the largely qualitative survey, the general impression was that for the majority of our respondents, the benefits and rewards of working abroad outweighed the personal and professional challenges of moving to a new and often unfamiliar context.Not only did such an immersion lead to an increased knowledge and awareness of different education and health care systems and new cultures, for many, it was also a journey of self-discovery and personal development.While a number of technical skills had clearly been developed, the positive impact of rich experiences with a range of individuals from other cultures on their personal development was immense.This personal development was largely around the broadening of their perspectives and the changing of worldviews, corroborating the findings of our pilot study conducted in the Middle East (McLean et al., 2014).
From respondents' responses, there was clear evidence that their immersion in a new context, which for many was a new culture, had required considerable adaptation on many levels.This happened largely in situ, on arrival in the new country.Together with personal issues (mostly relating to their families), culture and language emerged as a major challenge, with "culture shock" being mentioned by several respondents."Shock" can probably be interpreted as the challenge to their mental frame of reference or to a misalignment their between expectations and reality (Lewin, 1997).
Using Lee's (2006) and Haslberger and colleagues' (2013) frameworks, both of which integrate a number of theoretical and/or psychological perspectives, and including issues arising from our study and other relevant work on expatriation, Figure 1 offers a modified and more inclusive conceptualisation of the factors and processes involving in adjusting and adapting to a new cultural environment.In Lee's (2006) framework, adaptation to a new country and/or culture comprises two aspects (Lee, 2006): Pre-departure (i.e.anticipatory) adjustment which relates to the various personal and professional activities and factors that prepare the individual (mostly psychologically) for the move, and in-country adjustment which happens when the individual arrives in the new country.In our model, the journey to a new country and/or cultural context needs to acknowledge pre-existing factors (antecedents) which relate largely to the individual (e.g.personality traits; cultural intelligence) but also to the anticipated environment (e.g.culture novelty; work-related conditions).

Individual factors
The Big Five personality traits (extraversion, agreeableness, openness to experience, conscientiousness and neuroticism) have been identified as important individual factors for working in a new context (Bhatti et al., 2014).Table 4 aligns the attributes and qualities our respondents identified as essential for working in a new culture with the Big Five personality traits.Most of their identified attributes and qualities could be aligned with agreeableness and openness to experience.
Two other individual factors we believe influence an individual's decision to work abroad are self-efficacy and professional identity (Bandura, 1977) and motivation (Ryan & Deci, 2000a,b).Self-efficacy relates to the strength of one's belief in one's own ability to complete tasks and reach goals, while Ryan and Deci's (2000a,b) selfdetermination theory describes an individual's tendency to support intrinsically-driven beliefs and goals.
An antecedent we consider important in the context of experiencing new cultures, and which is particularly important in-country, is cultural intelligence (CQ), defined as an individual's capability to detect, assimilate, reason and act on cultural cues appropriately in culturally diverse situations (Ang et al., 2007;Shaffer & Miller, 2009;Rockstuhl et al., 2011;Van Dyne et al., 2012).Van Dyne and colleagues (2012) recently expanded their original four factor model (metacognitive CQ, cognitive CQ, motivational CQ, behavioural CQ) to include sub-dimensions (e.g.under cognitive CQ, intrinsic interest, extrinsic interest, self-efficacy to adjust have been identified).Shaffer and Miller (2009) offer several propositions for the direct and indirect effects of CQ on several expatriate success outcomes, including adjustment, performance, retention and career success.

Environmental factors
Cultural novelty, the cultural distance between the host culture and a person's own culture (Palthe, 2004) and which can relate to, for example, food, housing, safety, entertainment, religion (Farooq & Bagul, 2015), is a consideration when deciding whether to live and work in a particular context.The assumption is that the greater the difference between the new culture and an individual's culture, the greater the adjustment, with the individual looking for differences.Selmer (2006), however, makes the important point that when a culture is perceived as similar to one's own (e.g. the same language is spoken), nuances can be overlooked and inappropriate behaviour is just as likely as in a culture that is very different.Culture shock can therefore sometimes be more intense as anticipatory adjustment has not occurred.

Pre-departure or anticipatory adjustment
This describes the numerous activities and factors that culminate in expectations of the impending move.These relate to the individual (mainly in terms of preparation of self and attending to family) who will make the move as well as the processes put in place by the future employer, e.g.clarity of job role ; communication.Collectively, these factors (process; information) allow the individual (and presumably also his/her family) to make some psychological adjustment in preparation for the move.

In-country adjustment and adaptation
While anticipatory adjustment is required, most of the adjustment takes place in-country, the extent of which depends to some degree on whether the anticipatory expectations are met (or not met) as well as personal characteristics.Adaptation has been described as the degree of fit between the individual and the environment in terms of social processes and structures and usually involves the convergence over time of behaviours, values and norms and the underlying assumptions of the individual, i.e. reconstruction of a mental frame of reference (Grove and Torbiörn, 1985).
As depicted in Figure 1, once in-country, adjustment involves constant interpretation and understanding of the environment and circumstances, with the individual making cognitive, affective and behavioural adaptions both in terms of his or her personal and professional lives (Figure 1).For Osman-Gani and Rockstuhl (2008), a key consideration in adjusting and adapting to a new context relates to the social network structures that expatriates develop.In their model, antecedents such as neuroticism, extraversion, openness, metacognition and self-efficacy influence social networking characteristics (i.e.strength, diversity), which in turn impact on outcomes such as job performance, global identity and social status.In our model, two networks are depicted: Social (for the individual and for the family) and professional (for the individual in the workplace).
A major issue not commonly reported in the literature on working abroad but which emerged as a major challenge for our respondents, was the impact of the move on individual's partner and children (Caligiuri, Hyland & Bross, 1998;Palthe, 2004;Rosenbusch & Cseh, 2012;Nam, Cho & Lee, 2014).This relates both to separation if the family remains in the home country or an inability of the accompanying family to adjust to the new environment.Caligiuri and colleagues' (1998) found that in a global assignment, the adjustment of the accompanying family members becomes the critical factor influencing the overall adjustment of the expatriate.
Not surprisingly, after family factors, the challenge of adapting to a new culture (and language) was identified by our respondents.Haslberger and colleagues (2013) conceptualise adjustment as a person-environment fit: Do the environmental resources or supplies meet with expectations?and Does the individual have the ability to meet the environment demands?They recognise three dimensions of adjustment: Cognitive, affective and behavioural, each with an internal (individual) and an external standard (environment).If, in moving, expectations are not met, increased demands (and stress) are placed on the individual, creating a 'crisis' which then triggers coping strategies.Although this adjustment-crisis-adaptation process is particularly pronounced on arrival, for Haslberger and colleagues (2013), it is never-ending as there are continuous demands on expatriates, both personally and professionally.While they may be willing to meet external standards more easily in some instances (e.g.leisure activities), this may not be the case in terms of, for example, religion.For some individuals, this may lead to a conscious decision not to adjust.
The learning and teaching environment is a particularly interesting and challenging one in a new cultural context.
Educators are often hired for their expertise in particular areas, e.g.curriculum development, assessment, as some respondents in the present study identified.While teaching in a new context brought opportunities for broadening horizons, they also acknowledged that it could be easy to impose views and standards (i.e.be patronising): I found the divide between being empathetic and patronising difficult at first.I learned to put what I 'knew' about the culture and way of teaching aside and learn what works for my students Fernandez and colleagues (2006) identified three steps to adapting to a new cultural environment, which they see as "first and foremost about breaking with a number of biases and certainties so as to become familiar with a social atmosphere" (p.14): Step 1: Immersion-Adjustment: Touching, feeling, seeing, listening and tasting: The starting point of a different way of thinking and doing things.
Step 2: Immersion-Comprehension: Acquired competencies: One realises intercultural mediation is possible, developing relationships while taking into account of potentially opposing logic, customs and habits.It is during this process that one develops patience, humility and trust.
Step 3: Immersion-Integration: Enlightened pragmatism: The language is learnt and one is integrated into the cultural and intercultural configurations.
Adjustment is thus a precondition first of adaptation and then of integration.If an individual is able to adjust to new ways of doing things, is satisfied with his or her employment conditions and on the personal front, and has settled (including the family), then he/she is more likely to adapt, if adaptation is viewed as adopting "norms" of the local context (Fernandez, Mutabazi & Pierre, 2006).For Fernandez and colleagues (2006), on a personal level, the process of immersion, adjustment, comprehension and enlightened pragmatism is about "embarking on a profoundly humble journey" (p.18), which ultimately leads to an alteration in personal identity.True integration might, however, only come about by extended contact and socialisation with host country nationals (Hechanova, Beehr & Christiansen, 2003;Lineberry, 2012) and if one relinquishes "home" culture (Lineberry, 2012).In the longer term, if the employment contract is renewed and the family has settled, then the new country might become a place of residency or home.If, however, the initial adjustments are too far removed from one's internal standards (or one's family's), then adaptation will be difficult and may culminate in the individual and/or the family returning home.
Although training and orientation emerged as being important for adjusting to the new work context, our educators were generally offered no training or what was offered was inadequate.Being "socialised" was recognised as important (as Palthe's (2004)

study demonstrated):
A greater period of cultural orientation/acclimatisation may have helped with the initial process (we had none, and there was a culture locally where people would say what they thought you wanted to hear rather than what was necessarily the case, which made obtaining and acting upon feedback tremendously challenging!)Those who had been there longer could have discussed some of their own initial frustrations or conflicts and how they resolved them, and this would have helped greatly!Nam and colleagues' (2014) recent review on our current understanding of cross-cultural training has identified that there needs to be a shift from learning about culture to developing skills to manage oneself and others across cultures.If expatriate adjustment relates to the degree of psychological comfort and familiarity an individual feels in terms of the new culture, then "developing intercultural competence … is no longer just a recommendation but a requirement for responding to the challenges of globalization" (Nam et al., 2014;p.49).
Bandura's social cognitive theory ( 2002) is of relevance to this discussion in terms of three proposed modes of agency, all of which are important in adapting to a new cultural context: Direct personal agency, in which an individual can regulate him-or herself and the new environment Proxy agency, in which an individual tries to get those who with access to resources, expertise or have the power to act on their behalf to secure their desired outcomes, and Collective agency, in which an individual, recognising that a collective effort is more likely to achieve the desired result, will work with others to pool their knowledge, skills and resources, while providing mutual support.
In the present study, direct personal agency and collective agency were the most commonly identified modes of agency, reflecting individuals' need to adjust and adapt, while relying on the support of new colleagues.

Take Home Messages
Am I the right sort of person?Will I be able to adapt? would be some of the questions facing academics contemplating working abroad.Working abroad does not suit everyone.Having selected the appropriate academic to be employed or to undertake an international activity, considerable support is required, either by the "home" institution (Bovill et al., 2015) or by the international employer.Once in-country, the question might then be To stay or not to stay?The outcome would depend on an individual's (and his/her family's) adaptation and adjustment and the support received.
Our study of 89 health profession educators, some with little international experience and others with decades of experience have contributed to our understanding of what it means to be an international educator.Together with the available literature and models on expatriate experiences in general, this study has contributed to a relatively unexplored expatriate situation -that of academics working internationally.Emerging from this study was the overwhelming enthusiasm respondents expressed in terms of the opportunity to work abroad and the benefits of their experiences, particularly in terms of their personal development (i.e.broadening views).Their decisions to become an international educator were, however, not taken lightly as they need to be personally introspective, weighing up the pros and cons for themselves and their families.Our findings have been integrated into an extensive expatriate literature to develop a model which we believe is representative of across both academic and business contexts.Tharenou's (2015) recent article on the need to consider expatriate types (i.e.organisational transfer, self-initiated, skilled migration) is an area of future research as this might impact on adjustment, adaptation and integration.Based on our own experiences as educators who have worked across several geographic regions and in a range of cultural contexts, supplemented by the input of respondents to our Middle Eastern (McLean et al., 2014) and current survey, Box 1 offers advice to academics contemplating taking up a position abroad.While the pre-departure or anticipatory adjustment is important in preparing oneself for change, it is only once one is immersed in the new culture that the adjustment and adaptation can happen.